The End

A nurse is teaching a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? (Select all that apply.) - Refined cereals - Lean turkey - Blackberries - Kidney beans - Whole wheat bread

- Blackberries - Kidney beans - Whole wheat bread

A nurse is planning care for a client who requires screening for rectal cancer. Which of the following tests should the nurse anticipate in the client's plan of care? - Upper Gl series - Colonoscopy - Upper Gl endoscopy - Endoscopic retrograde cholangiopancreatography (ERCP)

- Colonoscopy

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? - "DIC is caused by abnormal coagulation involving fibrinogen." - "DIC is characterized by an elevated platelet count." - "DIC is a genetic disorder involving a vitamin K deficiency." - "DIC is controllable with lifelong heparin usage."

- "DIC is caused by abnormal coagulation involving fibrinogen."

A nurse is teaching a 12-year-old child who is newly diagnosed with asthma about managing the condition to prevent asthma attacks. Which of the following statements by the child should indicate to the nurse that the teaching has been effective? - "Eliminating allergens that irritate my lungs can help me avoid getting an asthma attack." - "If I don't control my asthma I will miss fewer days of school." - "Coughing and shortness of breath in the morning can be a sign that my asthma is well controlled." - "Even if I control my asthma well, I won't be able to participate in sports or physical activities.

- "Eliminating allergens that irritate my lungs can help me avoid getting an asthma attack."

A nurse is reinforcing discharge teaching with a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? - "I should take ibuprofen for my joint pain" - "I'm thankful that this type of lupus only affects the skin" -"Each day I should apply a sunblock with a sun protector factor of 15" - " A mild fever is common with SLE and usually does not require medical intervention"

- "I should take ibuprofen for my joint pain"

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching? - "I will use both medications immediately after exercising." - "I will be sure to take the albuterol before taking the cromolyn." - "I will administer the medications 10 minutes apart." - "If my breathing begins to feel tight, I will use the cromolyn immediately."

- "I will be sure to take the albuterol before taking the cromolyn."

A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate? - "Use simple, child-like statements when speaking - "Ask multiple choice questions as part of the conversation." - "Use a higher-pitched tone of voice when speaking." - "Incorporate nonverbal cues in the conversation."

- "Incorporate nonverbal cues in the conversation."

A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective? - "My partner should cough while swallowing food." - "My partner should place their food on the weaker side of their mouth when eating." - "My partner should sit at a 30° angle while eating their meals." - "My partner should tilt their head forward when swallowing."

- "My partner should tilt their head forward when swallowing."

A nurse is evaluating teaching on a client who has a new prescription for montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching? - "Will take this medication once a day in the evening." - "I'll take this medication when I get an asthma attack." - "Will use a spacer device when inhaling this medication." - "I'll rinse my mouth after taking this medication."

- "Will take this medication once a day in the evening."

A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take? - Administer a short-acting B2 -agonist (SABA). - Administer an inhaled glucocorticoid. - Determine the cause of the acute exacerbation. - Obtain a peak flow reading

- Administer a short-acting B2 -agonist (SABA).

A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). Which of the following actions should the nurse plan to take? - Perform vibration during the client's inspirations. - Administer albuterol prior to CPT. - Perform CPT immediately after the child eats. - Percuss each lung segment for 15 min.

- Administer albuterol prior to CPT.

A nurse is caring for a child who has asthma and a prescription for montelukast granules. Which of the following instructions should the nurse provide the client's parent on administering the medication? - Administer the medication 2 hr before exercise. - Give the medication at the onset of wheezing. - Administer the granules mixed with 20 oz of water. - Give the medication in the morning daily.

- Administer the medication 2 hr before exercise.

A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms? - Cromolyn via metered-dose inhaler - Budesonide via dry-powder inhaler - Albuterol via jet nebulizer - Montelukast orally

- Albuterol via jet nebulizer

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve ll? - Ask the client to read a Snellen chart. - Listen to the client's speech. - Ask the client to identify scented aromas - Ask the client to clench his teeth.

- Ask the client to read a Snellen chart.

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? - Increase the oxygen flow to 3 L/min. - Assess the client's respiratory status. - Have the client cough and expectorate secretions. - Call emergency services for the client.

- Assess the client's respiratory status.

