326,a2
A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include? "Sleep on your left side." "Drink milk to soothe your stomach." "Eat four small meals each day." "Wait to go to bed for 1 hr after eating."
"Eat four small meals each day."
A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? "I will keep my baby in an upright position after feedings." "My baby's formula can be thickened with oatmeal." "I will have to feed my baby formula rather than breast milk." "I should position my baby side-lying during sleep."
"I will keep my baby in an upright position after feedings."
A nurse is providing discharge teaching to a client who has gastroesophageal reflux disease. Which of the following statements by the client indicates an understanding of the teaching? "The type of foods I eat does not affect this condition." "I will sleep on my left side." "I will eat a snack just before going to bed." "I will sleep with the head of my bed elevated."
"I will sleep with the head of my bed elevated."
11.A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include? A. "Take aspirin for discomfort." B. "Restrict lifting objects greater than 10 pounds." C. "Expect reduced vision for 48 hours after procedure." D. "Apply warm compresses for discomfort."
"Restrict lifting objects greater than 10 pounds." Rationale: The nurse should instruct the client to restrict lifting objects greater than 10 lb to reduce the risk for increased intraocular pressure.
A nurse is providing teaching to a client who has peptic ulcer disease and a new prescription for sucralfate tablets. Which of the following information should the nurse provide? A. "An antacid may be taken with the medication if indigestion occurs." B. "Take sucralfate 1 hr before meals." C. "Take the tablets whole." D. "Store sucralfate in the refrigerator."
"Take sucralfate 1 hr before meals." Rationale: Sucralfate is a mucosal protectant. The client should take it on an empty stomach, 1 hr before meals, for maximum effectiveness.
14.A nurse is caring for a client who is scheduled for an arthroplasty. The nurse asks client to state if he understands the procedure that is being performed. Which of the following statements by the client indicates an understanding of the procedure? A. "This procedure determines the extent of joint damage." B. "This procedure will fuse my point to reduce my pain." C. "This procedure will prevent further joint damage." D. "This procedure will replace my joint to improve function."
"This procedure will replace my joint to improve function." Rationale: Arthroplasty is the reconstruction or replacement of a joint. This procedure is done to relieve pain, improve or maintain range of motion, and correct the present deformity.
A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. Which of the following client statements indicates an understanding of the teaching? A. "I can use either heat or ice to help relieve the discomfort." B. "Ibuprofen is the first step in medication therapy for osteoarthritis." C. "I should limit physical activity to prevent further injury." D. "I will elevate my legs by placing two pillows under my knees when I go to bed."
A. "I can use either heat or ice to help relieve the discomfort." Heat application can help with muscle relaxation in the area around the affected joint. The application of cold numbs nerve endings and decreases joint inflammation.
9. A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? A. "Without treatment, glaucoma can cause blindness." B. "Double vision is a common symptom of glaucoma." C. "Glaucoma is caused by inadequate production of fluid within the eye." D. "Use of eye drops will improve vision over time."
A. "Without treatment, glaucoma can cause blindness."
A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client? A. 208 B. 212 C. 214 D. 216
A. 208 Rationale: A client who has or might have tuberculosis requires airborne precautions. That means a private room with negative-
A nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. The nurse should anticipate that the client will require teaching about which of the following medications? A. Acetaminophen B. Celecoxib C. Cyclobenzaprine D. Ibuprofen
A. Acetaminophen
A nurse is preparing a presentation at a community center about osteoarthritis. The nurse should plan to include which of the following information? (Select all that apply.) A. Affects weight-bearing joints B. Crepitus can occur in affected joints C. Affects bilateral, symmetrical joints D. Causes joint stiffness E. Causes joint pain
A. Affects weight-bearing joints B. Crepitus can occur in affected joints D. Causes joint stiffness E. Causes joint pain
A nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take first? A. Assess orthostatic blood pressure. B. Explain the procedure for an upper gastrointestinal series. C. Administer pain medication. D. Test the client's emesis for blood.
