Adult Health 1 Final
A client with hypertension is instructed to reduce his daily intake of sodium to?
1500 mg/day
Normal Hemoglobin
16 g/dL
When teaching the patient with COPD about exercise, which information should the nurse include?
Use the bronchodilator before you start to exercise
A student nurse asks what "essential (primary) hypertension" is. What response by the registered nurse is best?
It is hypertension with both genetic and environmental factors
A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura?
Visual disturbances
A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply?
b. ice packs
The client who tripped and fell down several stairs reports having heard a popping sound and fears a broken ankle. How does the nurse initially assess a fracture in this patient?
b. observing for deformity and misalignment
A nurse is assessing a client who has osteoarthritis. Which of the following assessment findings should the nurse expect?
b. pain in 1 or more joints (usually weight bearing)
A home health nurse assesses a client with diabetes who has a new cast on the arm. The nurse notes the clients fingers are pale, cool, and slightly swollen. Which action should the nurse take first?
b. raise the arm above the level of the heart
Which of the following symptoms should the nurse assess for when assessing a client with a slightly cloudy appearance to the lens?
blurring of vision
Crohn's disease has the following characteristics. Select all that apply. a) Effects the mucosal layer of the GI tract b) Effects the patient from mouth to anus c) Effects the colon only d) Effects all layers of the GI tract
ACD
A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following lab findings as indicators of the advanced disease process? Select all that apply
ALT (alanine aminotransferase) elevated Ammonia levels elevated AST (aspartate aminotransferase) elevated Serum protein decreased
A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?
Assess distal pulses and skin color
A nurse admits a client who is experiencing acute decompensated heart failure. Which action should the nurse take first?
Assess the clients respiratory status and lung sounds
The surgical unit has just received a patient with a history of smoking from the postanesthesia care unit (PACU). Which action is most important initially?
Assess the patient's respiratory status
A nurse is planning interventions for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? Select all that apply
Assist with early ambulation Encourage the use of incentive spirometry 10 times per hour Instruct the patient to splint their incision with a pillow when coughing and deep breathing Reposition the client every 2 hours
Lispro insulin (Humalog), a rapid acting insulin, is ordered for a patient with newly diagnosed type 1 diabetes. The nurse knows that when lispro is used, it should be administered?
At mealtime or within 15 minutes of meals
When a hospitalized patient with chronic obstructive pulmonary disease (COPD) is receiving O2, the best action by the nurse is to:
Avoid administration of O2 at a rate of more than 2-3 L/min per nasal cannula
Which topic is most important to include in patient teaching for a male client diagnosed with early cirrhosis?
Avoiding alcohol ingestion
A nurse cares for a young woman with a new ileostomy. The client states, "I cannot have a wedding with an ostomy." How should the nurse respond? a) "The pouch won't be as noticeable if you avoid broccoli and carbonated drinks prior to the ceremony and if you don't serve them at the reception." b) "Let's talk to the enterostomal therapist about options for ostomy supplies and dress styles." c) "Sure you can. Purchase a wedding gown one size larger to hide the ostomy appliance." d) "You can remove the pouch from your ostomy appliance when you during the wedding and reception so that it is less noticeable."
B
A nurse plans care for a client with lower back pain from a work-related injury. Which interventions should the nurse include in this client's plan of care? a) Encourage the client to stretch the back by reaching toward the toes b) Apply moist heat for 20 minutes at least 4 times a day c) Massage the affected area with ice twice a day d) Advise the client to avoid warm baths or showers
B
A nurse teaches a client about self-care after experiencing a urinary calculus treated by lithotripsy. All but which of the following statements should the nurse include in this client's discharge teaching? a) "Finish the prescribed antibiotic even if you are feeling better." b) "It is normal to experience pain and difficulty urinating." c) "The bruising on your back may take several weeks to resolve." d) "Drink at least 3 liters of fluid each day."
B
All patients with diverticulosis have diverticulitis. a) True b) False
B
The client returns to the nursing unit postoperatively after a colostomy. Which of the following assessments would require immediate action by the nurse? a) Stoma is bright red in color b) Stoma is bluish in color c) Stoma is draining no fluid d) Stoma is draining serous fluid
B
The nurse is caring for a client with a diagnosis of Multiple Sclerosis. The client is concerned about the recurrent exacerbations and fatigue. The nurse suggests which of the following interventions to help? a) Identify where assistive devices can be obtained at reasonable prices b) Space activities throughout the day with opportunities for rest c) Ask the clients mother's help with the children in the evening Limit activities and take morning and afternoon naps
B
The nurse is instructing a client diagnosed with a hiatal hernia on ways to reduce the symptoms. Which of the following should be included in these instructions? a) Lie down after eating b) Avoid lying down after meals c) Drink lots of liquids d) Eat large meals
B
The nurse teaches the client with Gastroesophageal Reflux Disease about ways to minimize symptoms. Which of the following statements made by the client indicates that more teaching is needed? a) "I will take a walk after I eat." b) "I will be sure to drink cola instead of coffee." c) "I will avoid late evening snacks." d) "I will try to eat smaller meals more frequently."