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan? - Include foods high in starch and proteins. - Include foods high in fiber. - Avoid foods high in fat. - Avoid foods high in sodium.

- Avoid foods high in fat.

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? - Pigeon - Barrel - Funnel - Kyphotic

- Barrel

A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse include? - Both require frequent surgery - Both begin in the rectum - Both manifest fistula formation - Both are inflammatory

- Both are inflammatory

A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia? - Intestinal malabsorption syndrome - Chronic blood loss - Dietary iron restrictions - Intestinal parasites

- Chronic blood loss

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? - Reposition the client toward the left side. - Immediately notify the provider. - Continue to monitor the client. - Clamp the chest tube near the water seal.

- Continue to monitor the client.

A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention? - Continuous bubbling in the suction control chamber - Development of subcutaneous emphysema - Presence of tidal fluctuation in the water seal chamber - Chest tube eyelets not visible

- Continuous bubbling in the suction control chamber

A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? - Fluctuations in the fluid level in the water-seal chamber - Continuous bubbling in the water-seal chamber - Constant bubbling in the suction-control chamber - Occasional bubbling in the water-seal chamber

- Continuous bubbling in the water-seal chamber

A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors? - Greenish-brown - Dark and foamy - Pale yellow - Red

- Dark and foamy

A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect? - Decreased bowel sounds - Rigid abdomen - Hypothermia - Dehydration

- Dehydration

A nurse is completing dietary teaching on consuming a low fiber diet with a client who has ulcerative colitis. Which of the following foods should be eliminated in the client's diet? - Ripe bananas - Cooked cabbage - Ice cream - Dried apricots

- Dried apricots

A nurse is assessing a client who has a pleural effusion. Which of the following findings should the nurse expect? - Crackles auscultated over the client's lung fields. - Crepitus palpated on the clients chest. - Dullness percussed over the client's lung fields. - Substernal retractions noted on the client's chest.

- Dullness percussed over the client's lung fields.

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions? - Radiofrequency catheter ablation - CPR - Defibrillation - Elective cardioversion

- Elective cardioversion

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? - Place food in the affected side of the mouth. - Place the client with the head reclined back to facilitate swallowing. - Encourage brief exercise before meals to promote appetite. - Encourage the client to take small bites.

- Encourage the client to take small bites.

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? - Maintaining a semi-Fowler's position as often as possible - Administering oxygen via nasal cannula at 2 Limin - Helping the client select a low-salt diet - Encouraging the client to drink 2 to 3 L of water daily

- Encouraging the client to drink 2 to 3 L of water daily

A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next? - Ensure the client has been taking their prescribed diuretic. - Document the findings and continue with the visit. - Reinforce the importance of daily weights. - Call the health care provider for further instructions.

- Ensure the client has been taking their prescribed diuretic.

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? - Methylprednisolone - Furosemide - Epinephrine - Dobutamine

- Epinephrine

A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should Instruct the client to notify the provider about which of the following manifestations? - Increased urine output - Rapid pulse - Sneezing - Fatigue

- Fatigue

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect? - Fatty stools - Tenderness in the left upper abdomen - Straw-colored urine - Ecchymosis of the extremities

- Fatty stools

A nurse is caring for a client who reports having chronic constipation. Which of the following herbal supplements should the nurse recommend? - Cranberry juice - Flaxseed - Ginseng - Coenzyme Q-10

- Flaxseed

A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level? - Nitroglycerin - Spironolactone - Metoprolol - Furosemide

- Furosemide

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include? - History of smoking - History of hypertension - Obesity - Genetics

- Genetics

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? - Abdominal distension - Jugular venous distention - Dependent edema - Hacking cough

- Hacking cough

A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat chemotherapy-induced nausea. For which of the following adverse effects should the nurse monitor? - Headache - Polyuria - Dependent edema - Photosensitivity

- Headache

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings? - Intellectual impairment - Impaired sense of humor - Loss of depth perception - Poor judgment

- Impaired sense of humor

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? - Inability to recognize his family members - Aphasia - Right hemiparesis - Difficulty reading

- Inability to recognize his family members

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? - Increased anteroposterior diameter of the chest - Oxygen saturation level 96% - Respiratory alkalosis - Petechiae on chest

- Increased anteroposterior diameter of the chest

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective? - Decreased blood glucose level - Increased heart rate - Decreased blood pressure - Increased urine output

- Increased urine output

A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. Which of the following actions should the nurse take? (Select all that apply.) - Administer an analgesic prior to the procedure. - Keep the client NPO after midnight. - Inspect the electrode pads. - Wash the skin with plain water before placing the electrodes. - Instruct the client not talk during the test.

- Inspect the electrode pads. - Wash the skin with plain water before placing the electrodes. - Instruct the client not talk during the test.

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? - Have the client use the early-morning hours for exercise and activity. - Provide the client with a low-protein diet. - Restrict the client's fluid intake to less than 2 L/day. - Instruct the client to use pursed-lip breathing.

- Instruct the client to use pursed-lip breathing.

A nurse is collaborating on care for a client who has COPD. Which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance? - Instructing how to measure oxygen saturation - Instruction how to plan a diet based on individual caloric needs - Instructing how to use kitchen tools to prepare a meal - Instructing how to perform pursed lip breathing

- Instructing how to use kitchen tools to prepare a meal

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (Select all that apply.) - Jugular vein distention (JVD) - Hypotension -Confusion -Dyspnea

- Jugular vein distention (JVD) -Confusion -Dyspnea

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain? - Upper right quadrant - Lower left quadrant - Upper left quadrant - Lower right quadrant

- Lower left quadrant

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? - Manifestations preceded by a severe headache - History of neurologic deficits lasting less than 1 hr - Maintains consciousness - Gradual onset of several hours

- Manifestations preceded by a severe headache

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take? - Place the client in protective isolation - Limit the client's ambulation to once a day. - Minimize environmental stimuli. - Elevate the head of the client's bed 45%

- Minimize environmental stimuli.

A nurse is caring for a client who has asthma and allergies. The client asks the nurse about environmental influences they should avoid. The nurse should inform the client to avoid which of the following? - Radon - Hepatitis B - Mold - Cockroaches

- Mold

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? - Occasional bubbling in the water-seal chamber - Oxygen saturation of 95% - No fluctuations in the water seal chamber - No reports of pleuritic chest pain

- No fluctuations in the water seal chamber

A nurse is teaching a client about causes of biliary cirrhosis. Which of the following information should the nurse include in the teaching? - Obstruction of the bile duct -Hepatotoxic medications - Hepatitis C -Excessive alcohol consumption

- Obstruction of the bile duct

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension? - A diet high in potassium - Obstructive sleep apnea (OSA) - Taking benazepril - High-density lipoprotein (HDL) level of 70 mg/dL

- Obstructive sleep apnea (OSA)

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? - Hypertension - Oliguria - Flushing of the skin - Bradypnea

- Oliguria

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? - Conjunctivae - Oral mucosa - Ear lobes - Soles of the feet

- Oral mucosa

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? - Pacemaker spikes before each QRS complex - Pacemaker spikes after each QRS complex - Pacemaker spikes before each P wave - Pacemaker spikes with each T wave

- Pacemaker spikes before each QRS complex

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? - Pantoprazole 80 mg IV bolus twice daily - Pancrelipase 500 units/kg PO three times daily with meals - Ambulate twice daily. - Initiate a low-residue diet.

- Pantoprazole 80 mg IV bolus twice daily (treats upper GI Bleeds)

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? - Determine if pain radiates to the left arm. - Check the client's blood pressure. - Auscultate heart tones. - Perform a 12-lead ECG

- Perform a 12-lead ECG

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? - Heart murmur - Peripheral edema - Crackles in lungs - Chest pain

- Peripheral edema

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? - Provide range-of-motion exercises to the client's neck and shoulders. - Apply an eye patch to the client's right eye. - Avoid the use of warm water to wash the client's face. - Place suction equipment at the client's bedside.

- Place suction equipment at the client's bedside.

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? - Motor retardation - Deficits in the right visual field - Poor impulse control - Unable to discriminate words and letters

- Poor impulse control

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? - Remind the client to look for food on the left side of the tray. - Provide a nonskid mat to alleviate plate movement. - Encourage the client to use his right hand when feeding himself. - Encourage the use of the wide grip utensils.

- Remind the client to look for food on the left side of the tray.