A. Assess orthostatic blood pressure.
A client is starting celecoxib to treat osteoarthritis. The nurse should instruct the client to watch for and report which of the following adverse effects? A. Black, tarry stools B. Bone pain C. Dry mouth D. Polyuria
A. Black, tarry stools
6. A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? A. Body weight B. Skin integrity C. Blood pressure D. Respiratory rate
A. Body weight
4. A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings should the nurse expect? (Select all that apply.) A. Coughing B. Apnea C. Sunken abdomen D. Cyanosis E. Frothy saliva
A. Coughing B. Apnea D. Cyanosis E. Frothy saliva
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? (Select all that apply.) A. Emptying urine from an indwelling urine collection bag B. Providing oral care C. Changing an ostomy pouch D. Delivering a food tray to a client who has AIDS E. Placing oral medication tablets into a client's hand
A. Emptying urine from an indwelling urine collection bag B. Providing oral care C. Changing an ostomy pouch
A nurse on the day shift is preparing to change a client's total parenteral nutrition (TPN) solution, but the new TPN solution has not arrived from the pharmacy. The client receives additional IV fat emulsion during the night shift. Which of the following actions should the nurse take? A. Hang dextrose 10% in water (D10W) until the TPN solution is delivered. B. Saline lock the IV catheter after discontinuing the TPN solution. C. Hang the IV fat emulsion solution. D. Call the provider for new TPN orders.
A. Hang dextrose 10% in water (D10W) until the TPN solution is delivered.
2. A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets? A. Low-sodium, fluid-restricted B. Regular diet, no added salt C. Low-carbohydrate, low-protein diet D. Low-protein, low-potassium diet
A. Low-sodium, fluid-restricted
10.A nurse is caring for a client who is postoperative following a total hip arthroplasty. The nurse assists the client into a supine position. Which of the following actions is appropriate to prevent dislocation of the hip? A. Place a wedge pillow between the legs. B. Elevate the head of the bed to a Fowler's position. C. Position the legs in alignment with the spine. D. Place a footboard on the bed.
A. Place a wedge pillow between the legs.
10.A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.) A. Poor skin turgor B. Bradycardia C. Hypotension D. Pale yellow urine E. Flat neck veins
A. Poor skin turgor C. Hypotension E. Flat neck veins
16.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? A. Sudden decrease in abdominal pain B. Absent Rovsing's sign C. Flaccid abdomen D. Low-grade fever
A. Sudden decrease in abdominal pain Rationale: A sudden decrease in abdominal pain should indicate to the nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. However, once peritonitis sets in, the pain returns and can spread into the whole abdomen.
A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide? A. This service began with the client's admission to the hospital. B. This service focuses on teaching the primary caregiver to meet the client's needs. C. The emphasis is on the client's complete recovery from the illness or injury. D. Services are centered in long-term care facilities.
A. This service began with the client's admission to the hospital.
1. A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan? A. Administer antibiotics. B. Encourage increased fluid intake. C. Obtain weight weekly. D. Encourage frequent ambulation.
Administer antibiotics. Rationale: Acute glomerulonephritis related to a streptococcal infection is treated with antibiotic therapy, including penicillins and erythromycin.
A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching? Limit fluid intake not related to meals. Chew on mint leaves to relieve indigestion Avoid eating within 3 hr of bedtime. Season foods with black pepper.
Avoid eating within 3 hr of bedtime.
A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions? A. "I will wear gloves whenever I am in contact with clients." B. "I will wear gloves and a gown when bathing a client who has open skin lesions." C. "I will wear gloves to minimize the number of times I have to wash my hands." D. "I will wear gloves when measuring a client's blood pressure."
B. "I will wear gloves and a gown when bathing a client who has open skin lesions."
7. A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include? A. "Rest in bed for at least 2 days." B. "Keep your head up and straight." C. "Deep breathe and cough four times a day." D. "Lie on the side of the surgery when in bed."
