Chronic Evolve Adaptive Outline
Which finding is an indication of ulcer perforation in a client with peptic ulcer disease (PUD)? Select all that apply. One, some, or all responses may be correct. Tachycardia Hypotension Rigid abdomen Nausea and vomifing Back and shoulder pain
Tachycardia Hypotension Rigid abdomen Nausea and vomifing Back and shoulder pain
Which would the school nurse's first action be when a child reports a sore throat?
Examine the throat.
The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome?
Fluid and electrolyte balance
Which type of emergency assessment is being performed when the nurse is inserting a gastric tube and arranging for diagnostic studies for a client who sustained injuries after a bus accident?
Focused adjuncts
Which health care system focuses solely on palliative care?
Hospice
Which dressings would the nurse view as beneficial for the recovery of a client's red-colored wound that was caused by pressure? Select all that apply. One, some, or all responses may be correct. Absorptive dressings Hydrocolloid dressings Transparent film dressings Moist gauze dressings with antibiotics Non-adhering dressings with antibiotic ointment
Hydrocolloid dressings Transparent film dressings Non-adhering dressings with antibiotic ointment
Which finding would the nurse document as normal for a second, postabdominoperineal resection stoma?
Moist, red, and raised above the skin surface
The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. Which is an important nursing intervention?
Observe the client for increasing confusion.
The nurse is caring for a client who has cancer of the rectum and is scheduled for an abdominoperineal resection with creation of a colostomy. For which type of surgery would the nurse prepare the client?
Permanent sigmoid colostomy
A client with an acute attack of cholecystitis has a cholecystectomy with a choledochostomy. The client returns from surgery with a T-tube connected to a drainage bag. What would the nurse conclude is the purpose of the T-tube?
Permit drainage of bile
Which definition of photophobia is accurate?
Persistent abnormal intolerance to light
For which purpose would the nurse use hypoallergenic tape or Montgomery straps in postoperative skin care?
Protecting the fragile skin of the older client
A health care provider discusses with a client the need for an abdominoperineal resection and a colostomy. After the health care provider leaves the room, the client tells the nurse about being relieved that only minor surgery is necessary. Which psychological process explains this client's reaction?
Repudiation
Which eye problem is the leading cause of blindness in clients with diabetes?
Retinopathy
An older adult is hospitalized for weight loss and dehydration due to nutritional deficit. Which factor would the nurse consider when planning care for this client?
The nutritional needs of an older adult are basically unchanged except for a decreased need for calories.
Which rational supports administering the medication pregabalin to a client with acquired immunodeficiency syndrome (AIDS)?
To reduce neuropathic pain
Which is the middle layer of the eyeball?
uveal tract
A child died from injuries sustained in an explosion at school. Which response will the emergency department nurse give to the parents who ask to see their child?
"You can see your child now and spend time with her."
Place the stages of the grieving process according to Kübler-Ross in the correct order.
1. Denial 2. Anger 3. Bargaining 4. Depression
A client with epilepsy is prescribed phenytoin for seizure control. Which instruction about phenytoin will the nurse provide during discharge teaching?
"Antiseizure medications will probably be continued for life.
A client with terminal bone cancer is to receive 2 mg of hydromorphone intravenously (IV) every 4 hours as needed for severe breakthrough pain. The vial contains 10 mg/mL. When the client reports severe pain, how much solution of hydromorphone would the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable.
0.2 mL
A family has decided to withhold extraordinary care for a newborn with severe congenital abnormalities. How would the nurse interpret this decision?
The newborn is being allowed to die.
Which pain-related clinical manifestation would the nurse expect in a client who had received a diagnosis of a peptic ulcer?
The pain occurs 1 to 2 hours after having a meal.
During a health symposium the nurse teaches the group how to prevent food poisoning. Which statement by one of the participants indicates the teaching is understood?
"Meats and cream-based foods need to be refrigerated."
A nursing student is listing factors that may improve the quality of life of clients in the community with chronic leg ulcers. Which factor listed by the nursing student needs correction?
"inform clients that the cost of care may be expensive and that the level of pain may increase.
A dient is scheduled for a colonoscopy, and the health care provider prescribes a tap water enema. In which position should the nurse place the client during the enema?
(•) Left Sims
Which rationale explains why the nurse also monitors a client with a history of gastroesophageal reflux disease (GERD) for clinical manifestations of heart disease?