A nurse is caring for a client who has COPD. The nurse should identify the client is at risk for which of the following acid-base imbalances? - Respiratory acidosis - Respiratory alkalosis - Metabolic alkalosis - Metabolic Acidosis

- Respiratory acidosis

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? - Check the client's perianal skin integrity. - Review the client's electrolyte values. - Investigate the client's emotional concerns. - Obtain a dietary history from the client.

- Review the client's electrolyte values.

A nurse is admitting a client who has end-stage chronic obstructive pulmonary disease (COPD) and has been intubated on previous hospitalizations. The client refuses intubation and any invasive treatment. Which of the following client rights is the client exercising? - Right of confidentiality - Right of justice - Right of autonomy - Right to medical records

- Right of autonomy

A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. Which of the following instructions should the nurse provide? - Limit caffeine intake. - Check the pulse after medication administration. - Take the medication with meals. - Rinse the mouth after administration.

- Rinse the mouth after administration.

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain which of the following medications puts clients at risk for both hyperkalemia and hyponatremia. - Furosemide - Spironolactone - Hydrochiorothiazide - Metolazone

- Spironolactone

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated? - Low-grade fever - Sudden decrease in abdominal pain - Flaccid abdomen - Absent Rovsing's sign

- Sudden decrease in abdominal pain

A nurse is assessing a client who is taking lisinopril to treat hypertension. Which of the following findings is a priority to report? - Swelling of the tongue - Dry cough - Nausea - Nasal congestion

- Swelling of the tongue

A nurse is teaching a group of middle adult clients about early detection of colorectal cancer. The nurse should include the American Cancer Society recommendation that men and women beginning at age 50 who are at average risk should have a fecal occult blood test (FOBT) and a colonoscopy at which of the following intervals? - One year - Ten years - Two years - Five years

- Ten years

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? - The T wave is in the inverted position. - The P-R interval measures 0.22 seconds. - The QRS duration is 0.20 seconds. - The P wave falls before the ORS complex

- The P wave falls before the ORS complex

A nurse is collecting data from an older adult client who has chronic obstructive pulmonary disease (COPD), arthritis, cataracts, and a BMI of 18.5. Which of the following findings should the nurse identify as a potential barrier to the client's nutritional goal? (Select All that Apply.) - The client's adult child visits once a week - The client has potential mobility impairment because of arthritis. - The client receives supplemental nutrition assistance - The client relies on the public transit system for transportation - Diet restrictions to manage the client's condition

- The client has potential mobility impairment because of arthritis. - The client relies on the public transit system for transportation

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching? - The client waits 10 min between inhalations. - The client exhales as the medication is released from the inhaler. - The client holds his breath for 10 seconds after inhaling the medication. - The client takes a quick inhalation while releasing the medication from the inhaler.

- The client holds his breath for 10 seconds after inhaling the medication.

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include? - The client can carry his ICD in a small pocket. - The client should avoid the use of small electric devices. - The client cannot travel by air due to security screening. - The client should hold his cell phone on the side opposite the ICD.

- The client should hold his cell phone on the side opposite the ICD.

A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock? - The client who has a severe burn injury - The client who has Guiltin-Barre syndrome - The client who has chronic kidney disease - The client experiencing an asthma attack

- The client who has Guiltin-Barre syndrome

A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat-soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following? - Vitamin B1 - Vitamin B12 - Vitamin C - Vitamin A

- Vitamin A

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG? - Widening of the QRS complex - Reduction of T-wave amplitude - Restoration of QRS complex amplitude - Shortening of P-wave duration

- Widening of the QRS complex Polystyrene sulfonate is used to treat hyperkalemia by exchanging sodium for potassium in the colon, leading to potassium excretion. As potassium levels decrease, the QRS complex on the ECG may widen, indicating a potential reduction in the risk of dangerous cardiac arrhythmias associated with hyperkalemia.

A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan? - Wipe perianal area with warm water and apply a barrier cream - Cleanse with antimicrobial scrub and vigorously dry. - Soak in a sitz bath for 20 min after each stool. - Administer a soap-suds enema to cleanse the colon.

- Wipe perianal area with warm water and apply a barrier cream

A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching? -"I will eat smaller meals if I feel nauseated." -"I will eat foods that are served at room temperature." -"I will drink more liquids with my meals." -"I will increase the amount of unsaturated fats in my diet."