B. "Keep your head up and straight."
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? A. Sleep on the abdomen to facilitate wound healing. B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. C. Bend at the waist to pick objects up from the floor. D. Notify the surgeon if white drainage develops on the eyelids.
B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid A. Nonfat milk B. Chocolate C. Apples D. Oatmeal
B. Chocolate
13.A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action? A. Place the client in a supine position postoperatively. B. Encourage ambulation once fully awake. C. Offer the client ice cream postoperatively. D. Instruct the client not to lift over 4.5 kg (10 lb).
B. Encourage ambulation once fully awake.
A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? A. Ask the x-ray technician to come to the client's room to obtain a portable x-ray. B. Have the client wear a mask. C. Notify the x-ray department that the client requires airborne precautions. D. Wear a filtration mask and gloves during transport.
B. Have the client wear a mask.
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition? A. History of bulimia B. History of NSAID use C. Drinks green tea D. Has a glass of wine with dinner each day
B. History of NSAID use
12.A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take? A. Encourage the client to use full weight bearing. B. Identify the client's pain level and medicate if needed. C. Teach the client which positions to avoid during PT. D. Perform the client's morning care.
B. Identify the client's pain level and medicate if needed.
8. A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client? A. Airborne B. Protective C. Contact D. Droplet
B. Protective
12.A nurse is teaching a client who has cholecystitis about required dietary modifications. The nurse should include which of the following foods as appropriate for the client's diet? A. Creamed chicken B. Roast turkey C. Ice cream D. Macaroni and cheese
B. Roast turkey
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? A. Electrical cords are placed along the walls. B. Scatter rugs are present in the kitchen. C. Handrails are present in the bathroom. D. Uses a microwave for cooking.
B. Scatter rugs are present in the kitchen.
18.A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take? A. Place the client in a room with negative airflow. B. Wear a mask when providing care to the client. C. Ensure the client's room has HEPA filtration. D. Wear a gown when providing care to the client.
B. Wear a mask when providing care to the client.
3. A clinical nurse educator is preparing an educational program about transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitalized clients. Which of the following information should the nurse include in the program? A. Place clients who have MRSA on airborne precautions. B. MRSA can be effectively treated with an antiviral medication. C. MRSA can live on the hands for 1 hr. D. Bathe clients with water and chlorhexidine gluconate.
Bathe clients with water and chlorhexidine gluconate. Rationale: Bathing hospitalized clients with premoistened cloths or warm water that is mixed with chlorhexidine gluconate significantly decreases infection with MRSA.
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? A. Lactated Ringer's B. Dextrose 5% in 0.9% sodium chloride C. 0.45% sodium chloride D. Dextrose 10% in water
C. 0.45% sodium chloride A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride.
A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Bacteria B. Diuretics C. Aging D. Obesity E. Smoking
C. Aging D. Obesity E. Smoking
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? A. Remain on bedrest for the first 24 hr. B. Keep the leg in a dependent position. C. Apply ice to the affected area. D. Begin active range of motion.
C. Apply ice to the affected area.
2. A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching? A. Limit fluid intake not related to meals. B. Chew on mint leaves to relieve indigestion. C. Avoid eating within 3 hr of bedtime. D. Season foods with black pepper.
C. Avoid eating within 3 hr of bedtime.
10.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? A. Include foods high in starch and proteins. B. Include foods high in fiber. C. Avoid foods high in fat. D. Avoid foods high in sodium.
C. Avoid foods high in fat.
6. A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating? A. Assign an assistive personnel to feed the client. B. Explain to the client that her tray is here and place her hands on it. C. Describe to the client the location of the food on the tray. D. Ask the client if she would prefer a liquid diet.
C. Describe to the client the location of the food on the tray.
A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's Jackson-Pratt (JP) drain? A. Measure the drainage every hour for the first 8 hr postoperative. B. Secure the drain to the client's bed sheet. C. Expel the air from the JP bulb after emptying to re-establish suction. D. Remove the JP drain when the drainage has ceased, covering the opening with sterile gauze.