Esophageal pain may imitate the symptoms of a heart attack.
Which client would the nurse see first among this group of clients?
A 2-year-old client with diarrhea
A client with a diagnosis of incarcerated hernia asks the nurse for an explanation of the condition. Which description should the nurse give?
A piece of the intestine has become stuck in a hole in the abdominal wall.
According to Kübler-Ross' theory of death and dying, which stage is a terminally ill client displaying by gradually moving towards resolution of feelings about impending death?
Acceptance Stage
A client expresses a complete lack of interest in food. How would the nurse document this finding in the client's medical record?
Anorexia
A client has a large, open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing?
Cleanse the wound with wet, sterile gauze from the center of the wound outward.
The nurse provides education to a client about colostomy care. To be effective when providing the teaching, the nurse would start with which step?
Assess barriers to learning colostomy care.
A client who is being treated for uncontrolled hypertension develops a nosebleed. After applying pressure to the nose, which action would the nurse take next?
Assess the clients BP
A terminally ill client is receiving a morphine drip that exceeds the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. Which action will the nurse take?
Assess the pts pain before increasing the dose of morphine
The nurse has taught a client about a low-sodium diet. Which food choice by the client indicates successful learning?
Banana
A client with terminal cancer says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving would the nurse conclude the client is experiencing?
Bargaining
While obtaining the client's health history, which factor would the nurse identify that predisposes the client to type 2 diabetes?
Being 20 pounds (9 kg) overweight
Which food or drink would the nurse instruct a client with a new colostomy to avoid because it produces large amounts of gas?
Cabbage
A client with a high cholesterol level says to the nurse, "Why can't I take a medication that will eliminate all of the cholesterol in my body so it isn't a problem?" The nurse explains that some cholesterol is needed to perform which body function?
Cellular membrane structure
A client with known peripheral arterial disease calls the clinic and tells the nurse about experiencing several symptoms. Which symptom requires the most rapid action by the nurse?
Chest pain
The nurse asks the client to shrug the shoulders and to turn the head against passive resistance. Which cranial nerve is involved in this action?
Cranial nerve XI
Which information would the nurse provide a client with a new colostomy about managing the appliance?
Cut opening 1/8- to 1/16-inch larger than stoma.
Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion?
Cyanosis
Which test provides information on bladder capacity, bladder pressure, and voiding reflexes?
Cystometrography (CMG)
Which finding in older adult clients is associated with aging?
Decrease in height
According to Kübler-Ross, during which stage of grieving are individuals with serious health problems likely to seek other medical opinions?
Denial
Which hormone may cause vaginal carcinoma in a female child after birth?
Diethylstilbestrol
An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult, the nurse recalls which expected sensory losses associated with aging? Select all that apply. One, some, or all responses may be correct. Difficulty in swallowing Diminished sensation of pain Heightened response to stimuli Impaired hearing of high frequency sounds Increased ability to tolerate environmental heat
Diminished sensation of pain Impaired hearing of high frequency sounds
Assessment findings of a client who is admitted to the emergency department include cramping pain in the left lower quadrant, weakness, bloating, malaise, and a low-grade fever. The nurse suspects which condition?
Diverticulitis
An adolescent having premenstrual syndrome displays pelvic fullness, irritability, depression, fatigue, and backaches. Which instructions would the nurse provide to help obtain relief? Select all that apply. One, some, or all responses may be correct. Follow stress reduction techniques. Do aerobics three to four times a week. Take nonsteroidal anti-inflammatory drugs (NSAIDs) or progesterone. Consume sugar, salt, red meat, alcohol, and coffee regularly. Eat food rich in complex carbohydrates and fiber in three small portions.
Follow stress reduction techniques. Do aerobics three to four times a week. Take nonsteroidal anti-inflammatory drugs (NSAIDs) or progesterone. Eat food rich in complex carbohydrates and fiber in three small portions.
Which age-related effects on the immune system occur in the older client?
Increased autoantibodies
The registered nurse (RN) delegates the tasks of caring for a client with pressure ulcers. The client suffers further tissue necrosis during treatment. Which factor could result in further tissue damage?
Irrigation of the wound by the patient care associate (PCA)
A client is scheduled for a pyloroplasty and vagotomy because of strictures caused by ulcers unresponsive to medical therapy. Which information about the purpose of a vagotomy would the nurse include in the client's education?