B
What potential outcome does the nurse anticipate when administering total parenteral nutrition (TPN)? a) Electrolyte Imbalance b) Hyperglycemia c) Dehydration d) Infection
B
Which of the following would not be included in a medication regime for a patient being treated for peptic ulcer disease (PUD)? a) H2 receptor blocker b) NSAID c) Proton pump inhibitor d) Antibiotics
B
Which patient education will the nurse provide before discharge for a patient who has had a herniorrhaphy to repair an incarcerated inguinal hernia? a) Encourage the patient to cough b) Apply a scrotal support and ice to reduce swelling c) Encourage warm baths several times a day d) Avoid the use of acetaminophen for pain
B
You are assessing a client who has been taking prednisone following an exacerbation of inflammatory bowel disease, which of the following findings are the highest priority? a) Patient reports gaining 4 pounds in the last 6 months. b) Patient reports having an elevated body temperature c) Patient reports he is having a hard time falling and staying asleep. d) Urinanalysis is + for glucose
B
A nurse is caring for a patient who has pneumonia. Assessment findings include temperature 100 F, respirations 30/min, BP 130/76, heart rate 100/min, and SpO2 91% on room air. Prioritize the following nursing interventions. A. Administer antibiotics as prescribed B. Administer oxygen therapy C. Obtain a sputum culture D. Administer an antipyretic medication (such as Acetaminophen) for comfort
B, C, A, D
A client with cirrhosis is admitted to the hospital. Which of the following assessments made by the nurse would indicate the presence of portal hypertension?
Elevated blood pressure
The health care providers progress note for a patient states that the CBC shows a "shift to the left." Which assessment finding correlates with this information?
Elevated temperature
A nurse is obtaining informed consent for a client who is having a colonscopy through same day surgery. Which of the following are appropriate nursing actions. Select all that apply.
Ensure client understands information about the procedure Determine if the client is capable of understanding the reason for the procedure Witness the client signing the informed consent form
A nurse is completing an admission assessment of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
Epigastric pain radiating to the back
Which of the following are times a type 1 diabetic would be taught to perform fingerstick blood sugar monitoring? Select all that apply
Every 2 - 4 hours when ill, before meals, before and after exercise, when having symptoms of hypoglycemia
The nurse assesses a client who has a 15 year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first?
Examine the clients feet for signs of injury
A patient's T-tube has drained 300 cc dark green fluid in the 24 hours following gallbladder surgery. All of the following are appropriate assessments and expectations from the nurse regarding a T-tube except?
Expect removal of the T-tube within 48 hours.
A 45 year old client's blood pressure has been measured at 130/86 mmHg on two separate occasions at two different times of day. The nurse realizes this classifies the patient as Stage 1 hypertensive.
False
When teaching the patient with diabetes about insulin administration, the nurse should tell the patient that each injection should be rotated from arms to thighs to abdomen to prevent lipodystrophies (abnormal accumulation of fat tissue)
False
The acronym FACES is used to help educate patients to identify symptoms of heart failure. What does this acronym mean?
Fatigue, limitation of activities, chest congestion/cough, Adema, SOB
The nurse assessing the patient notes a bounding pulse quality, neck vein distention when supine, presence of crackles in the lungs, and increasing peripheral edema. What condition does the nurse suspect?
Fluid volume excess
A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? Select all that apply
Fruity odor of breath, metabolic acidosis, kussmaul respirations
Hyponatremia can be caused by:
GI vomiting or diarrhea
An absence seizure is classified as a:
Generalized seizure
The client with seizure disorder develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How will the nurse document this seizure activity?
Generalized tonic clonic seizure
A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this client's plan of care? Select all that apply.
Have section equipment at the bedside, ensure that the client has IV access
When assessing a newly admitted patient, the nurse notes pallor of the skin and nail beds. The nurse would review which component of the complete blood count (CBC) for a possible cause?
Hemoglobin level
Which breathing technique should the nurse teach the client with chronic obstructive lung disease to promote clearing of the airways of sputum?
Huff coughing
Which diagnostic lab test would be the most diagnostic to determine if a patient admitted with acute shortness of breath has heart failure?
Human b-type natriuretic peptide (hBNP)
Which information should the nurse include when teaching a patient with newly diagnosed hypertension?
Hypertension is usually asymptomatic until target organ damage occurs
A patient with type 1 diabetes uses 20 units of 70/30 NPH/Regular insulin in the morning and at 6 pm. When teaching the patient about this regimen, what should the nurse emphasize?
Hypoglycemia is most likely to occur before the noon meal
A nurse is caring for a client who has a NG tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?
Hyponatremia
Which statement by the patient with type 2 diabetes is accurate?
I am supposed to have a meal or snack if I drink alcohol
A client asks the nurse why it is important to be weighed every day if he has heart failure. How will the nurse respond?
Wait is the best indication that you were gaining or losing fluid
A client had cataract surgery. While repeating discharge instructions back to the nurse, which of the following statements by the patient would need to be corrected?
I can lift my two year old grandchild without concerns
The nurse discusses management of upper respiratory infections with a patient who has acute sinusitis. Which statement by the patient indicated that additional teaching is needed?
I can use my nasal decongestant spray weekly to prevent symptoms
A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left sided heart failure?
I must stop halfway up the stairs to catch my breath
A nurse is teaching a group of clients about influenza. Which of the following statements by a client requires clarification?
I need to avoid drinking fluids if symptoms develop
Which statement made by the client newly diagnosed with type 2 diabetes mellitus needs clarification regarding diet therapy?
I should keep my diet free from all carbohydrates
Which statement by the patient with chronic heart failure should cause the nurse to determine that additional discharge teaching is needed?
I should weigh myself every morning and go on a diet if I gained more than 3 pounds in two days
A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching?
I take this medication to prevent asthma attacks
In evaluating an asthmatic patient's knowledge of self care, the nurse recognizes that additional instruction is needed when the patient says
I use my corticosteroid inhaler when I feel short of breath
The nurse plans to teach the patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan?
Identification and avoidance of environmental triggers are the best way to avoid symptoms
After teaching a client newly diagnosed with a seizure disorder, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?
If I am nauseated I will not take my seizure medication
All but which of the following would be an appropriate nursing diagnosis for a patient experiencing anemia:
Impaired gas exchange
When caring for a patient admitted with hypernatremia due to a fluid deficit from diabetes insipidus, which actions will the nurse anticipate taking?