C. Expel the air from the JP bulb after emptying to re-establish suction.
A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide? A. The medication is to be applied when the client is experiencing eye pain. B. The medication will be used until the client's intraocular pressure returns to normal. C. The medication should be applied on a regular schedule for the rest of the client's life. D. The medication is to be used for approximately 10 days, followed by a gradual tapering off.
C. The medication should be applied on a regular schedule for the rest of the client's life.
A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases? A. Pertussis B. Mycoplasma pneumonia C. Tuberculosis D. Respiratory syncytial virus
C. Tuberculosis Tuberculosis is transmitted by small droplets. Therefore, nurses providing care to clients who have tuberculosis should wear individually fitted N95 respirator masks.
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? A. Wear an N95 respirator mask. B. Wear sterile gloves. C. Wear clean gloves. D. Wear protective eyewear.
C. Wear clean gloves.
A nurse is caring for a school-age child who has a systemic disorder and is receiving antibiotics, immunosuppressants, and corticosteroids. Both of the child's parents have a smoking history. The child reports soreness in his mouth and refuses to eat. Inspection of his mouth reveals a white, milky plaque that does not come off with rubbing. The nurse should suspect which of the following conditions? A. Candidiasis B. Dermatitis C. Herpes simplex D. Squamous cell carcinoma
Candidiasis Rationale: Manifestations of oral candidiasis include white patches that adhere to the inner cheeks, tongue, and palate that are painful and can cause the child to refuse to eat.
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority? A. Place the child on a no-salt-added diet. B. Check the child's daily weight. C. Educate the parents about potential complications. D. Maintain a saline-lock.
Check the child's daily weight. Rationale: The first action the nurse should take using the nursing process is to assess the child. Therefore, checking the child's weight daily is the priority.
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid Nonfat milk Chocolate Apples Oatmeal
Chocolate
A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings should the nurse expect? (Select all that apply.) Coughing Apnea Sunken abdomen Cyanosis Frothy saliva
Coughing Apnea Cyanosis Frothy saliva
A nurse is teaching a client who has a new prescription for sucralfate to treat a gastric ulcer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take this medication as needed to reduce pain." B. "I will reduce my fluid intake with this medication." C. "I will take this medication with an antacid." D. "I will take this medication 1 hour before meals and at bedtime."
D. "I will take this medication 1 hour before meals and at bedtime."
A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? A. "Wear an eye patch on the right eye at all times." B. "Plan to relax in a hot tub spa each day." C. "Engage in a vigorous exercise program." D. "Implement a schedule to include periods of rest."
D. "Implement a schedule to include periods of rest."
A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include? A. "Bloodshot eyes on the day of surgery should be reported to the provider." B. "Warm compresses should be applied to the eye three times daily." C. "Photophobia is expected for 2 to 3 days." D. "Vision will be greatly improved on the day of surgery."
D. "Vision will be greatly improved on the day of surgery."
11.A nurse is caring for a client following a right total hip arthroplasty. Postoperatively the nurse should maintain the right leg in which of the following positions? A. Adduction. B. External rotation. C. Internal rotation. D. Abduction.
D. Abduction.
17.A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify? A. Maintain NPO status. B. Monitor oral temperature every 4 hr. C. Medicate the client for pain every 4 hr as needed. D. Administer sodium biphosphate/sodium phosphate.
D. Administer sodium biphosphate/sodium phosphate.
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? A. Pale yellow B. Greenish-brown C. Red D. Dark and foamy
D. Dark and foamy Rationale: The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are filtering excess bilirubin from the blood.
A nurse is completing a medication history for a client who reports using over-the-counter calcium carbonate antacid. Which of the following recommendations should the nurse make about taking this medication? A. Decrease bulk in the diet to counteract the adverse effect of diarrhea. B. Take the medication with dairy products to increase absorption. C. Reduce sodium intake. D. Drink a glass of water after taking the medication.
D. Drink a glass of water after taking the medication.
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority? A. Epigastric discomfort B. Dyspepsia C. Constipation D. Hematemesis
D. Hematemesis Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding is hematemesis, which indicates massive bleeding.
15.A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority? A. Bowel sounds B. Surgical dressing C. Temperature D. Oxygen saturation
D. Oxygen saturation
A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care? A. Properly disposing of contaminated equipment B. Discarding used syringes in appropriate containers C. Changing soiled linens daily for clients who have draining wounds D. Performing hand hygiene frequently and consistently
D. Performing hand hygiene frequently and consistently
17.A nurse is preparing to exit the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A. Perform hand hygiene. B. Remove the face mask. C. Remove the gown. D. Remove the gloves. E. Remove the eyewear.
D. Remove the gloves. E. Remove the eyewear. C. Remove the gown. B. Remove the face mask. A. Perform hand hygiene.
A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching? A. Take ibuprofen for eye discomfort. B. Creamy white drainage is an indication of infection. C. Notify the provider immediately if the operative eye itches. D. The client should wear dark glasses while outdoors.
D. The client should wear dark glasses while outdoors.
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? A. The client who has been NPO since midnight for endoscopy. B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. C. The client who has end-stage renal failure and is scheduled for dialysis today. D. The client who has gastroenteritis and is febrile.
D. The client who has gastroenteritis and is febrile. This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit
A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene? A. The nurse uses clean gloves when discontinuing a client's intravenous infusion. B. The nurse empties a client's drainable colostomy pouch when it is one-third full. C. The nurse uses the client's telephone number as one form of identification when administering medications to a client. D. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.
D. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis. Created
3. A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report A. loss of central vision. B. having a loss of peripheral vision. C. seeing bright flashes of light and floaters. D. having a decreased ability to perceive colors.
D. having a decreased ability to perceive colors.
A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take? A. Apply pressure to the bridge of the nose after administration. B. Wipe the eye from the outer canthus to the inner canthus before instillation. C. Drop prescribed amount of medication into the conjunctival sac. D. Protect the distal portion of the eyedropper using clean technique.
Drop prescribed amount of medication into the conjunctival sac. Rationale: With the dominant hand resting on client's forehead, hold filled medication eyedropper or ophthalmic solution approximately 1 - 2 cm above conjunctival sac. Instill prescribed number of medication drops into the conjunctival sac. After instilling the drops, ask the client to close his eye gently. If the client is to receive more than one eye medication to the same eye, wait at least 5 min before administering the next medication
9. A nurse is teaching a client who has a new prescription for cimetidine to treat peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) A. "I can take this medication with or without food." B. "I will take this medication in the morning." C. "I should expect my stools to turn black." D. "I will take this medication with an antacid." E. "I will take this medication when I need it for pain." F. "I will eat five small meals each day."
F. "I will eat five small meals each day." A. "I can take this medication with or without food."
A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect? A. Hypothermia B. Protruding eyeballs C. Elevated blood pressure D. Furrows in the tongue
Furrows in the tongue Rationale: In older adult clients who have dehydration, the surface of the tongue will be dry with deep furrows.
A nurse on the day shift is preparing to change a client's total parenteral nutrition (TPN) solution, but the new TPN solution has not arrived from the pharmacy. The client receives additional IV fat emulsion during the night shift. Which of the following actions should the nurse take? Hang dextrose 10% in water (D10W) until the TPN solution is delivered. Saline lock the IV catheter after discontinuing the TPN solution. Hang the IV fat emulsion solution. Call the provider for new TPN orders.
Hang dextrose 10% in water (D10W) until the TPN solution is delivered.
A nurse is admitting a toddler who has respiratory syncytial virus (RSV). Which of the following actions should the nurse take? A. Initiate airborne precautions. B. Keep thermometer in the toddler's room. C. Allow the toddler to play in the common room. D. Place the toddler in a room that has negative air pressure. Created
Keep thermometer in the toddler's room. Rationale: The nurse should keep and use dedicated equipment, such as blood pressure monitor, stethoscope, and thermometer in the client's room to prevent the spread of infection from client to client
A nurse manager is providing an educational program on antibiotic sensitivity to bacterial infections. The nurse should include in the teaching that vancomycin is indicated for which of the following infections? A. Pseudomonas aeruginosa B. Klebsiella C. Candida D. Methicillin-resistant Staphylococcus aureus
Methicillin-resistant Staphylococcus aureus Rationale: The nurse should teach that vancomycin is sensitive to the infection methicillin-resistant Staphylococcus aureus and Clostridium difficile infections, and should be the antibiotic of choice to treat this organism.
A nurse is caring for a client who has herpes zoster. Which of the following findings should the nurse expect? A. Multiple furuncles located on the client's back B. Different-sized papules in the genital area C. Painful lesions following a nerve pathway D. Patches scattered across the torso
Painful lesions following a nerve pathway Rationale: Clients who have herpes zoster, also known as shingles, have painful vesicles that are distributed along infected nerve pathways.
A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions following feedings? Place the infant in a prone position. Place the infant in an infant seat. Place the infant on his left side Place the infant on his right side
Place the infant in an infant seat.
A nurse is planning care for a client who is postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care? A. Instruct the client to avoid movement of the affected leg. B. Prevent hip flexion of the affected extremity C. Position the lower extremities so that they are touching. D. Ensure that the client's heels are touching the bed.
Prevent hip flexion of the affected extremity Rationale: The nurse should implement measures to prevent hip flexion of the affected extremity beyond 90 degrees due to the risk of dislocation. Raised toilet seats and reclining chairs help prevent hyper-flexion.
A nurse is caring for a client who is 4 hr postoperative following a hip replacement. The nurse should instruct the client to avoid which of the following activities? A. Placing a large pillow between legs when turning B. Putting on shoes and socks C. Using a raised toilet seat D. Using a walker
Putting on shoes and socks Rationale: The client should not bend over to put on shoes and socks. It increases the risk of dislocation of the prosthesis to create more than 90° of flexion at the hip.
A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic? Relief of heartburn Cessation of diarrhea Passage of flatus Absence of constipation
Relief of heartburn
6. A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI? A. The client had an appendectomy 6 months ago. B. The client has bipolar disorder. C. The client is a male. D. The client is 71 years old.
The client is 71 years old. Rationale: Clients older than 70 years of age are at an increased risk of acquiring an HAI. Decreased immune system function increases the susceptibility to infection.
A nurse is caring for a client who has shingles with multiple skin lesions. Which of the following actions by the nurse require intervention by the nurse's supervisor? A. The nurse wears an N95 respirator mask. B. The nurse admits another client who has shingles to the client's double room. C. The nurse wears gloves when providing direct care to the client. D. The nurse wears a gown when bathing the client.
The nurse admits another client who has shingles to the client's double room. Rationale: When a private room is not available, clients who are infected with the same organism may be placed together in a double room. However, cohorting is reserved for clients who both require droplet precautions. This client should be in a private room.
A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing this client's laboratory values? A. WBC 17,000/mm3 B. Neutrophils 3,000/mm3 C. RBC 4.2 million/mm3 D. Lymphocytes 3,000/mm3
WBC 17,000/mm3 Rationale: The expected reference range for a WBC count for a child is 5,000 to 10,000/mm3. A WBC count of 17,000/mm3 is elevated. The nurse should expect to see an elevated WBC count because appendicitis is an acute bacterial infection.
A nurse is caring for an infant who has gastroesophageal reflux. The nurse should recognize that which of the following findings are associated with this condition? (Select all that apply.) Vomiting Weight loss Rigid abdomen Wheezing Fever
vomiting weight loss wheezing
