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The clinic nurse completes the wellness assessment for an older adult female. Which statement by the client would require the nurse to discuss HIV prevention?

"I do not have to worry about getting pregnant at my age"

Which information about an 80-year-old client at the senior center is of most concern to the nurse?

Unintended weight loss

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan? Select all that apply, one, some, or all may be correct.

a. Cook food thoroughly before eating c. Avoid public transportation such as buses e. Talk to the oncologist before having any dental work.

The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?

a. Give the patient 4 to 6 oz more orange juice.

Which actions should the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur? Select all that apply, one, some, or all may be correct.

a. Monitor serum calcium c. Explain the use of sustained-release opioids. d. Support the left leg when repositioning the patient. e. Assist family and patient as they discuss the prognosis.

The nurse on a medical-surgical unit cares for a client who reports pain in the jaw, back, and shoulder, shortness of breath, and nausea. What action should the nurse take? Select all that apply, one, some, or all may be correct.

a. Obtain an electrocardiogram (ECG) b. Administer aspirin c. Administer nitroglycerin sublingual d. Maintain oxygen saturation greater than or equal to 92%

Which finding should the nurse expect to find for a client experiencing an acute myocardial infarction (MI). Select all that apply, one, some, or all may be correct.

a. Orthopnea b. Headache c. Nausea d. Tachycardia e. Diaphoresis

A registered nurse (RN) cares for a client with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching? Select all that apply, one, some, or all may be correct.

a. The RN checks the initial blood pressure in one arm. b. The RN palpates the neck to assess thyroid size c. The RN orders saline eyedrops to lubricate the clients bulging eyes. e. The RN offers warm blankets for the clients cold feet.

1.A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?

a.Folate deficiency b.Malabsorption of fat c.Intestinal obstruction d.Fluid and electrolyte imbalance

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment?

absent bowel sounds

To monitor for complications in a client with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? Select all that apply, one, some, or all may be correct.

b. Blood pressure c. Serum creatinine d. Urine for microalbuminuria f. Eye exam

A nurse reinforces instructions to a client who is taking levothyroxine (Synthroid). The nurse tells the client to take the medication:

on an empty stomach

A nurse reinforces medication instructions to a client who is taking levothyroxine (Synthroid). The nurse instructs the client to notify the health care provider (HCP) if which of the following occurs?

tremors

EMG test (What is it for?)

• discontinue muscle relaxants (e.g. cyclobenzaprine) before the procedure.

A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GERD is needed?

"I eat small meals during the day and have a bedtime snack."

The nurse has taught a client with a history of Reynaud's syndrome about preventing complications. Which statement by the client would indicate to the nurse the need for further teaching?

"I should use hot packs on my hands when I have a flare-up"

The healthcare provider orders 14 units/kg/hr heparin infusion. The patient weighs 253 lbs. The heparin is supplied as 20,000 units /500mL bag. The nurse will set the infusion rate at _____ mL/hr. Round to the nearest whole number.

40

A patient has peptic ulcer disease that has been associated with Helicobacter pylori. About which medications will the nurse plan to teach the patient?

Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec)

After the healthcare provider recommends amputation for a patient who has a nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best?

"Tell me what you know about your options for treatment"

A 29-year-old woman with systemic lupus erythema has been prescribed 2 weeks of high dose prednisone therapy. Which information about prednisone is most important for the nurse to include?

"The prednisone dose should be decreased gradually"

The healthcare provider orders dopamine at 8mcg/kg/min for a client who weighs 286 pounds. Dopamine is supplied as 800mg in 250mL D5W. The nurse will set the infusion rate at ____ ml/hr. Round to the nearest whole number.

20

A doctor prescribes 1 unit of packed red blood cells to infuse over 2 hours and 15 minutes. The unit of blood contains 250ml. The drop factor is 15 drops/ml. A nurse prepares to set the flow rate at how many drops per minute?

28 gtts/min

The healthcare provider prescribes a heparin infusion of 1800 units/hour. The heparin is supplied as 25,000 units in 500mL D5W. The nurse will set the infusion rate at ___ mL/hr.

36

What statements will the nurse include when teaching a client who is scheduled for oral glucose tolerance testing in the outpatient clinic? Select all that apply. One, some, or all may be correct.

-"You will need to avoid smoking before the test" -"Several blood samples will be obtained during the testing" -"The test requires that you fast for at least 8 hours before testing"

Which information should the nurse include when teaching a patient with acute musculoskeletal pain? (select all that apply)

-Expect symptoms of acute pain to improve in a few weeks. -Avoid activities that require twisting of the back or prolonged sitting -Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain

The nurse at the clinic interviews a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 lb (57 kg). The patient has not seen a healthcare provider for 20 years. She walks outside 5 miles most days and has a glass of wine 2 to 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk? Select all that apply. One, some, or all may be correct.

-pap testing -sunscreen use -colorectal screening -mammogram

The ECG findings of hypocalcemia include:

1. A prolonged QT interval 2. A lengthened ST segment

The nurse is caring for a client w/ lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply.

1. Facial edema in the morning 3. Serum calcium level of 12 mg/dL 6. Numbness and tingling of the lower extremities

A client with carcinoma of the lung develops SIADH as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply.

1. Radiation 2. Chemotherapy 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone

A histamine (H2)-receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2-receptor antagonists? Select all that apply.

1.Nizatidine 2.Ranitidine 3.Famotidine 4.Cimetidine

Which client should the nurse assess first after receiving change-of-shift report?

A client with esophageal varices who has a rapid heart rate

A patient with left knee pain is diagnosed with bursitis. What area should the nurse explain is the site of inflammation in bursitis?

A fluid filled sac found at some joints

Which action will the nurse include in the plan of care for a patient who is being admitted with Clostridium difficile?

Place the patient in a private room on contact isolation.

A patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is important for the nurse to communicate to the health care provider before the test? (REPEAT #48)

Allergies to iodine

A patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is important for the nurse to communicate to the healthcare provider before the test?

Allergies to iodine and shellfish

A patient with a complex pelvic fracture from a motor vehicle crash is on bedrest. Which assessment finding should indicate to the nurse a potential complication of the fracture?

Abdomen is distended, and bowel sounds are absent.

What action should the urgent care nurse take for a patient with a possible knee meniscus injury?

Apply an immobilizer to the affected leg

A nurse is completing a preoperative teaching for a client who is to undergo an arthroscopy to repair a shoulder injury.Which of the following statements should the nurse include? (Select allthat apply.)

B."Inspect your incision daily for indications of infection." C."Apply ice packs to the area for the first 24 hours." D."Keep your arm in a dependent position."

An active 32-yr old male who has type 1 diabetes is being seen in the endocrine clinic. Which finding indicates a need for the nurse to discuss a possible a change in therapy with the health care provider?

Blood pressure of 140/88 mmHg

The nurse cares for a client who has HIV and is taking prescribed nucleoside reverse transcriptase inhibitors (NRTI). Which finding would indicate the client is experiencing an adverse effect of the medication?

Elevated liver function tests

Eight years into treatment, a patient with human immunodeficiency virus infection has a CD4+ cell count of 800/µL and an undetected viral load. Which is the priority intervention in the plan of care at this time?

Encourage adequate nutrition, exercise, and sleep.

What information will a review of a patients glycol hemoglobin (A1C) results provide to the nurse?

Glucose control over the past 90 days

Which finding for a 77-yr-old patient seen in the outpatient clinic is the highest priority for further nursing assessment and intervention?

History of recent loss of balance and fall

The nurse cares for a client who is scheduled for a bone marrow aspiration. The client asks the nurse about the sites the providor might use for the procedure. Which location should the nurse identify as a site used for this procedure?

Iliac crest

The nurse assesses a client who is postoperative coronary artery bypass graft. The nurse notes the client has an audible pericardial friction rub and has a low-grade fever. Which intervention is the priority for the nurse to implement to decrease the workload of the heart?

Initiate strict bed-rest for client

Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action?

New onset changes in the patients voice

The evening shift nurse cares for a client scheduled for surgery. The client states, "I once got a rash from wearing rubber gloves" which action should the nurse take?

Note in the medical record that the client has a latex allergy

A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weened off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first?

Obtain a glucose reading using a finger stick

Arthroscopy - diagnostic test or surgical procedure, most commonly used for knee & shoulder evaluation.

Post procedure care Wrap area with pressure bandage

1.A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. The nurse should identify that the client is experiencing which of the following complications?

Pulmonary embolus

A patient is being admitted with a diagnosis of Cushing syndrome. Which finding will the nurse expect during the assessment

Purplish streaks on the abdomen

The nurse assesses a client who is 30 minutes postoperative from an insertion of a permanent pacemaker. Which finding would require immediate follow up by the nurse?

Report of shortness of breath

The nurse provides education to a patient with stomatitis cause by chemotherapy treatments to treat esophageal cancer. Which nursing diagnosis is the nurses priority?

Risk for infection

A fat embolism may occur = Priority

SOB

The nurse takes a health history from a 29-yr-old client at the first prenatal visit. The client does not have diabetes, but has a first degree family history of diabetes. Which action will the nurse plan to visit?

Schedule the client for a fasting blood glucose level

A client has been admitted with suspected hypercalcemia. Which of the following ECG changes should the nurse expect to find on the ECG?Select all that apply

Short ST segment Short QT intervals

Alendronate (Fosamax) is prescribed for a client with osteoporosis. The client taking this medication is instructed to:

Take the medication with a full glass of water after rising in the morning.

The clinic nurse reviews the medical records for clients who are scheduled for annual physicals and require health promotion teaching. Which client has the highest risk for contracting HIV?

The older adult client who is recently widowed and is sexually active

The nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure?

The patient declined to drink the prescribed laxative solution.

The nurse cares for a client with stage Ⅳ cervical cancer receiving prescribed chemotherapy. The client states "I don't want anymore chemotherapy, but my children insist I keep going." In what role will the nurse be acting for this client after her comment?

The role of patient advocate

A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. What should the nurse ask the patient to determine possible risk factors for gastritis?

Use of non-steroidal anti-inflammatory drugs

A patient is scheduled for an electromyography (EMG) to evaluate diffuse or localized muscle weakness. What question should the nurse ask the patient before the test?

What herbal over-the-counter medicines do you take?

A nurse is reinforcing teaching for a client regarding how to mix regular insulin and NPH insulin in the same syringe. Which of the following actions, if performed by the client, indicates the need for further teaching?

Withdraws the NPH insulin first

In preparation for which test should the nurse teach the patient to minimize physical and emotional stress?

a 24-hour urine test for free cortisol.

What statements will the nurse include when teaching a client who is scheduled for oral glucose tolerance testing in the outpatient clinic? Select all that apply. One, some, or all may be correct.

a. "You will need to avoid smoking before the test" c. "Several blood samples will be obtained during the testing" e. "The test requires that you fast for at least 8 hours before testing"

The nurse assesses an alert an independent older adult client for malnutrition risk. Which is the most appropriate initial question?

b. "Can you tell me the food that you ate yesterday?"