Infuse 0.45% NS IV
A nurse is caring for a client with total parenteral nutrition infusing. Which of the following interventions are appropriate by the nurse? Select all that apply.
Infusion through a micron filter attached to the tubing, administration through an IV pump only, FSBS assessment every 4 to 6 hours
Which information will the nurse include when teaching the patient with asthma about the use of the prescribed inhaler medications?
Inhale slowly while counting to 10 when using the inhaler
The client complains of eye pain and has nausea 2 hours after cataract surgery on the left eye. What is the nurses' priority intervention?
notify the physician of the client's complaints
How should the nurse position the television set for the long term care resident who has macular degeneration in both eyes?
on either side of the client
picture of hands-not gross
osteoarthritis
really gross yellow drainage from a thumb
purulent
A herniated disc can cause severe burning or stabbing pain down into the leg or foot due to compression on the __________ nerve
sciatic
The term used to describe a pink-blood tinged watery exudate from a would is:
serousanguinous
For the nursing diagnosis of Ineffective Airway Clearance in a postoperative patient, the nurse evaluates that the interventions have been successful when:
the patient's breath sounds are clear to auscultation
The nurse is reviewing the medical records for 5 patients who are scheduled for their yearly physical exam in September. Which patient would not need to receive the pneumonia vaccine?
A 36-year-old female patient who has been diagnosed with rheumatoid disease taking steroid therapy
A client is diagnosed with an elevated serum calcium level and is symptomatic. Which of the following interventions would be appropriate for this client? Select all that apply.
Be gentle when moving the patient, administer diuretics as prescribed, strained urine for stones, administer intervenous fluids as prescribed
What characterizes type 2 diabetes? Select all that apply
Beta cell destruction, abdominal/visceral obesity, decreased production of insulin by the beta cells, insulin resistance, genetic mutations over time
Which findings indicates arterial insufficiency?
Bluish discoloration of the toes
A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider?
Bright red clots in the sputum
A nurse is reviewing nutrition teaching for a client who has cholecystitis. The nurse should identify that which of the following food choices can trigger cholecystitis?
Brownie with nuts
Which finding indicates venous insufficiency?
Brownish discoloration of the legs
A client with glaucoma having the intraocular pressure measured asks the nurse why this is necessary every year. How will the nurse respond?
"Elevated eye pressure can compress blood vessels in the eye, keeping the eye nerves from getting enough oxygen."
A nurse is teaching a client with frequent episodes of external otitis media how to prevent it. After the nurse provides patient teaching, which patient statement indicates that more teaching is needed?
"I should clean inside the ear canal with a cotton-tipped applicator daily."
The nurse is providing discharge teaching for a client who will be receiving pancreatic enzyme replacement at home. Which statement by the client is incorrect?
"I should take my pancreatic enzyme after meals and snacks."
After the nurse has finished teaching a patient about oral ferrous sulfate (Feosol), which statement indicates that additional instruction is needed?
"I will call the doctor if my stools turn dark."
A 52 year old patient has a new diagnosis of pernicious anemia. After teaching the patient about pernicious anemia, the nurse determines that the patient understands the disorder when the patient states:
"I will need cyanocobalamin replacement for the rest of my life."
The client who had a cholecystectomy asks why a T-Tube has been inserted. The best response by the nurse is:
"T-tubes drain edema fluid and bile to keep the duct patent."
A nurse is completing pre-operative teaching for a client who will undergo a laparoscopic cholecystectomy. Which of the following should be include in the teaching?
"You may have shoulder pain following surgery."
The typical isotonic fluid replacement for the patient with a fluid volume deficit is?
0.9% NS
A normal serum sodium level is?
135-145 meq/mL
The nurse in the ED receives arterial blood has results for a recently admitted patient with COPD. Which patient will require the most rapid action by the nurse?
20-year-old with ABG results of pH 7.28, paCO2 60, paO2 58, HCO3 24
Normal Platelet Count
200,000 mm3
A fat embolism is most likely to occur _____ hours following a long bone fracture.
24-72
A normal serum potassium level is?
3.5-5.0 meq/L
Normal RBC count
4.8 million/uL
A normal cardiac ejection fraction is ______% or higher
50
Normal WBC count
8,000 mm3
Which of the following is a normal WBC count?
8,000 mm3 or 8.0 K/uL
A normal serum calcium level is?
9-10.5 mg/dL
A client has an nasogastric tube in place for gastric decompression and complains of increasing nausea. Which action should the nurse take first? a) Check for proper functioning of the tube b) Measure the abdominal girth c) Check the patient for a gag reflex d) Advance the tube 2 cm
A
A nurse assesses a patient to have a rolling hiatal hernia when they present with symptoms of a feeling of fullness and breathlessness after eating, and chest pain like angina, particularly when in a recumbent position. a) True b) False
A
A nurse contacts the healthcare provider after reviewing a client's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. Which action should the nurse recommend? a) Intravenous fluids b) Urine culture and sensitivity c) Hemodialysis d) Fluid restriction
A
A nurse is doing a nursing assessment on a patient with chronic constipation. What data obtained during the interview may be a factor contributing to the constipation? a) Suppressing the urge to defecate while at work b) High dietary fiber with high fluid intake c) History of hemorrhoids and hypertension d) Taking methylcellulose (Citrucel) daily
A
A nurse is reviewing the results of a client's urinalysis. The findings indicate the urine is positive for leukocyte esterase and nitrites. Which of the following actions should the nurse take? a) Obtain a clean-catch urine specimen for culture and sensitivity. b) Repeat the test early the next morning. c) Insert an indwelling urinary catheter to collect a urine specimen. d) Start a 24-hr urine collection for creatinine clearance.