It decreases acid in the stomach.
A 15-year-old adolescent is found to have type 1 diabetes. Which would the nurse include when teaching the adolescent about type 1 diabetes?
It has a more rapid onset than does type 2 diabetes.
Which information obtained by the nurse about a client would represent risk factors for the client's admission diagnosis of hypertension? Select all that apply. One, some, or all responses may be correct. Daily use of 1 aspirin Occasional cocaine use Reduced hemoglobin level African American heritage Increased high-density lipoprotein (HDL)
Occasional cocaine use African American heritage
Which guideline would the nurse consider when planning care for a hospitalized older client with Alzheimer disease?
Routines provide stability for clients with neurocognitive disorders.
The primary health care provider instructs the nurse to manage fluid replacement therapy in a client with cancer. Which type of care is the client receiving?
Supportive care
Which recommendation is important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet?
Use lemon juice to season meat.
How would the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate?
Yellow
The nurse is caring for a client with cholelithiasis. Which clinical manifestation would the nurse expect if the client develops obstructive jaundice?
Yellow sclera
When teaching a client about digoxin, which symptom will the nurse include as a reason to withhold the digoxin?
Yellow vision
A client with end-stage renal disease has a mature arteriovenous (AV) fistula. Which interventions would the nurse include in the client's plan of care? Select all that apply. One, some, or all responses may be correct. Auscultate the fistula for the presence of a bruit. Palpate the site to identify the presence of a thrill. Irrigate the fistula with saline to maintain patency, Avoid drawing blood from the affected extremity. Keep the fistula clamped until ready to perform dialysis.
Auscultate the fistula for the presence of a bruit. Palpate the site to identify the presence of a thrill. Avoid drawing blood from the affected extremity.
Which laboratory value supports the presence of diabetic ketoacidosis in a client with type 1 diabetes?
Increased blood urea nitrogen levels
Which laboratory value supports the presence of diabetic ketoacidosis?
Increased serum lipids
The nurse is working in a palliative care setting. Which members of the health care team would the nurse identify as providing ancillary services to clients? Select all that apply. One, some, or all responses may be correct. Pharmacists Spiritual advisors Occupational therapists Primary health care providers Unlicensed assistive personnel (UAP)
Pharmacists Occupational therapists Unlicensed assistive personnel (UAP)
After obtaining client blood pressures of 172/104 mm Hg and 164/98 mm Hg during a blood pressure screening, which action would the nurse take next?
Refer the client to a primary health care provider.
After numerous diagnostic tests, a client with jaundice receives the diagnosis of pancreatic cancer. Which rational explains the cause of the client's jaundice?
Obstruction of the common bile duct by the pancreatic neoplasm
The nurse is providing dietary teaching to a client receiving a high-protein diet while recovering from an acute episode of colitis. Which would the nurse include in the rationale for this diet?
Repairs tissues
The nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. Which instruction would the nurse include in the teaching plan? Select all that apply. One, some, or all responses may be correct. The client should obtain a finger-stick blood glucose reading before each meal. The client does not need to follow a specific diet until insulin is required. The teaching plan should include signs and symptoms of hypoglycemia. The teaching plan should include how to administer regular insulin. The teaching plan should include sick day rules.
The client should obtain a finger-stick blood glucose reading before each meal. The teaching plan should include signs and symptoms of hypoglycemia. The teaching plan should include sick day rules.
A teenager is being discharged with a cast. Which would the nurse recommend if the client experiences pruritus around the cast edges?
"Put an ice pack on the affected area."
A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, which would the nurse emphasize?
For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful.
A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. Which topic would the nurse include in the postoperative care teaching?
Gastric suction
Which description would most likely fit the wound healing process shown in the figure?
Gradual filling of the cavity with connective tissue
Which action would the nurse take for an older client with Alzheimer disease who has laid out several outfits on the bed to wear to a recreational session but is still wearing nightclothes?
Help the client select appropriate attire and offer to help the client get dressed.
Which assessment parameter is used to determine the severity of blood loss in a client with an upper gastrointestinal (UGI) bleed? Select all that apply. One, some, or all responses may be correct. Hematocrit Hemoglobin Platelet count Oxygen saturation Blood urea nitrogen (BUN)
Hematocrit Hemoglobin Platelet count Oxygen saturation Blood urea nitrogen (BUN)
The nurse educator of a college health course is discussing tattoos with the class. Which type of hepatitis associated with tattoos would the nurse include in the teaching plan?
