ATI AH

A nurse is teaching a client who has addisons disease about healthy snack foods. Which of the following food choices by the client indicated an understanding of the teaching

a client who has addisons disease requires a diet low in potassium, high in Na, carbs, and protien.

a nurse is providing preoperative teaching for a client with colorectal cancer who is scheduled to undergo a colostomy placement with a perineal wound. which of the following statements by the client indicates an understanding of the teaching?

"I can only have liquids for 2 days prior to the surgery"- to decrease bulk. client should consume a low residual diet for several days prior to surgery to decrease peristalsis. colostomy will begin to function 2-4 days after surgery

A nurse is teaching a client about the Prostate pecific antigen PSA test. which directions should the nurse provide?

DONT ejaculate 24 hrs prior bc this can falsely elevate PSA - values increase as you age

A nurse is providing teaching to a client who has stomatitis as a result of chemotherapy and radiation. Which indicated a need for further teaching?

I will use glycerine lemon swabs to clean my mouth

A nurse is assessing a client who has manifestations of acromegaly which of the following findings should the nurse expect?

Increased head size- these patients will also have barrel shaped chest , vocal deepening, and thickened skeletal

a nurse is caring for a client who has a prescription of silver sulfadiziazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following lab findings?

Leukopenia- this is an adverse effect

A nurse is teaching a client who has chronic kidney disease. Which instructions should the nurse include

Limit fluid intake- a client who has CKD should limit fluid to prevent hypervolemia (FVE)

a nurse is assessing a client who is recieving a unit of whole blood. which of the following findings indicated a hemolytic transfusion reaction?

Low back pain- other manifestations include tachycardia, tachypnea, dark urine, headache, and chest pain

A nurse is caring for a client who has a demand pacemaker inserted with a set rate of 74/min. Which of the following findings should the nurse expect?

Tele monitoring showing QRS complexes occuring at a rate of 74/min with no pacing spikes

a nurse in planning to administer cisplatin IV to a client with lung cancer. The nurse should identify that which of the following findings is an adverse effects of this medication

Tinnitis- ototoxicity

A nurse is caring for a client ho has a large wound healing by secondary intention. the nurse should inform the client that which of the follolwing nutrients aids in healing in addition to protien

Vitamin C

A nurse is teaching breathing techniques to a client who has emphysema. which of the following statements indicates that the client understands the mechanism of pursed lip breathing

When I breathe out through pursed lip breathing my airways dont always collapse between breaths

A nurse is performing an assessment of a client who is about to undergo a cholycyctectomy the nurse should identify a risk for latex allergy if the client is allergic to

banannas- or avocados kiwi mangoes, pinneapple, or passion fruit

A nurse is caring for a client who is postop following a radial mastectomy, which of the following interventions should the nurse include in the plan

begin exercises with the client 1 day after procedure- the nurse should also plan to elevate the arm to promote return of lymphatic fluid, avoid flexing the arm to prevent contractures, plan to ambulate the client on the first day postop to increase mobility, ventilation and circulation

A nurse is assessing a patient with pericarditis which of the following should the nurse expect?

dypsnea with hiccups- and a nonproductive cough these manifestations can indicate heart failire, from pericardial compression

a nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with a colostomy. which of the following statements by the nurse indicates a need for further teaching?

ill have to consume a soft diet after surgery- after surgery the client quickly returns to a regular diet and there are no food restrictions unless the client chooses to decrease intake of foods that increase gas or odor

a nurse in the ER is caring for a client who has a snakebite on her arm. which of the following interventions should the nurse implement?

immobilize the limb at the level of the heart- limit spread of the venom. any constrictive clothing or jewelry should be removed before swelling occurs, affected limb should be immobilized at the level of the heart

A nurse is assessing a client who has several risk factors for osteoporosis. Which of the following findings indicate that the client needs additional teaching

lower back pain- this is common among patients

A nurse is assisting a provider with a comprehensive physical examination of a client. When the provider uses transillumination, the nurse should explain to the client that this technique helos visualize and evaluate which structure

maxillary sinuses

A nurse is planning care for a client who has thrombocytopenia. which of the following should the nurse plan to include in the care.

measure the clients abdoment daily - s/s of internal bleeding, check IV sites every 2 hours not every 4!

a nurse is teaching a client who has osteoporosis which of the following instructions should the nurse include in the teaching?

perform weight bearing exercises - use heat rather than cold compresses, and eat 1200-1500mg of calcium daily rather than 900

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the clients question about the dressing, the nurse explains that it is obtained from which of the following sources?

pig skin- homographs are from cadaver skin, artificial skin made from beef collagen is used to treat burns however it is not a heterograft

A nurse is providing teaching to a client who is wheelchair bound and his caregiver about ways to reduce pressure injiru formation. which of the following information should the nurse include

shift your weight in the wheelchair every 15 minutes- if wheelchair bound change position every 1hr and

A nurse is planning care for a client following placement of a chest tube 1hr ago. which of the following actions should the nurse include in the plan of care

tape all connections between the chest tube and drainage system- nurse should avoid clamping unless the drainage system needs to be replaced or there is an air leak. the nurse should now empty the collection chamber system unless it is almost full.

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following?

third degree frostbite

a nurse is providing discharge teaching to a client who is post-op following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a moles potential malignancy.

ulceration- ulceration, bleeding and exudate are indications of possible malignancy. size increasing is also a warning sign. self examen every month and follow up

a nurse is preparing a client for a bone marrow biopsy. which of the following pieces of information should the nurse include in the preoperative teaching

you'll feel a painful pulling sensation when the doctor withdraws the bone marrow- as well as some discomfort from the rotation of the needle in the bone marrow