A
The nurse is planning discharge teaching for a client who has experienced chronic constipation. Which instructions will the nurse provide to the client? a) "Take fiber supplements every day with at least 8 ounces of water." b) "Drink carbonated beverages to help prevent becoming constipated." c) "Take 2 teaspoons of castor oil every morning to prevent consiptation." d) "Take 2 teaspoons of aluminum hydorxide (Amphojel) if you become constipated."
A
The tensilon test (ACTH injection) is used as a positive indicator for the disease of myasthenia gravis? a) True b) False
A
Twenty four hours after undergoing a gastric surgery, a patient has absent bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The most appropriate action by the nurse at this time is to? a) Notify the surgeon b) Continue to monitor the NG drainage c) Irrigate the NG tube d) Administer the prescribe morphine sulfate
A
What intervention should the nurse suggest to a client to prevent nighttime Gastroesophageal Reflux disease? a) "Elevate the head of the bed 8 to 12 inches for sleep." b) "Sleep in the right lateral decubitus position." c) "Have alcoholic beverages early in the evening." d) "Have a light evening snack before bedtime."
A
When providing care for a client with Amyotrophic Lateral Sclerosis, the nurse recognizes what as one of the most distressing problems experienced by the client. a) Retention of cognitive function with total degeneration of the motor function b) Uncontrollable writhing and twisting movements of the face, limbs, and body c) Knowledge that the disease could have been prevented with early treatment d) Painful spasticity of the face and extremities
A
Which clinical manifestation of Guillain-Barre Syndrome reflects the most common clinical pattern of the disease? a) Progressive, ascending weakness, numbness and tingling of lower extremities b) Urinary frequency and diplopia c) Weakness of the face, jaw, and sternocleidomastoid muscles d) Progressive weakness without sensory involvement
A
Which of the following is appropriate for a client with irritable bowel syndrome? a) Broiled chicken, brown rice, salad and a glass of water b) Tuna salad on white bread with grapes and a diet cola c) Grilled steak with carmelized onions, green beans, dinner roll and coffee d) Fried shrimp, salad, baked potato, and a glass of wine
A
You are caring for a patient with an anorectal abscess. What item will you not include in your teaching plan? a) Drink water sparingly to prevent over hydration. b) Proper perineal hygeine, particularly after bowel movements. c) Bulk forming fiber supplements will help keep stools soft and less painful to pass. d) Analgesics will help improve comfort.
A
Which is the nurses' best response when a client asks how the common cold is transmitted?
A cold is spread through droplets from sneezing or coughing and through secretions
A nurse reviews a client's laboratory results. Which results from the client's urinalysis should the nurse identify as normal? (Select all that apply). a) Glucose negative b) pH 6.0 c) Protein: 1.2 mg/dL d) Specific gravity: 1.015 e) Nitrate small
ABD
The nurse has received a change of shift report about the following patients with COPD. Which patient should the nurse assess first?
A patient with a respiratory rate of 38
During routine health screening, a patient is found to have a fasting blood sugar of 132 mg/dL. A dx of diabetes would be made, during a follow-up visit, based on which laboratory result?
A1C of 7.5%
You are completing an admission assessment on a patient admitted with a small bowel obstruction (SBO), which of the following you you report to the provider? (Select all that apply) a) Serum potassium 3.0 mEq/L b) Emesis prior to insertion of NG tube (NGT). c) Hematocrit of 60% d) dry mucous membranes e) WBC 9,500/uL
ABC
You are preparing to discharge a patient that was admitted with peptic ulcer disease (PUD) and bleeding ulcers. You provide education pertaining to behaviors to reduce symptoms and aggravate PUD. What teaching do you provide? Select all that apply. a) H. pylori can be a concern in patients with peptic ulcers b) Sit upright 30-60 minutes after meals c) Extreme vomiting should be reported to your health care provider d) Spices should be added to food to enhance flavor e) The goal of initial intervention is to control symptoms and prevent further complications
ABCE
A 21 year old male reports burning and difficulty with urination. What priority question assists in evaluating the client's concern? a) "Do you have low back pain?" b) "Have you ad a fever in the past 24 hours?" c) "Are you sexually active?" d) "How long have you had these symptoms?"
C
You are caring for a patient with newly diagnosed type 1 diabetes. What information is essential to include in your patient teaching before discharge from the hospital? Select all that apply
Insulin administration, hypoglycemia prevention, symptoms, and treatment, sick day management, management of oral anti diabetic medications
To prevent hyperglycemia or hypoglycemia related to exercise, what should the nurse teach the patient using glucose lowering agents about the best time to exercise?
About 1 hour after eating when blood glucose levels rise
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with heart failure. Which instructions should the nurse provide to the UAP when delegating care for this? Select all that apply.
Accurately record I & O, reposition every two hours, use the same scale to weigh the client each morning
You, as the home care nurse, administered 4 oz of orange juice to the client with diabetes who was experiencing symptoms of shakiness, dizziness and irritability (a mild hypoglycemic episode). The client's clinical manifestations have not changed and a 15 minute repeat FSBS indicates a reading of 60. What is your next best action?
Administer an additional 4 oz of orange juice, or regular soda
Which intervention by the nurse will be the most helpful in promoting ambulation, coughing, deep breathing, and turning by a patient on the first postoperative day?
Administer ordered analgesic medications before these activities
A nurse is preparing to administer an intramuscular (IM) dose of iron to a client with anemia. Which of the following precautions should the nurse take?
Administer the drug utilizing a Z-track technique
Which of the following terms describes the force against which the left ventricle must expel blood (systematic vascular resistance), according to the "balloon theory".
Afterload
The patient puts on their call light and states they are able to see "internal organs" at their incision site. What is the patient describing?
An evisceration
A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best?
Ask the client to describe current feelings
A client is in the family practice clinic, he is noted to have a weight loss of 12%. What action by the nurse is best? a) Determine if there are food allergies or intolerances. b) Gastric weight loss surgery enables a dramatic weight loss with very minimal side effects. c) Ask the client if the weight loss was intentional.. d) Schedule the patient for a comprehensive nutritional assessment.
C
A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? a) Remind the client to remain NPO. b) Tell the client to wait 4 hours. c) Assess the client's gag reflex d) Allow the client cool liquids only.
C
A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? a) Check the surgical incision. b) Program the morphine pump. c) Ensure an adequate airway d) Assess the client's pain.
C
A client with Multiple Sclerosis (MS) asks the nurse to explain the disease. What response by the nurse is the best? a) "MS is a viral infection of the myelin sheath." b) "MS is an inherited destruction of peripheral nerve endings and junctions." c) "MS is an autoimmune disorder which causes patchy demyelinization of the nerves." d) "MS consists of trauma induced paralysis of specific cranial nerves."
C
A nurse is caring for a client who has a urinary tract infection (UTI). Which of the following is the priority intervention by the nurse? a) Encourage increased fluids. b) Offer a warm sitz bath. c) Administer an antibiotic. d) Recommend drinking cranberry juice
C
A nurse is teaching a patient with a new ileostomy about incorporating preventive strategies at home. To prevent excoriation and breakdown of the peristomal skin the nurse should instruct the patient to: a) Apply hydrocortisone cream to the skin when changing the appliance b) Wash the peristomal skin frequently with soap and water c) Empty the pouch when it is no more than half full d) Choose a time shortly after a meal for replacing the pouch
C
A patient is newly admitted to the acute medical care unit. Which laboratory results would support a diagnosis of malnutrition? a) Hemoglobin of 12 g/dL b) Hematocrit of 37% c) Serum albumin 3.5 g/dL d) Pre albumin of 13 mg/dL
C
All of the following are examples of tubes that would be used for short term providing of total enteral nutrition, except? a) Nasoenteric b) Nasoduodenal c) Percutaneous endoscopic gatrostomy (PEG) d) Nasogastric
C
The following test values are returned for a client. Serum BUN 18 mg/dL and Serum Creatinine 1.0 mg/dL. These findings demonstrate? a) The creatinine is low, but the BUN is high b) The The creatinine is normal, but the BUN is high is normal, but the BUN is high c) Both creatinine and BUN levels are within normal limits The creatinine is high, and the BUN is high
C
The symptoms of severe ulcerative colitis include: a) The client may have five or six soft stools per day with some blood visible b) The client will have bloody emesis. c) The client may have abdominal pain, but the stool appearance is normal d) The client may have >20 bloody stools per day
C
Which of the following preoperative interventions would be contraindicated for the client with acute appendicitis? a) Placing the client in a semi-Fowler's position b) Administering IV fluids c) Placing a heating pad on the abdomen d) Keeping the client NPO
C
You are assessing a client with peritonitis. Which clinical manifestations should you expect to find? a) Hyperactive bowel sounds b) Increased urine output c) Abdominal distention d) Bradycardia
C
A client is admitted to the critical care unit with possible Guillain-Barre syndrome. Which symptom of neurologic impairment will require priority nursing interventions? Select all that apply. a) New-onset nausea following a position change b) A respiratory rate of 12 c) New adventitious breath sounds d) A SpO2 reading of 90% e) Rapid, shallow breathing pattern
CDE
A nurse is preparing educational material to present to a female client who has frequent urinary tract infections. Which of the following information should the nurse include? (Select all that apply.) a) Wipe the perineal area back to front following elimination. b) Take a shower daily. c) Empty the bladder when there is an urge to void. d) Wear synthetic fabric underwear. e) Avoid sitting in a wet bathing suit.
CDE
The nurse caring for a client with Guillain-Barre syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? Select all that apply. a) Decrease the amount of fluid intake b) Reposition the patient at least every 4 hours c) Consult with the provider about a physical therapy consult d) Work with nutrition to design a high protein diet e) Keep the skin dry and use heel boots
CDE
Medications to help treat severe hyperkalemia include:
Calcium gluconate, regular insulin, and Kayexalate
You are teaching a patient with hypernatremia that he needs to restrict his intake of sodium. Which foods high in sodium should you tell him to avoid?
Canned soups, ketchup and cheese
A nurse is caring for a client who has heart failure and reports increasing shortness of breath. The nurse increases the client's oxygen per protocol. Which of the following actions should the nurse take next?
Check oxygen saturation with pulse oximeter
The following interventions are planned for a diabetic patient. Which intervention can the nurse delegate to an unlicensed assistive personnel?
Check that the bath water is not too hot
The nurse goes into the room to give a patient with type 2 diabetes mellitus their morning insulin. What is the priority action for the nurse to take if the patient complains of being hungry and is irritable?
Check the patient's blood glucose level
A nurse assesses a client who has pancreatitis. Which clinical manifestation indicates that the condition is chronic rather than acute?
Clay colored stools
A nurse is caring for four clients with anemia. After hand-off report, which client should the nurse see first?
Client who had two bloody diarrhea stools this morning
A nurse is documenting the plan of care for a patient who has type 1 diabetes mellitus that has remained unstable despite conventional insulin therapy. The provider has explained to the patient that the new plan will incorporate the use of a long-acting insulin preparation. The nurse anticipates seeing a prescription for the addition of which of the following insulin preparations?