Hepatitis C
Which condition would the nurse question using a negative-pressure wound treatment device?
Hip wound with slight bleeding
A client had a pancreaticoduodenectomy for cancer of the pancreas. The nurse provides education about long-term complications related to this type of surgery, including information about hypoinsulinism. The nurse would instruct the client to report which symptom that may be indicative of the complication?
Increased thirst
A client has been diagnosed with cholelithiasis. Which fact about the condition would the nurse recall when assessing this client for risk factors?
Individuals who are obese are more prone to this condition than those who are thin.
A client who previously resided in a foreign country has a chronic vitamin A deficiency. Which information about vitamin A would the nurse consider when assessing the client?
It is a necessary element of rhodopsin, which controls responses to light and dark environments.
The nurse is caring for a client who has cachexia. Which information about the function of adipose tissue in fat metabolism will assist the nurse in meeting the needs of the client?
It stores triglycerides for energy reserves.
Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation?
Leave a dim light on in the client's room at night.
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? Select all that apply. One, some, or all responses may be correct. Diplopia Skin rash Leg cramps Tachycardia Muscle weakness
Leg cramps muscle weakness
A client with type 1 diabetes for 25 years states, "I have been really bad for the past 15 years. I have not paid attention to my diet and have done little to control my diabetes." Which common complications of diabetes might the nurse expect to identify when assessing this client? Select all that apply. One, some, or all responses may be correct. Leg ulcers Loss of visual acuity Thick, yellow toenails Increased growth of body hair Decreased sensation in the feet
Leg ulcers Loss of visual acuity Thick, yellow toenails Decreased sensation in the feet
A client is admitted to the hospital with a diagnosis of Crohn disease. Which is important for the nurse to include in the teaching plan for the client?
Meeting nutritional needs
A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a flapping tremor. Based upon this assessment, which prescribed diet would the nurse anticipate?
Moderate protein
Which medication would the nurse identify as a potential cause for the formation of abnormally small eyes in the newborn if used during pregnancy?
Nitrofurantoin
Which would the nurse do to understand the nature of a client's pain? Select all that apply. One, some, or all responses may be correct. Cover the area of discomfort. Observe where the client locates the pain. Refrain from touching the area of tenderness Note whether the pain radiates to any other part of the body. Instruct the client not to moves so as not to increase the pain.
Observe where the client locates the pain. Note whether the pain radiates to any other part of the body.
On the third postoperative day after a subtotal gastrectomy, a client reports severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. Which action would the nurse perform first?
Obtain the client's vital signs.
Which intervention would the nurse use to provide emotional support for a resident in a nursing home who recently immigrated from another country?
Offer choices consistent with the resident's heritage.
Which statement is true about older adults and type 2 diabetes?
Older adults seldom develop ketoacidosis.
The nurse is caring for a client with suspected appendicitis. Which assessment finding would the nurse determine would further support the diagnosis?
Pain in right lower quadrant
Which type of nerve helps the client's pupil constrict?
Parasympathetic-motor
Which finding indicates that a client is at an increased risk for colorectal cancer (CRC)? Select all that apply. One, some, or all responses may be correct. Presence of dark, tarry stools Family history of polyposis 20-year history of ulcerative colitis Unintentional 20-pound weight loss Change in bowel pattern for 3 months
Presence of dark, tarry stools Family history of polyposis 20-year history of ulcerative colitis Unintentional 20-pound weight loss Change in bowel pattern for 3 months
Which is the primary reason an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium is prescribed for a client with a nasogastric (NG) tube set to low intermittent suction?
Prevent electrolyte imbalance
A client recently had an abdominoperineal resection and colostomy. While the nurse changes the dressing, the client states, "You think that it looks repulsive." The nurse identifies that the client as using which defense mechanism?
Projection
The nurse is caring for a client with a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy?
Readiness to accept an altered body function
The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? Select all that apply. One, some, or all responses may be correct. Diarrhea Bradycardia Rebound tenderness Diminished bowel sounds Rigid, boardlike abdomen
Rebound tenderness Diminished bowel sounds Rigid, boardlike abdomen
Which factor can be used to determine the source of infection in a client who tests positive for Giardia lamblia? Select all that apply. One, some, or all responses may be correct. Sexual orientation Past antibiotic use Recent camping trips Raw egg consumption Canned vegetable intake
Recent camping trips
A hospice client who has severe pain asks for another dose of oxycodone. Which consideration is the nurse's primary concern when responding to the client's request?
Reduce the client's pain
Which information would the nurse provide for a client who is discharged from the health care facility with a surgical wound? Select all that apply. One, some, or all responses may be correct. Potential drug-drug interactions Skill to care for the surgical wound Safe and effective use of medications List of appropriate community resources Need to report any change in the surgical area
Skill to care for the surgical wound Safe and effective use of medications List of appropriate community resources
Which sign in the newborn infant would reflect an Apgar score of I in the category of respiration?
Slow, weak cry
A client with a terminal illness is grateful for the care received in the hospital and has slowly started to come to terms with imminent death. The nurse recognizes that the client's behavior and attitude are most consistent with which cultural group?
Somalian culture
A recently hospitalized client with multiple sclerosis voices a concern about generalized weakness and fluctuating physical status. Which nursing intervention is the priority for this client?
Space activities throughout the day.
After consistently obtaining a blood pressure of 140/76 mm Hg for a client, which stage of hypertension will the nurse document?
Stage 2
A client dies while several family members are in the room. Which intervention will the hospice nurse initially use during the shock phase of a grief reaction?
Stay at the bedside with the family and the deceased.
A client is scheduled for a cholecystectomy and asks the primary nurse about the function of the gallbladder. Which explanation would the nurse give?
Stores and concentrates bile
Which are the current leading causes of death in the United States? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected Stroke Cancers Dementia Accidents Infections
Stroke Cancers Dementia
Which accurately describes hospice care?
System of family-centered care that allows clients to remain at home in comfort while easing the pains of terminal illness
During history-taking, the nurse discovers that a client takes megadoses of vitamin A. How would the nurse interpret this finding?
The body stores excess vitamin A, even in toxic amounts.
The nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. Which type of pain would the client experience?
Visceral pain
Which response would the nurse make to a client whose spouse recently died and who says, "What's the use in talking? I'd rather be dead. I can't go on without my spouse"?
"Are you thinking about killing yourself?"
A client is experiencing chronic constipation, so the nurse discusses how to include more bulk in the diet. Which statement by the client indicates teaching by the nurse is successful?
"Bulk promotes defecation by absorbing water, which softens stool and promotes peristalsis."
A client with invasive carcinoma of the bladder is scheduled for a cystectomy and an ileal conduit. The client expresses worries about the possibility of offensive odors associated with the urinary diversion. How would the nurse respond?
"Tell me more about your concerns."
The health care provider prescribes haloperidol 0.5 mg intramuscularly (IM). The haloperidol is available in a vial that contains 2 mg/mL. How much solution will the nurse administer? Record your answer using two decimal places. Include a leading zero if applicable.
0.25 mL
Which of these clients seen at a health fair will be most at risk for hypertension?
62-year-old African American man
Which of these clients in the vascular clinic would the nurse assess first?
65-year-old who reports tearing abdominal pain and has a history of uncontrolled hypertension
An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontological implications the nurse must consider? Select all that apply. One, some, or all responses may be correct. Assessment of skin turgor Documentation of vital signs Assessment of intake and output Administration of antiemetic medications Replacement of fluid and electrolytes
Assessment of skin turgor documentation of vital signs Administration of antiemetic medications Replacement of fluid and electrolytes
A client is admitted to the hospital after 2 days of painful abdominal spasms and severe diarrhea. Which appropriate sequence does the nurse use to examine the client's abdomen starting with inspection?
Auscultation, percussion, palpation
A client is diagnosed with chronic pancreatitis. Which dietary instruction is important for the nurse to share with the client?
Avoid ingesting alcoholic beverages.
Which physiological changes would the nurse expect to find in a client with a 20-year history of type 2 diabetes?
Blurry, spotty, or hazy vision
The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause?
Bowel obstruction
Which information to promote self-management would the nurse provide to a client being discharged with a new ileostomy? Select all that apply. One, some, or all responses may be correct. Consume 1000 mL/day of fluid. Limit alcohol to one or two glasses daily. Include plenty of nuts and seeds in the diet. Change the appliance every 4 to 7 days. Empty the ostomy pouch when it is two-thirds full.
Change the appliance every 4 to 7 days.
A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply. One, some, or all responses may be correct. Chemotherapy Repositioning Regular oral care Blood transfusion Radiation therapy
Chemotherapy Blood transfusion Radiation therapy
Which type of bone tumor occurs most commonly in elderly clients?
Chondrosarcoma
Which client's care can the registered nurse (RN) safely delegate to unlicensed assistive personnel (UP) based on the given data?
Client A, with chronic hypertension and stable vitals
A client with a body mass index (BMI) of 35 verbalizes the need to lose weight. The nurse encourages the client to lose weight safely by making which dietary change?
Decrease portion size and fat intake.
When an obese client receives a diagnosis of high blood pressure, which topic would be the most important to include in client teaching?
Effect of weight loss in hypertension
Which priority medication will the nurse prepare to administer to the client admitted with acute salmonellosis?
Electrolytes
A client with advanced bone cancer is experiencing cachexia. The nurse reviews the nutritional components of palliative care with the client's family members. The nurse recognizes that the teaching is designed to achieve which outcome?
Enhance the quality of the client's life
When assessing a client's abdomen, the nurse palpates directly above the umbilicus. This location is known as which area?
Epigastric area
A client is scheduled to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is important for the nurse to obtain?
Infusion pump
Which dietary selections made by the client indicate understanding of previously taught dietary principles associated with having viral hepatitis?
Salad, sliced chicken sandwich, gelatin dessert
The nurse is preparing to insert a nasogastric (NG) tube for a client to allow continuous suction. Which tube would the nurse select?
Salem sump
The nurse is caring for a client who is having difficulty digesting fatty foods. To which deficiency would the nurse attribute this problem?
Bile
A client is admitted to the hospital with a long history of uncontrolled hypertension. Which laboratory result will be most important for the nurse to review?
Blood urea nitrogen
The home health nurse provides education for a client with cancer of the tongue who will begin gastrostomy feedings at home. Which client statement indicates effective teaching?
"Before I start the procedure, I will measure the residual volume."
Which question asked by the nurse is most appropriate to assess the nature of the client's pain?
"Can you describe your pain to me?"
A school-age child with end-stage cancer has a continuous infusion of morphine to manage their pain. Breakthrough pain occurs and a fentanyl "lollipop" is prescribed. Which instruction would the nurse give the child regarding the use of the lollipop when pain occurs?
"Hold it in your cheek only until the pain is relieved."
Which questions would the nurse ask to elicit psychosocial issues in a client with cancer? Select all that apply. One, some, or all responses may be correct. "Do you feel fatigue or restlessness?" "How is your family dealing with your condition?" "How do you rate your distress on a scale of 0 to 10?"
"How is your family dealing with your condition?" "How do you rate your distress on a scale of 0 to 10?"
The nurse provides postoperative teaching to a client who is scheduled for a bilateral herniorrhaphy. Which client statement indicates correct understanding of the teaching?
"I should cough and deep breathe regularly."
The nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk of spreading the disease when the client makes which statement?
"I should wash my hands frequently."
A health care provider prescribes an upper gastrointestinal (Gl) series and a barium enema. The client asks, "Why do I need barium for these tests?" Which explanation would the nurse give?
"It gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."
The student nurse is describing palliative care to a client's family. Which statement made by the student nurse indicates a need for correction by the registered nurse (RN)?
"Palliative care is the same as hospice care."
The nurse is caring for a client who had major abdominal surgery 1 day ago. Which factor increases the risk of this client developing wound dehiscence?
A body mass index (BMI) of 35
The spousal caregiver for a client receiving chemotherapy for inoperable bone cancer asks the nurse, "What can I do to help?" Which action best supports the client's spouse?
Assist the couple to maintain open communication.
Which type of allergic skin condition is associated with immunological irregularity, asthma, and allergic rhinitis?
Atopic dermatitis
Which complications would the nurse monitor in a client who sustained a transection of the spinal cord, but no other injuries?
Autonomic hyperreflexia
Which joint helps in the gliding movement of the wrist?
Biaxial joint
Which radiographic test is used to view the entire skeleton?
Bone scan
When determining the main difference between type 1 and type 2 diabetes, the nurse recognizes which clinical presentation about type 1?
Complications are not present at the time of diagnosis.
While caring for a client with a portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. Which nursing intervention would the nurse do next?
Compress the container before closing the port.
Which signs and symptoms would the nurse include when teaching a client about ketoacidosis? