Test

The client with enuresis is being talked regarding bladder retraining the nurse should advise the client to refrain from drinking after: 1000 0700 1200 1900

1900

A client has an order for Dilantin(phenytoin) .2 g orally twice a day. The medication is available in 100 mg capsules. For the morning medication, the nurse should administer: 1 capsule 4 capsules 3 capsules 2 capsules

2 capsules

A client with hypertension has begun an aerobic exercise program. The nurse should tell the client that the recommended exercise regimen should begin slowly and build up to: 20-30 minutes three times a week 1 hour two times a week 1 hour four times a week 45 minutes two times a week

20-30 minutes three times a week +

A client is admitted with burns of the right arm, chest and head. According to the rule of nines, the percent of brain injury is: a. 27% b. 45% c. 36% d. 18%

27%+

A client with cystic fibrosis is taking pancreatic enzymes the nurse should administer this medication: four times a day once per day in the morning once per day at bedtime 3 times per day with meals

3 times per day with meals

A camp nurse is applying sunscreen to a group of children enrolled in swimming classes. Chemical sunscreens are most effective when applied: just before sun exposure 30 minutes before sun exposure 5 minutes before sun exposure 15 minutes before sun exposure

30 minutes before sun exposure

What is the normal pH range for arterial blood? 7.35 to 7.45 7 to 7.49 7.50 to 7.60 7.55 to 7.65

7.35 to 7.45 +

A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: Dyspnea Chest pain A bloody, productive cough A cough with the expectoration of mucoid sputum

A cough with the expectoration of mucoid sputum

The nurse is administering morning medications at 07:00. Which medications should have priority? A proton pump inhibitor A narcotic analgesic A histamine receptor antagonist A mucosal barrier agent

A mucosal barrier agent +

The nurse is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true? A positive reaction indicates that the client has been exposed to the disease A negative reaction always excludes the diagnosis of TB The PPD can be read within 12 hours after the injection A positive reaction indicates that the client has active tuberculosis

A positive reaction indicates that the client has been exposed to the disease +

A patient who is in the 10th week of outpatient cardiac rehabilitation continues to exhibit symptoms of depression when developing a discharge plan the cardiac-vascular nurse includes: A referral for counseling and possible medication A trial of herbal remedies Alternative therapies including yoga and massage Comprehensive information about the patients cardiac status to help reduce his or her anxiety

A referral for counseling and possible medication +

The nurse is caring for an adult client diagnosed with GERD. Which condition is the most common comorbid disease associated with GERD? Adult onset asthma Pancreatitis Peptic ulcer disease Increased gastric emptying

Adult onset asthma

When reviewing a patients four week diet history the cardiac-vascular nurse identifies a pattern of high calorie intake on monday, wednesday, and friday nights. The patient states that the patients spouse recently started taking a night class on those evenings at a local university. Thepatients diet history indicates: A disabling family coping behavior A lack of dietary instruction A need for cooking classes An individual coping behavior

An individual coping behavior +

The client is admitted to the telemetry unit diagnosed with acute exacerbation of CHF. Which sign/symptom would the nurse expect to find when assessing this client? Apical pulse rate of 110 and 4+ pitting edema of feet Thick white sputum and crackles that clear with cough The client sleeping with no pillow and eupnea Radial pulse rate of 90 and CRT less than 3 sec

Apical pulse rate of 110 and 4+ pitting edema of feet +

Which home remedy is suitable to relieve the itching associated with herself? Applying gauze saturated in hydrogen peroxide Dusting the lesions with baby powder Using cool compresses of normal saline Applying a paste of baking soda and water

Applying a paste of baking soda and water

The nurse writes the problem of pain for a client diagnosed with lumbar strain. Which nursing interventions should be included in the plan of care? select all that apply Assess pain on a 1-10 scale Administer pain medication PRN Provide a regular bed pan for elimination Assess surgical dressing every 4 hrs Perform a position change by the log roll method every 2 hrs

Assess pain on a 1-10 scale Administer pain medication PRN

The client diagnosed with cervical disk degeneration has undergone a laminectomy; which interventions should the nurse implement? Position the client prone with the knees slightly elevated Assess the client for difficulty speaking for breathing Measure the drainage in the Jackson Pratt bulb everyday Encourage the client to postpone the use of narcotic medication

Assess the client for difficulty speaking for breathing

The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6 F. Which intervention should the nurse implement first? Notify the HCP Document the findings in the chart Administer oral antipyretic Assess the client's abdomen

Assess the client's abdomen +

The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first? Assess the nail beds for capillary refill time Remove the clients clothing from the left arm Call radiology for a stat x-ray of the extremity Prepare the client for the application of a cast

Assess the nail beds for capillary refill time

A patient is admitted to the hospital for a carotid angiogram with stent placement the patient's spouse states I don't want my spouse to find out there is a risk of a stroke connected with this procedure because he or she won't sign the consent form the cardiac vascular nurses most appropriate action is to: Assess the patient's level of understanding of risks benefits and alternatives Assure the patient spouse that the risk of stroke is minimal Offer the patient emotional support and reinforce the benefits of the procedure Perform a neurological assessment to establish a baseline

Assess the patient's level of understanding of risks benefits and alternatives +

The cardiac vascular nurse reviews risk factor reduction with a patient who is newly diagnosed with a myocardial infarction the patient states I don't know why you're making such a big deal about this stuff I feel fine and the doctor said that my heart attack was small the nurses most effective action is to: Assess the patient's perception of the event with open ended questions Present research to support the need for risk factor reduction Reinforce patient education Review the laboratory values with the patient

Assess the patient's perception of the event with open ended questions +

A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should the nurse include in a bladder retraining program? Establishing a predetermined fluid intake pattern for the client Encouraging the client to increase the time between voidings Restricting fluid intake to reduce the need to void Assessing present elimination patterns

Assessing present elimination patterns +

A primary prevention for reducing a female patient's risk of developing coronary heart disease is to: Avoid excessive weight gain during pregnancy Enroll in a cardiac rehabilitation program Take 81 mg of aspirin daily Take nitroglycerin at the onset of chest pain

Avoid excessive weight gain during pregnancy +

A male client with acute pyelonephritis receives a prescription for Co-trimoxazole (Septra) P.O. twice daily for 10 days which finding best demonstrates that the client has followed the prescribed regimen? Urine output increases to 2000 ML/day Flank and abdominal discomfort decreases Bacteria are absent on urine culture The red blood cell count is normal

Bacteria are absent on urine culture +

A patient with cardiogenic shock receives a nursing diagnosis of decreased cardiac output with the appropriate interventions the anticipated outcome is for the patient to achieve: Baseline activity level Baseline cardiac function Decrease afterload Reduced anxiety

Baseline cardiac function+

The nurse formulates a nursing diagnosis of activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis to minimize this problem the nurse instruct the client to avoid conditions that increase oxygen demand such as conditions include: Eating more than three large meals a day Drinking more than 1500 ml of fluid daily Eating a high protein snack at bedtime Being overweight

Being overweight +

Which finding is the best indication that a client with ineffective airway clearance needs suctioning? Arterial blood gases Respiratory rate Breath sounds Oxygen saturation

Breath sounds

The nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure the nurse can facilitate the insertion by asking the client to: Initiate a stream of urine Breathe deeply Turn to the side Hold the labia or shaft of penis

Breathe deeply +

Certain foods may increase the pain associated with gout. Which foods have the highest concentration of purines? Brian, liver, kidney Lettuce, corn, potatoes Beef, pork, chicken Fruits and juices

Brian, liver, kidney

A patient age, 68 has suffered an intertrochanteric fracture of the right hip before surgery to provide support and comfort any mobilizing device of a______is applied. Thomas split Bryant traction Russell traction Buck traction

Buck traction

A male client develops acute renal failure after receiving IV therapy with a nephrotoxic antibiotic because the clients 24 hour urine output calls 240 ML the nurse suspects that the client is at risk for: Cardiac arrhythmia Paresthesia Dehydration Pruritus

Cardiac arrhythmia +

Which diagnostic test should the nurse monitor for the client diagnosed with severe anorexia nervosa? Liver function test Kidney function test Cardiac function test Bone density test

Cardiac function test +

A patient who underwent coronary artery bypass surgery demonstrates effective understanding of discharge teaching by: asking whether smoking one cigarette per day is acceptable Clarifying when cardiac rehabilitation will begin Describing plans to relax in a hot tub during recovery Planning to resume driving his or her spouse to work next week

Clarifying when cardiac rehabilitation will begin+

The nurse is caring for a client who had a right shoulder replacement which data warrants immediate intervention. Clients hemoglobin is 8.1 G/DL The clients white blood cell count is 9000/mm3 The clients creatinine level is 0.8mg/dL The clients potassium level is 4.2 mEq/L

Clients hemoglobin is 8.1 G/DL

The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low cholesterol diet? Canola oil Sunflower oil Safflower oil Coconut oil

Coconut oil

For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? Providing the client with a sedative Restricting fluid intake to 1000ml/day Coughing and deep breathing Forcing absolute bed rest

Coughing and deep breathing

A 70 year old patient with cardiovascular disease attends group classes on disease process medication exercise nutrition and stress management to promote optimal and effective learning the cardiac vascular nurse uses which teaching strategy? Condensing the information to one session so the patient needs not in return for a second day Customizing teaching objectives based on the learners interest Preparing a PowerPoint presentation to enhance learning Teaching the most important information at the end of the session to maximize retention

Customizing teaching objectives based on the learners interest +

A patient who is recovering from a myocardial infarction may benefit from meditation because this technique: Decreases sympathetic nervous system activity Decreases vasodilation Increases sympathetic nervous system activity Increases the release of catecholamines

Decreases sympathetic nervous system activity+

A client with a hiatal hernia has been taking magnesium hydroxide for relief of heartburn. Overuse of magnesium-based antacids can cause The client to have: Constipation Anorexia Diarrhea Weight gain

Diarrhea

The nurse is caring for a client with an ileostomy. The nurse should play pay careful attention to care around the stoma because: Stools are less watery and contain more solid matter It is difficult to fit the appliance to the stoma site The stoma will heal more slowly than expected Digestive enzymes cause skin breakdown

Digestive enzymes cause skin breakdown

A patient had an open reduction with internal fixation for a compound fracture of the left tibia and has been placed in a long leg cast the assessments by the nurse are left foot warm/pink pedal pulse weaker than right capillary refill three seconds and small 1 cm area of blood on cast what should the nurse do? Notify charge nurse of impending compartment syndrome Document that all assessments are within normal limits Inform charge nurse about probable hemorrhage Place warm compresses on left foot

Document that all assessments are within normal limits

Which of the following diet instruction should be given to the client with the recurrent urinary tract infections? Perform Peri care with hydrogen peroxide increase intake of meats Drink a glass of cranberry juice every day avoid citrus fruits

Drink a glass of cranberry juice every day

A female client is suspected of having a pulmonary embolus. A nurse assesses the client knowing that which of the following is a common clinical manifestation of pulmonary embolism? Dyspnea Bradypnea Bradycardia Decreased respiratory

Dyspnea

The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? Select all that apply Eat high fiber diet Increase fluid intake Elevate the HOB after eating Walk30minaday Take an antacid every 2 hrs

Eat high fiber diet + Increase fluid intake + Walk30minaday+

The nurse is caring for a client who had a cerebrovascular accident(CVA) . Which nursing intervention promotes urinary incontinence? Encouraging intake of at least 2 L of fluid daily Giving the client a glass of soda before bedtime Taking the client to the bathroom twice per day Consulting with a dietitian

Encouraging intake of at least 2 L of fluid daily+

Before seeing a newly assigned female client with respiratory alkalosis the nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? Extreme anxiety Narcotic overdose Type 1 diabetes mellitus Myasthenia gravis

Extreme anxiety

The cardiac-vascular nurse reviews recommended activities with a patient who sustained a myocardial infarction. The patient states it doesn't really matter what i do or don't do i will either get better or die. This statement reflects: Acceptance of change health status An internal locus of control Feeling of loss of control Projection

Feeling of loss of control

A male a male client is admitted for treatment of glomerulonephritis on initial assessment the nurse detects one of the classic signs of acute glomerulonephritis of sudden onset such signs include: Generalized edema especially of the face and Periorbital area Green tinged urine Moderate to severe hypotension Polyuria

Generalized edema especially of the face and Periorbital area+

The nurse is preparing to give an oral potassium supplement the nurse should: Give the medication with 4 ounces of juice Give the medication on an empty stomach Give the medication with water only Give the medication without diluting it

Give the medication with 4 ounces of juice

As the cardiac-vascular nurse prepares to administer an experimental cardiac drug to a patient who is participating in a research study. The patient states that he or she no longer wants the medication the nurse advises the patient that: He or she has a right to refuse the medication and to withdraw from the study Participation in the study is critical to improving the quality of patient outcomes The mediction dose has been schedueled for administration The primary investigator will speak with the patient about his or her decision

He or she has a right to refuse the medication and to withdraw from the study +

The public nurse is teaching day care workers, which type of hepatitis is transmitted by the fecal oral route via contaminated food, water, or direct contact with an infected person? Hepatitis A Hepatitis B Hepatitis C Hepatitis D

Hepatitis A +

The nurse is providing dietary teaching for a client with Ménière's disease. Which statement indicates that the client understands the role of diet in triggering her symptoms? I can expect to see more problems with tinnitus if I eat a lot of dairy products I can help control problems with free to go if I avoid bread and cereals I need to limit foods that taste salty or that contain a lot of sodium I need to eat fewer foods that are high in potassium such as raisins and bananas

I need to limit foods that taste salty or that contain a lot of sodium

A male client is admitted to the healthcare facility for a treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client? Risk for infection related to retained secretions Anxiety related to actual threat to health status Impaired gas exchange related to airflow obstruction Activity intolerance related to fatigue

Impaired gas exchange related to airflow obstruction+

Excessive alcohol use while on warfarin (Coumadin) therapy leads to: Decrease anticoagulation effect Decreased internal normalized ratio Increased anticoagulation in effect Increased vitamin K absorption

Increased anticoagulation in effect +

Examination of a patient in supine position reveals distended jugular veins from the base of the neck to the angle of the jaw. This finding indicates: Decreased venous return Increased central venous pressure Increased pulmonary artery capillary pressure Left-sided heart failure

Increased central venous pressure

The nurse working on a medical surgical floor feels a pull in the back when lifting a client up in bed which should be the first action taken by the nurse ? Continue working until the shift is over and then try to sleep on the heating pad Go immediately to the emergency department for treatment and muscle relaxants Inform the charge nurse and the nurse manager on duty and document the occurrence See a private healthcare provider on the nurses off time but charge the hospital

Inform the charge nurse and the nurse manager on duty and document the occurrence

A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching? Inhales the mist and quickly exhales Removes the cap and shakes the inhaler well before use Presses the canister down with the finger as he breathes in Waits 1 to 2 minutes between puffs if more than one puff has been prescribed

Inhales the mist and quickly exhales

What should the nurse do when a patient with osteomyelitis is admitted with an open wound that is draining? Enforce the low calorie diet Initiate drainage and secretion precautions Frequently do passive range of motion on the elbow Ambulate several times daily

Initiate drainage and secretion precautions

A patient who underwent a percutaneous transluminal coronary angioplasty four weeks ago a subsequent ejection fraction of 30% the patient returns for a follow-up visit. Examination reveals lungs that are clear to auscultation and slight pedal edema edema the patients medications are digoxin (lanoxin), furosemide (lasix), enalapril meleate (vasotec) and aspirin the patient reports a 5-LB weight gain over the past two days the cardiac-vascular nurse's initial action is to : Document the weight and reassess the patient at the next session Inquire about the patients medications compliance Notify the patients physician Review the patients most recent nuclear scan

Inquire about the patients medications compliance +

The primary cause of anemia in a client with chronic renal failure is: Destruction of red blood cells Poor iron absorption Lack of intrinsic factor Insufficient erythropoietin

Insufficient erythropoietin

While the cardiac vascular nurse preceptor is orienting a graduate nurse on the telemetry unit a patient experiences cardiac arrest which action by the preceptor during the emergency cardiac care procedure facilitates the graduate nurses competence and professional development? Asking the graduate nurse to review the policy and procedure for cardiac arrest Assigning the graduate nurse to comfort the family during the arrest Directing the graduate nurse to attempt IV access Involving the graduate nurse in the resuscitation by assigning a basic task

Involving the graduate nurse in the resuscitation by assigning a basic task +

In an assessment for intermittent claudication the cardiovascular nurse assesses for leg pain and cramping with exertion then ask the patient: Does shortness of breath accompany the leg pain Does this same pain occur without activity Is the leg pain relieved by rest s the leg pain relieved with elevation

Is the leg pain relieved by rest

The nurse is teaching a client with emphysema how to perform pursed lip breathing. The client asked the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? It prolongs the inspiratory phase of respiration It increases inspiratory muscles strength It decreases use of accessory breathing muscles It helps prevent early airway collapse

It helps prevent early airway collapse +

The doctor has prescribed aspirin 325 MG daily for a client with transient ischemic attacks. The nurse knows that aspirin was prescribed to: Boost Coagulation Prevent cerebral anoxia Keep platelets from clumping together Prevent headaches

Keep platelets from clumping together +

For a male client in the oliguric phase of acute renal failure which nursing intervention is most important? Encouraging coughing and deep breathing Promoting carbohydrate intake Limiting fluid intake Providing pain relief measures

Limiting fluid intake

The nurse is monitoring the fluid intake and output of a female client recovering from an exploratory laparotomy. Which nursing intervention would help the client avoid a urinary tract infection (UTI)? Maintaining a closed indwelling urinary catheter system and securing the catheter to the leg Limiting fluid intake to 1 L/day Encouraging the client to use a feminine deodorant after bathing Encouraging the client to douche once a day after removal of the indwelling urinary catheter

Maintaining a closed indwelling urinary catheter system and securing the catheter to the leg +

For a male client who has a chest tube connected to a closed water seal drainage system, the nurse should include which action in the plan of care? Keeping the collection chamber at chest level Stripping the chest tube every hour Measuring and documenting the drainage in the collection chamber Maintaining continuous bubbling in the water seal chamber

Measuring and documenting the drainage in the collection chamber

The doctor has prescribed a diet high in vitamin B 12 for a client with pernicious anemia. Which foods are highest in B12 call? Meat, eggs, dairy products Peanut butter, raisins, molasses Shrimp, legumes, bran cereal Broccoli, cauliflower, cabbage

Meat, eggs, dairy products

When removing the dressing on a patient the nurse discovers that the gauze dressing has adhered to the wound what intervention should the nurse implement? Call the RN Gently remove the gauze with sterile forceps Cover with occlusive dressing Moisten the dressing with sterile water

Moisten the dressing with sterile water

The nurse is caring for a client with the right total knee repair. Which intervention should the nurse implement? Monitor the continuous passive motion machine Apply thigh high TED hose bilaterally Place the abductor pillow between the legs Encourage the family to perform ADLs for the client

Monitor the continuous passive motion machine+

A black male client with asthma six emergency care for acute respiratory distress because of this clients dark skin the nurse should assess for cyanosis by inspecting the: Nail Beds Earlobes Lips Mucous membranes

Mucous membranes +

A male client abruptly sit up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? Face tent Simple mask Non-rebreather mask Nasal cannula

Non-rebreather mask +

The client diagnosed with osteoarthritis is prescribed an oral nonsteroidal anti-inflammatory drug. Which instruction should the nurse teach the client? Take the medication on an empty stomach Make sure to taper the medication when discontinuing Apply the medication topically over the affected joints Notify the HCP if vomiting blood

Notify the HCP if vomiting blood

Nurse Joy is providing post procedural care for a client who underwent percutaneous lithotripsy in this procedure an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra high frequency sound waves to shatter renal calculi the nurse should instruct the client to: Limit oral fluid intake for 1 to 2 weeks Report the presence of find sound like particles through the nephrostomy tube Notify the physician about cloudy or foul smelling urine Report bright pink urine within 24 hours after the procedure

Notify the physician about cloudy or foul smelling urine

The nurse is caring for a client diagnosed with a fracture of the right distal humerus which data indicates a complication? Select all that apply Numbness and mottled cyanosis Paresthesia and paralysis Próximal pulses and point tenderness Coldness of the extremity and crepitis Palpable radial pulse and functional movement

Numbness and mottled cyanosis + Paresthesia and paralysis + Coldness of the extremity and crepitis +

A patient with negative troponins and stress test results reports recurrent chest pain that is similar to the patient's pain on admission according to the American nurses association's cardiovascular nursing scope and standards of practice the cardiac vascular nurses next action is to: Activate the cardiac catheterization team Administer analgesics Obtain a 12 lead electrocardiogram Promote relaxation and monitor the response

Obtain a 12 lead electrocardiogram+

The client with iron deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with: Orange juice Milk Water only Apple juice

Orange juice

Which statement best describes the difference between the pain of angina and the pain of myocardial infarction? Pain associated with myocardial infarction is referred to the left arm Pain associated with angina is relieved by rest Pain associated with myocardial infarction is always more severe Pain associated with angina is confined to the chest area

Pain associated with angina is relieved by rest

A nurse working on the surgical unit notices a patient is experiencing SOB calf pain and warmth over the posterior calf. All of these may indicate which of the following medical conditions? Patient may have DVT patient may be exhibiting signs of dermatitis patient may be experiencing anxiety after surgery patient may be in the late phases of CHF

Patient may have DVT

What is the large fan shaped muscle that covers the anterior chest from the sternum to the proximal end of the humerus and acts on the joint of the shoulder to flex, adduct and rotate? Serratus anterior Intercostal Transverse abdominis Pectoralis major

Pectoralis major

The nurse is caring for a client with an above the knee amputation to prevent contractions the nurse should: Place the client in a prone position 15-30 minutes twice a day Keep the foot of the bed elevated on Shock Blocks Put trochanter rolls on either side of the affected leg Keep the clients leg elevated on two pillows

Place the client in a prone position 15-30 minutes twice a day +

The nurse is caring for a male client with a chest tube. If the chest strange system is accidentally disconnected what should the nurse plan to do? Place the end of the chest tube in a container of sterile saline Apply an occlusive dressing and notify the physician Secure the chest tube with tape Clamp the chest tube immediately

Place the end of the chest tube in a container of sterile saline +

A male elderly client is admitted to an acute care facility with influenza. The nurse monitors the client closely for complications. What is the most common complication of influenza? Septicemia Pneumonia Pulmonary edema Meningitis

Pneumonia

What should the nurse include in the plan of care for a patient following myelogram? Position in a semi-Fowlers position for eight hours to reduce potential of headache lays patient flat on back to compress puncture site ambulate for brief periods to lessen post myelogram headache limit fluids to increase absorption of the dye

Position in a semi-Fowlers position for eight hours to reduce potential of headache

A 22-year-old man is admitted to the hospital with complaints of fatigue and weight loss. Physical examination reveals pallor and multiple bruises on his arms and legs. The results of the patient's test reveal acute lymphocytic leukemia and thrombocytopenia: which of the following nursing diagnoses MOST accurately reflects this condition? Potential for injury Self-care deficit Potential for self harm Alteration in comfort

Potential for injury+

During a clinic appointment a patient states I came in because my calcium score was positive on my computed tomography scan last week in which section of the patient's assessment does the cardiac vascular nurse document this finding? Past medical history Personal/social history Presenting problem Review of symptoms

Presenting problem+

The nurse explains to a patient who has had a knee replacement that warfarin(coumadin) is ordered to: Increase the red blood cells Reduce the threat of hemorrhage Prevent formation of emboli Help stabilize the prosthesis

Prevent formation of emboli

A client with a history of emboli is receiving Lovenox (enoxaparin). Which drug is given to counteract the effects of enoxaparin? Calcium gluconate Aquamephyton Methergine Protamine sulfate

Protamine sulfate

A male client with chronic renal failure has a serum potassium level of 6.8 MEQ/L. What should the nurse assess first? Blood pressure Respirations Temperature Pulse

Pulse+

A patient recently had a cardiac catheterization via right radial approach the patient has a compression device in place the patient complains of numbness and pain in the right hand the cardiac fascicular nurse notes a diminished pulse with equal and cyanotic and the nurse: Calls the physician Performs and Allen's test Reduces the pressure on the puncture site Uses a Doppler to assess for pulse signals

Reduces the pressure on the puncture site +

The client is 4 hrs postoperative open cholecystectomy. Which data warrants immediate intervention by the nurse? Absent bowel sounds in all 4 quadrants The T-tube has 60ml of green drainage Urine output has 100ml in the past 3 hrs Refusal to turn, deep breath, and cough

Refusal to turn, deep breath, and cough +

What should the nurse instruct the patient before a magnetic resonance imaging MRI procedure? Void completely Omit all citrus food for 12 hrs before the procedure Remove all metal such as jewelry glasses and hair clips Wear only cotton garments for the procedure

Remove all metal such as jewelry glasses and hair clips

A client with angina has an order for nitroglycerin ointment before applying the medication the nurse should: Remove the previously applied ointment Obtain both a radial and an apical pulse Tell the client he will experience pain relief in 15 minutes Apply the ointment to the previous application

Remove the previously applied ointment

The client has full thickness burns to 65% of the body including the chest area after establishing a patent airway which collaborative intervention is priority for the client? Replace fluids and electrolytes prevent contractures of extremities monitor urine output hourly prepare to assist with escharotomy

Replace fluids and electrolytes

efore administering a nasogastric feeding to a client hospitalized following a CVA, the nurse aspirated 40 ml of residual. The nurse should: Replace the aspirate and withhold the feeding Discard the aspirate and withhold the feeding Replace the aspirate and administer the feeding Discard the aspirate and begin the feeding

Replace the aspirate and administer the feeding

A patient has been receiving a heparin IV for the last three days the patient's most current platelet count is 65,000×10^3/ uL The platelet count on admission was 350,000 the cardiac vascular nurse contact the physician to: Report that the medication level is subtherapeutic Report that the patient is exhibiting signs of an adverse reaction Request an increase in the medication infusion Rate request in order for platelet transfusion

Report that the patient is exhibiting signs of an adverse reaction +

The nurse administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? Heart rate of 100 beats/minute Urine output of 40ml/hour Respiratory rate of 22 breaths/minute Dilated and reactive pupils

Respiratory rate of 22 breaths/minute

Nurse Erica is planning to administer a sodium polystyrene sulfonate (kayexalate) enema to a client with a potassium level of 5.9 MEQ/L correct administration and the effects of this animal would include having the patient client: Retained enema for 30 minutes to allow for sodium exchange afterward the client should have diarrhea Retained enema for 30 minutes to allow for the glucose exchange after with the client should have diarrhea Retained enema for 60 minutes to allow for sodium exchange diarrhea isn't necessary to reduce the potassium level Retain the animal for 60 minutes to allow for glucose exchange diarrhea isn't necessary to reduce the potassium level

Retained enema for 30 minutes to allow for sodium exchange afterward the client should have diarrhea +

How is rheumatoid arthritis distinguished from osteoarthritis? Rheumatoid arthritis is an autoimmune systemic disease osteoarthritis is a degenerative disease of the joints Rheumatoid arthritis is an autoimmune degenerative disease osteoarthritis is a systemic inflammatory disease People with osteoarthritis are considered to be genetically predisposed there is no known genetic component to rheumatoid arthritis Osteoarthritis is often caused by a virus. Viruses play no part in the pathogenesis of rheumatoid arthritis.

Rheumatoid arthritis is an autoimmune systemic disease osteoarthritis is a degenerative disease of the joints

Which of the following meal selections is appropriate for the client with celiac disease? Rice crispy bar and milk Cheese pizza and Kool-Aid Peanut butter cookies and milk Toast jam and apple juice

Rice crispy bar and milk

The nurse is aware that the following is an appropriate nursing diagnosis for a client with renal calculi? Ineffective tissue perfusion Functional urinary incontinence Risk for infection Decreased cardiac output

Risk for infection +

The day following surgery the nurse notes bloody drainage on the dressing how will the nurse describe this drainage when documenting Serosanguineous Sanguineous Serous Purulent

Sanguineous

Which is the primary consideration when preparing to administer thrombolytic therapy to a patient who is experiencing an acute myocardial infarction ? History of heart disease Sensitivity to aspirin Size and location of the MI Time since onset of symptoms

Size and location of the MI +

The nurse enters the room of the client diagnosed with CHF. The client is laying in bed gasping for breath. It is cool and clammy and has buccal cyanosis. Which intervention would the nurse implement first? Sponge the clients forehead Obtain a pulse oximetry reading Take the client's vital signs Assist the client into sitting position

Sponge the clients forehead +

which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? Airborne precaution Standard precaution Droplet precaution Exposure precautions

Standard precaution +

The nurse is providing dietary teaching for a client with gout. Which dietary selection is suitable for the client with gout? Baked chicken, pasta salad, asparagus casserole Steak, baked potato, tossed salad Broiled liver, macaroni and cheese, spinach Stuffed crab, steamed rice, peas

Steak, baked potato, tossed salad

A client with oxalate renal calculi should be taught to avoid eating: Strawberries Apples Oranges Pears

Strawberries

What technique will the nurse implement to assist the postoperative patient to cough. Support the Patients back Offer an antitussive Splint the abdomen with a pillow Lean patient against bedside table

Support the Patients back

A postoperative client has an order for Demerol (meperidine) 75 mg and Phenergan (promethazine) 25 mg IM every 3 to 4 hours as needed for pain the combination of the two medications produces a/an: Synergistic effect Antagonist effect Agonist effect Excitatory effect

Synergistic effect

What should the nurse include in the teaching plan for a patient who is taking alendronate(fosamax)? Take the drug with any meal Take drug first thing in the morning Drink at least 5 ounces of milk before taking the drug Take drug with an antacid to avoid heartburn

Take drug first thing in the morning

The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should: Tell the client that she can resume a regular diet in the next 24 hours Tell the client to avoid a tub bath for 48 hours Tell the client she can expect lower abdominal pain for the next week Tell the client to expect clay colored stools

Tell the client to avoid a tub bath for 48 hours +

The physician has ordered a blood test for H. pylori the nurse should prepare the client by: Giving an oral suspension of glucose one hour before the test Telling the client that no special preparation is needed Explaining that a small dose of radioactive isotope will be used With holding intake after midnight

Telling the client that no special preparation is needed

The nurse on the telemetry unit has just received the A.M. shift report. Which client should the nurse assess first? The client diagnosed with myocardial infarction who has an audible S3 heart sound The client diagnosed with congestive heart failure who has +4 sacral pitting edema The client diagnosed with pneumonia who has a pulse oximeter reading of 94% The client with chronic renal failure who has an elevated creatinine level

The client diagnosed with myocardial infarction who has an audible S3 heart sound +

When a female client with an indwelling urinary Foley catheter insists on walking to the hospital lobby to visit with family members the nurse teaches how to do it without compromising the catheter. Which client action indicates an accurate understanding of this information? The client sets the drainage bag on the floor while sitting down The client keeps the drainage bag below the bladder at all times The client clamps the catheter drainage tubing while visiting with family The client loops the drainage tubing below its point of entry into the drainage bag

The client keeps the drainage bag below the bladder at all times +

The nurse should visit which of the following clients first? The client with hypertension being maintained on lisinopril A client with diabetes with a blood glucose of 95 mg/DL The client with chest pain and a history of angina the client with Raynaud's disease

The client with chest pain and a history of angina

The physician scheduled a Whipple procedure for a client with pancreatic cancer nurse recognizes that the clients cancer is located in: The head of the pancreas The tail of the pancreas The entire pancreas The body of the pancreas

The head of the pancreas

Which action by the nurse indicates understanding of the herpes Zoster? The nurse wears gloves when providing care the nurse administers a prescribed antibiotic the nurse administers oxygen the nurse covers the lesions with a sterile dressing

The nurse wears gloves when providing care

A male client with bladder cancer has had the bladder removed and an ileal conduit created for urine diversion while changing this client pouch the nurse observes that the area around the stoma is red weeping and painful. What should the nurse conclude? The skin wasn't lubricated before the pouch was applied The pouch faceplate doesn't fit the stoma A skin barrier was applied properly Stoma dilation wasn't performed

The pouch faceplate doesn't fit the stoma +

The amount of air inspired and expired with each breath is called: Dead space volume Tidal volume Vital capacity Residual volume

Tidal volume

A physician has ordered aspirin therapy for a client with severe rheumatoid arthritis. A sign of acute aspirin toxicity is: Pruritus Anorexia Tinnitus Diarrhea

Tinnitus

A 55-year-old client with benign prostatic hyperplasia doesn't respond to medical treatment and is being admitted to the facility for prostate gland removal before providing preoperative and postoperative instructions to the client the nurse asks the surgeon which prostatectomy procedure will be done what is the most widely used procedure for prostate gland removal? Transurethral resection of the prostate (TURP) Suprapubic prostatectomy Retropubic prostatectomy Tranurethral incision of the prostate

Transurethral resection of the prostate (TURP)+

Which signs and symptoms should the nurse expect to find in a client diagnosed with ulcerative colitis? Twenty bloody stools a day Oral temperature of 102 F Hard rigid abdomen Urinary stress incontinence

Twenty bloody stools a day

A 65-year-old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient? Upon admit preoperative discussion within 48 hours of discharge following surgery

Upon admit

Is the nurse aware that the following statements describing urinary incontinence in the elderly is true? Urinary incontinence is a normal part of aging Urinary incontinence isn't a disease Urinary incontinence in the elderly cat retreated Urinary incontinence is a disease

Urinary incontinence isn't a disease +

A female adult client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. Which assessment finding suggests that the client is experiencing acute renal failure? Blood urea nitrogen (BUN) level of 22 MG/DL Serum creatinine level of 1.2 MG/DL Serum creatinine level of 1.2 MG/DL Urine output of 400 mL/24 hours

Urine output of 400 mL/24 hours

The nurse is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal? Pacific gravity of 1.03 Urine pH of 3.0 Absence of protein Absence of glucose

Urine pH of 3.0 +

Pulmonary disease (COPD) which nursing action best promotes adequate gas exchange? Using a high flow Venturi mask to deliver oxygen as prescribed Keeping the client in semi-Fowler's position Administering a sedative as prescribed Encouraging the client to drink three glasses of fluid

Using a high flow Venturi mask to deliver oxygen as prescribed +

A 55yo patient who is diagnose with an evolving myocardial infarction insists on going home. The cardiac-vascular nurse encourages the patient to be admitted because the greatest risk within the first 24hrs of sustaining an MI is: Heart failure Pulmonary embolism Ventricular aneurysm Ventricular fibrillation

Ventricular fibrillation

When caring for a patient who has intermittent claudication the cardiac-vascular nurse advises the patient to: Apply graduated compression stockings before getting out of bed Elevate the legs when sitting Refrain from exercise Walk as tolerated

Walk as tolerated

A female client is admitted for treatment of chronic renal failure nurse Juliet knows that this disorder increases the clients risk of: Water and sodium retention secondary to a severe decrease in the glomerular filtration rate A decreased serum phosphate level secondary to kidney failure An increase serum calcium level secondary to kidney failure A metabolic alkalosis secondary to retention of hydrogen ions

Water and sodium retention secondary to a severe decrease in the glomerular filtration rate +

The nurse is caring for a client with a history of diverticulitis. The client complains of abdominal pain, fever, and diarrhea. Which food was responsible for the client's symptoms? Whole grain cereal Mashed potatoes Baked fish Steamed carrots

Whole grain cereal

A female client with an in dwelling urinary catheter is suspected of having a urinary tract infection and they should collect a urine specimen for culture and sensitivity by: Discuss connecting the tubing from the urinary catheter and letting the urine flow into a sterile container Wiping the self sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle Draining urine from the drainage bag into a sterile container Clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine

Wiping the self sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle +

Before administering a clients morning dose of Lanoxin (digoxin) the nurse checks the apical pulse rate and find the rate of 50 for the appropriate nursing intervention is to: administer the medication and monitor the heart rate Withhold the medication until the heart rate increases Record the pulse rate and administer the medication Withhold the medication and notify the doctor

Withhold the medication and notify the doctor

The client with full thickness burns to 40% of the body including both legs is being transferred from a community Hospital to burn center which measures should be initiated before the transfer A 22 gauge intravenous line with normal saline infusion once covered with moist sterile dressing no intravenous pain medication ensure adequate peripheral blood circulation to both feet

adequate peripheral blood circulation to both feet

The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is to: alleviate pain facilitate mobility prevent nausea prevent addiction

alleviate pain

The recommended time for administering Zantac (ranitidine) is: mid afternoon after dinner before breakfast at bedtime

at bedtime

A patient comes to the emergency department with Reports of swollen and painful leg but denies sustaining an injury physical examination reveals a tense calf muscle decreased in session to the foot and leg and absent pedal pulses the cardiac vascular nurse asked the patient when the symptoms began because: a. A compartment syndrome develops days after an arterial occlusion b. An arterial thrombosis is sudden and emergent and an embolism develops gradually c. irreversible anoxic injury to muscles and nerves can occur in as few as four hours d. Metabolic alkalosis for muscle swelling is cardiotoxic

c. irreversible anoxic injury to muscles and nerves can occur in as few as four hours +

A client is receiving pyridium for urinary tract infection the client should be taught that the medication may: cause diarrhea change the color of her urine cause changes in taste cause mental confusion

change the color of her urine

A patient is getting discharged from a sniff facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breathe easily. Which of the following should be the best instruction for this patient? Decreased CO2 levels by increase oxygen intake output during meals cough following bronchodilator utilization cough regularly and deeply to clear airway passages deep breathing techniques to increase O2 levels

cough following bronchodilator utilization

The client comes in to the emergency department in severe pain and reports that a pot of boiling water accidentally spilled on his lower leg the assessment reveals blistered multiple red skin and both feet are edematous which step of burn should the nurse document a.Superficial partial thickness b.deep partial thickness c.full thickness d.first degree

deep partial thickness +

The nurse is admitting a client with a suspected duodenal ulcer the client will most likely report that his abdominal discomfort lessens when he: Sits up right after eating Rests in recumbent position skips a meal eats a meal

eats a meal

Gina, a home health nurse, is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? Delirium hypoxia Semiconsciousness Hyperventilation

hypoxia +

Which food should the home health nurse suggest for the patient with osteoporosis to help slow the disease? leafy green vegetables Foods high in sodium Tea and coffee Vitamin A

leafy green vegetables

The client with a pacemaker should be talked to: refrain from using a microwave oven monitor his pulse rate check his blood pressure daily report ankle edema

monitor his pulse rate

Which of the following test should be performed before beginning a prescription of Accutane? Obtain a creatinine level perform a pregnancy test monitor apical pulse check the calcium level

perform a pregnancy test

A client is admitted for an MRI the nurse should question the client regarding: allergies to antibiotics A titanium hip replacement pregnancy ability to move his feet

pregnancy

A 25-year-old is diagnosed with a topic dermatitis nursing interventions will focus on: administering antipyretics preventing infection keeping the skin free of moisture limiting oral fluid intake

preventing infection

The primary physiological alteration in the development of asthma is: hyper secretion of abnormally viscous mucus bronchiolar inflammation and dyspnea infectious process is causing mucosal edema spasm of bronchiolar smooth muscle

spasm of bronchiolar smooth muscle

As per phone screening on a patient that has been casted recently on the left lower extremity which of the following statements of the nurse be most concerned about? The patient reports I didn't keep my extremity elevated like the doctor asked me to the patient reports I have been having pain in my left half the patient reports the arthritis in my wrist is firing up when I put weight on my crutches the patient reports my left leg has really been itching

the patient reports my left leg has really been itching

A client with a deep did the cutest ulcer is receiving therapy in the hyperbaric oxygen chamber before therapy the nurse should: cover the area with the petroleum gauze apply a lanolin based lotion to the skin wash the skin with water and pat dry apply an occlusive dressing to the site

wash the skin with water and pat dry