Insulin glargine (Lantus)
Oral drug therapy agents for diabetes work on the following 3 defects: Select all that apply
Insulin resistance, increased hepatic glucose production, decreased insulin production
A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best? a) Ask the client to call back if this happens again today. b) Tell the client to come in to the clinic this afternoon. c) Ask the client to call back if this happens again today. d) Remind the client that a small amount of bleeding is possible.
D
A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow? a) Blood tinged urine b) Urine output of 30 mL / hr c) Hypotension d) Overflow incontinence
D
The healthcare provider prescribes the following therapies for a client who has been admitted with dehydration and hypotension after 3 days of nausea and vomiting. Which order will the nurse implement first (highest priority)? a) Administer IV ondansetron (Zofran) b) Provide oral care with moistened swabs c) Insert a 16 gauge nasogastric (NG) tube d) Infuse normal saline at 250 mL/hr per order
D
The nurse cares for a client with Amyotrophic Lateral Sclerosis. The client states, "I do not want to be placed on a mechanical ventilator." How should the nurse respond? a) "Using the incentive spirometer each hour will delay the need for a ventilator." b) "You should discuss this with your family and health care provider." c) "Why are you afraid of being placed on a breathing machine." d) "What would you like to be done if you begin to have difficulty breathing."
D
The nurse is advising a client with diverticulitis. Which statement made by the client indicates that additional teaching is needed? a) "I will ride my bike or take a long walk at least three times a day." b) "I will try to include fiber in my diet every day." c) "I will breathe out through my mouth when having a bowel movement." d) "I will take a senna laxative at bedtime to avoid becoming constipated."
D
The nurse notes a bulge in the client's groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings? a) The client has an indirect umbilical hernia b) The client has a strangulated inguinal hernia c) The client has an irreducible femoral hernia d) The client has a reducible inguinal hernia
D
What action should the nurse in the doctor's office anticipate for a client who has had several episodes of new onset diarrhea from an unknown cause? a) Administer antidiarrheal medication b) Teach about the adverse effects of acetaminophen c) Provide teaching about antibiotic therapy d) Obtain a stool specimen for culture
D
When the nurse is assessing a patient with Myasthenia Gravis, which action will be the most important to take? a) Check pupil size and reaction b) Assess level of consciousness c) Monitor bilateral grip strength d) Observe respiratory rate and depth
D
Which clinical manifestation would serve to alert the nurse to the early onset of Multiple Sclerosis? a) Excessive somnolence and periods of loss of consciousness b) Hyper-reactive reflexes, flaccid muscles c) Tachycardia and increased blood pressure d) Blurry vision, increasing urinary urgency and affected balance
D
Which of the following statements regarding chronic sinusitis are true? Select all the apply.
Daily fluid intake should be increased, can be caused by nasal polyps, warm packs over the sinus area will help with comfort, keeping the room humidified will help
A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?
Demonstrate how to splint the abdomen incision
After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations?
Diabetes can cause blindness, so I should see the ophthalmologist yearly
Which of the following assessment questions would be appropriate for the nurse to use when assessing a client for hypertension. Select all that apply.
Do you wake up with headaches, do you use nicotine products, do you consume alcohol products
A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what next action by the nurse is most important?
Double-checking the client and blood product identification
A nurse is preparing to administer morning doses of insulin regular 10 units and NPH insulin 20 units to a client who has a blood glucose of 278 mg/dL. The nurse remembers that it is appropriate to mix the insulin to allow for a single injection for the patient. What would be the appropriate next steps for the nurse to mix the insulin after cleaning both vials with an alcohol pad?
Draw 20 units of air into syringe and inject into the NPH vial
A nurse is caring for a client who has a serum potassium of 5.4 mEq/L. The nurse should assess for which of the following?
ECG changes
After the nurse completes the preoperative teaching, Grace states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurses' best response?
Early movement and ambulation will help prevent complications following your surgery
Which menu choice indicates that the patient understands the nurses' teaching about best dietary choices for iron-deficiency anemia?
Egg, kale and spinach omelet
The client with diabetes getting ready to engage in a 30 minute, moderate intensity exercise program, performs a self-assessment. Which data indicates that exercise should be avoided at this time?
Ketone bodies in the urine
A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find?
Lasts 30 minutes to 2 hours
Signs and symptoms of a patient with a serum Na+ level of 125 meq/mL include:
Lethargy, weakness (limp muscles), orthostatic hypotension, stomach cramping
A nurse is teaching a client with chronic migraine headaches. Which statement should the nurse include in this client's teaching?
Lie down in a darkened room with the head of the bed elevated when you experience a headache
In the client with a history of complex partial seizures, which clinical symptom will the nurse assess for?
Lip smacking, patting and pulling on clothes
A person who is experiencing an acute asthmas attack is admitted to the ED. The nurse's first action should be to:
Listen to the patient''s breath sounds
A patient with diabetes has been diagnosed with sensory neuropathy. What problems should the nurse expect to find in this patient? Select all that apply
Loss of sensation in hands or feet, painless foot ulcers, burning foot pain worse at night
The nurse is teaching the patient with prediabetes ways to prevent or delay the development of type 2 diabetes mellitus. What is the best information to include.
Maintain a healthy weight
A common cause of hypomagnesemia is:
Malnutrition
A nurse is planning care for a client who has a Hgb of 7.5 g/dL and Hct of 21.5%. Which of the following actions should the nurse include in the plan of care? Select all that apply.
Monitor oxygen saturation Schedule daily rest periods Provide assistance with ambulation Obtain stool specimen for occult blood
What instruction should you emphasize when teaching the diabetic client about how to alter diabetes management during a period of illness that includes nausea and vomiting?
Monitor your blood glucose levels at least every 4 hours
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
Most people with hypertension do not have symptoms
Which statement made by a client would alert the nurse to the possibility of right sided heart failure?