-"I will eat foods that are served at room temperature." (hot foods cause nausea)

A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse plan to include in the teaching? -"Avoid the use of any NSAIDs." - "Stop taking the corticosteroids when your symptoms resolve." -"Exposure to ultraviolet light will help control the skin rashes." -"Monitor your body temperature and report any elevations promptly."

-"Monitor your body temperature and report any elevations promptly."

A nurse is teaching a client who has COPD about purse-lipped breathing. Which of the following statements should the nurse make? - "You should cough forcefully during exhalation when you are purse-lipped breathing." - "You should be flat on your back when you perform purse-lipped breathing. - "Your inspiration should be longer than expiration during purse-lipped breathing." -"You should inhale through your nose and exhale through your mouth during purse-lipped breathing."

-"You should inhale through your nose and exhale through your mouth during purse-lipped breathing."

A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma? -Painless, raised purple nodules on the hard palate -A firm nodule with a hard crust -A small macule with a yellow-brown scale -Yellow-white patches of growth on the tongue

-A firm nodule with a hard crust

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.) - Hyperthermia - Polyuria -Absence of bowel sounds -Weakened gag reflex -Hypotension

-Absence of bowel sounds -Weakened gag reflex -Hypotension

A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching? -Remain on bedrest for the first 24 hr. -Apply ice to the affected area. -Begin active range of motion. -Keep the leg in a dependent position.

-Apply ice to the affected area.

A nurse is planning an in-service for nursing staff about managing care for clients who develop disequilibrium syndrome. Which of the following interventions should the nurse include in the teaching? -Administer an opioid medication. -Monitor for the development of chest pain. -Assess level of consciousness. -Start an intravenous infusion of dextrose 50%.

-Assess level of consciousness.

A nurse is reviewing nutrition therapy with a client who has Cushing's disease. Which of the following dietary modifications should the nurse include in this discussion? -Limit potassium-rich foods in the diet. -Decrease sodium intake. -Increase calorie intake. -Consume more calories from carbohydrates than protein.

-Decrease sodium intake.

A nurse is assessing a client who has Graves' disease. The nurse should expect which of the following laboratory results? -Decreased thyrotropin receptor antibodies -Decreased thyroid-stimulating hormone (TSH) -Decreased free thyroxine index -Decreased triiodothyronine

-Decreased thyroid-stimulating hormone (TSH) Graves' Disease = hyperthyroidism

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) -Dyspnea -Bradycardia -Barrel chest -Clubbing of the fingers - Deep respirations

-Dyspnea -Barrel chest -Clubbing of the fingers

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history? -Gallstones -Diabetes mellitus -COPD -Hypolidemia

-Gallstones

A nurse is caring for a client who is 2hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication? -Output of burgundy-colored urine -Pulse rate of 88/min -Oral temperature of 38.2 (100.76) -An urge to void despite having an indwelling urinary catheter

-Output of burgundy-colored urine

A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values . -RBC count -Protein -Calcium -Potassium

-Potassium

A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation? -Increased blood pressure -Hyperactive bowel sounds -Bradycardia -Sudden abdominal pain

-Sudden abdominal pain

A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest? -Tennis - Canoeing -Swimming -Rowing

-Swimming

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? -Straw-colored urine from an including catheter. -Yellow-green drainage on the surgical incision. -Respiratory rate 20 breaths/min. - Blood pressure 102/66 mmHg.

-Yellow-green drainage on the surgical incision.

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement? -administer ferrous sulfate supplementations -increase dietary intake of folic acid -initiate weekly injections of vitamin B12 -initiate a blood transfusion

-initiate weekly injections of vitamin B12

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? -Initiate a low residue diet -pantoprazole 80 milligrams Ivy bolus twice daily -pancrelipase pays 500 units per kilogram PO three times a day with meals Ambulate twice daily

-pantoprazole 80 milligrams Ivy bolus twice daily

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider? -shiny, moist stoma -rosebud-like stoma orifice -purplish-colored stoma stoma oozing red drainage

-purplish-colored stoma A purple stoma = stomal ischemia = a serious impairment of blood flow and requires immediate intervention.

- Loud, scratchy sounds

A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear? - Popping sounds - Snoring sounds - Loud, scratchy sounds - Squeaky, musical sounds

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

RLQ