My shoes fit really tight
What piece of O2 delivery equipment is used when you want to easily deliver up to 24-44% O2?
Nasal cannula
The clinic nurse reviews the complete blood count (CBC) results for a male client who is scheduled for surgery in one day. The results are RBC 4,800 (4.8 m/uL); WBC 7,200 (7.2 k/uL); Hbg 15 g/dL; Hct 45%. Which action should the nurse take?
No action is needed. These are normal results.
When reviewing the chart of a hospitalized patient, which of the following laboratory results indicates the need for rapid assessment of the patient?
Noon finger stick blood sugar of 52 mg/dL
A 59 year old man is scheduled for a herniorrhaphy tomorrow. During the preoperative evaluation he reports that he has been taking the supplement ginkgo biloba daily. What is the priority intervention?
Notify the anesthesia care provider
The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." What action is best for the nurse to take?
Notify the surgeon that the patient needs more information on the planned surgery
The nurse assesses a patient with Vitamin B12 deficiency (pernicious anemia). Which assessment finding would the nurse expect?
Numbness and tingling of the extremities
A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take when admitting the patient pre-operatively?
Obtain a blood glucose measurement before any insulin is administered
A patient with chronic obstructive lung disease has a NDx of imbalanced nutrition: less than body requirements. An appropriate intervention for this problem is to:
Offer high calorie snacks between meals and at bedtime
Postoperatively, the nurse assesses an area of drainage on the dressing of a patient's surgical wound and note's a quarter size area of pink drainage underneath the dressing. Which of the following should the nurse do?
Outline the area and mark it with a date and time
A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this client's teaching? Select all that apply
Pat the feet dry, especially between the toes, trim your toenails straight across with an emery board, do not walk around barefoot
A client who had a surgical repair of a hip fracture 2 days previously, has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for this patient is?
Potential complication: venous thromboembolism
A nursing student is to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium?
Preparing the medication for IV bolus administration
How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work to reduce heart failure?
Reduce afterload
A patient is prescribed insulin to be given through an IV line (port). The nurse knows that which of the following types of insulin can be administered intravenously?
Regular
Which of the following should the nurse instruct a client who desires to reduce his blood pressure through increasing his physical activity?
Regular aerobic exercise 3 times/week has the greatest effect on controlling blood pressure
The nurse is implementing a discharge teaching plan for a client with heart failure. When discussing fluid status with the client, the nurse would explain the importance of doing which of the following?
Report a weight gain of 4 or more pounds in a week
A patient with COPD is admitted to the hospital. How can the nurse best position the patient to improve gas exchange?
Resting in bed with the head elevated and a bedside stand to lean on
A client with vitamin B12 deficiency anemia has been taught to eat foods high in Vitamin B12. Which meal selected by the client indicates that he or she understands the prescribed diet?
Salmon, spinach salad and milk
Which of the following laboratory test results will the nurse monitor when evaluating if treatment is effective for a 62 year old who has acute pancreatitis?
Serum Amylase
The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the healthcare provider?
Serum creatinine of 2.8 mg/dL
A nurse is providing education to a newly diagnosed patient with type 1 diabetes. Which of the following types of insulin should the nurse tell the patient to expect onset of action 30 minutes to 1 hour after administration?
Short acting
A female client is admitted to the hospital with a hemoglobin of 10 g/dL. When assessing this client, the nurse should expect which symptom?
Shortness of breath with exertion
gross pressure ulcer
Stage 3
The nurse is evaluating the hydration status of the patient. If the patient is hypovolemic, the nurse expects to observe which type of cardiovascular change?
Tachycardia with weak peripheral pulses and flat neck veins
A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care?
Take a deep breath in through your nose
A patient is transferred from the postanesthesia care unit (PACU) to the surgical floor. Which would be the first action by the nurse on the clinical unit receiving the patient?
Take the patient's vital signs
Patient teaching on how to take oral calcium supplements should include all but which of the following?
Take with a full meal to avoid stomach upset
A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important?
Taking a set of vital signs and notifying the surgeon
A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as possible contributors to this client's condition? Select all that apply.
Taking oral contraceptives Recent weight loss of 50 pounds in past 6 months BMI (body mass index) of 46 Type II diabetes
A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test?
Tap lightly on the clients face just anterior to the ear
When a client is experiencing a migraine headache, the nurse will plan to assess for?
Tearing of the eyes with a runny nose
The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should:
Tell the client they can resume their normal activities in 1 - 3 weeks.
A nurse is assigned to care for a group of patients. On review of the client's medical records, the nurse determines that which client is at risk for excess fluid volume?
The client with renal failure
The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test?
Thoracentesis
An 83 year old with heart failure develops hypokalemia as a result of her diuretic therapy. You suggest that she increase her dietary intake of potassium. Which foods should she consume?
Tomatoes, bananas, and baked potatoes
A meal or snack with protein should be provided to the client who has been treated for hypoglycemia within one hour of the hypoglycemic episode.
True
Hypoglycemia symptoms can include mild shakiness, mental confusion, and headache all the way to seizures and coma.
True
Partial thromboplastin time (PTT) is increased with enoxaparin (Lovenox) therapy.
True
Pre-operative medications are given to inhibit gastric secretion and help prevent aspiration.
True
Serum hematocrit levels can be affected by a patient's hydration (volume) status?
True
The nurse is assessing the patient's serum sodium level and notes that the value is elevated. This could relate to the patient being hypovolemic.
True
The systolic blood pressure range for pre-hypertension classification is 120-139 with a diastolic of 80-89.
True
The first 24 hours after surgery, when caring for a patient following an incisional (open) cholecystectomy for cholelithiasis, the nurse places the highest priority on assisting the patient to:
Turn, cough, and deep breathe every 2 hours
The nurse is conducting nutrition counseling for a patient post cholecystectomy. Which of the following information is important to communicate?
The patient should limit fatty, gas forming foods.
A client comes to the clinic with an acute asthma episode. Which breath sound does the nurse expect to find upon auscultation?
Wheezing in all lobes
When auscultating breath sounds in the client with an acute asthmas episode, the nurse uses which of the following to guide interpretation of severity of findings?
Wheezing may be absent with severe airway obstruction
A male client with cholecystitis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to find?
Yellow sclera
List four observations you would document for a patient who is experiencing a seizure
a) Duration b) type of seizure c) nursing interventions d) clients VS and LOC after the seizure
The home care nurse is making a follow-up visit to a client who had a total hip replacement surgery 2 weeks ago. Which statement made by the client indicates a need for further teaching regarding her postoperative routine?
a. "Now that I am stronger, I no longer need the raised toilet seat."
The nurse working in the opthamology clinic sees clients with eyelid and eye problems. Which statements listed below are accurate about these disorders? (SATA)
a. a hordeolum is a bacterial infection causing localized swelling of the eyelid c. a chalazion is an inflammation of the eyelid sebaceous gland d. blepharitis causes greasy scales on brows
The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best?
a. assess neurovascular status in the leg
a. multiple fracture lines b. fracture with bone penetrating through skin c. circular fracture up through the bone d. bone fragments that are not in alignment e. repetitive use fracture
a. comminuted fracture b. open fracture c. spiral fracture d. displaced fracture e. stress fracture
What is the primary difference between healing by primary intention and healing by secondary intention?
a. healing by secondary intention takes longer because more steps in the healing process are necessary
Which dietary choice is best for a client who has been identified as being at risk for imbalanced nutrition and formation of pressure ulcers?
a. high protein diet with vitamins and mineral supplements
A nurse is discussing home care for a client who will be discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (SATA)
a. install grab bars in the shower and by the toilet c. remove all throw rugs throughout the house d. buy and install an elevated toilet seat e. use a shower chair while taking a shower
Which of the following instructions would be provided for suture/stitches care? (SATA)
a. return to the physician for removal in approximately 7 days b. keep the sutures clean and dry c. report any redness or drainage
a. systemic disease b. Heberden's nodes c. ulnar deviation d. aggravated by activity e. worse when awakening
a. rheumatoid b. osteoarthritis c. rheumatoid d. osteoarthritis e. rheumatoid
The following statement describes psoriasis
a. thick, reddened plaques covered by silvery, white scales
A patient is hospitalized for treatment of severe anemia. An appropriate nursing action for the patient is to:
alternate periods of rest and activity
An older adult client in the family practice clinic reports a decrease in hearing over the last week. Which action by the nurse is most appropriate?
assess for cerumen buildup
A plan of care for the patient with COPD should include: Select all that apply. a) high flow rate of O2 administration b) exercise such as walking c) decreased fluid intake to reduce sputum production d) use of long term medications to control symptoms e) breathing exercises such as pursed-lip breathing that focuses on exhalation
b, d, e
A nurse is caring for an older adult client with a right hip fracture with surgery scheduled for the next morning. Which of the following skin immobilization devices should the nurse anticipate will be used for this client preoperatively.
b. Buck's traction
The patient is diagnosed with suspected hearing loss. Which precautions would the nurse teach the patient and his family about ear care before discharge? (SATA)
b. ear plugs should be used when engaging in all water sports to avoid infection. c. use an ear irrigation syringe to remove built up ear was (cerumen) d. nothing smaller than a fingertip should be inserted into the ear canal e. avoid exposure to loud musing or other noises
The client with a leg cast denies pain, toes are pink, capillary refill is brisk and toes move freely. The leg is elevated with an ice pack. Six hours later, the patient reports worsening pain, especially with movement, unrelieved by medication. The patient's toes are cool and capillary refill is sluggish. What does the nurse suspect is occurring with this client?
b. acute compartment syndrome
When teaching a client with contact dermatitis of the legs ways ways to decrease pruritus, which information will the nurse include? (SATA)
b. add oiled oatmeal to your bath water to aid in moisturizing the affected skin c. take a bath in lukewarm water 3-4 times a day e. use over the counter antihistamine medication to reduce itching
A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best?
b. arrange a home safety evaluation
Which of the following should be included when instructing a client with a cast? (SATA)
b. do not scratch under the cast c. one finger should be able to be inserted between the cast and skin e. inspect the cast daily
A client came to the emergency department after accidently puncturing his hand with an automatic nail gun which penetrated into the bone. Which disorder is this patient primarily at risk for?
c. osteomyelitis
The nurse is caring for a client who is recovering from an above the knee amputation of the right leg. The client reports pain in the limb that was removed. How should the nurse respond?
d. "How would you describe the pain that you are feeling?"
The use of percutaneous pins or wires to stabilize a fracture is called?
d. external fixation
The type of dressing which is absorbent and pulls fluid away from the wound is termed?
d. hydrophilic
A nurse caring for a patient observes that the patient has small red lesions flush with the skin on the body. The patient complains of severe itching at the sites, particularly at night. What further assessment should the nurse perform?
d. the presence of burrows between the fingers and anterior axillary folds
Which clinical manifestation alerts the nurse to the onset of acute angle-closure glaucoma?
excruciating pain in or around the eyes
Which of the following statements regarding nursing interventions with joint replacement are correct (SATA)
idk if these answers are right or not b. a pillow or abductor pillow should be placed between the knees for turning with hip surgery c. limb shortening is a sign of hip displacement d. a continuous passive motion machine may be used at night for hip surgery
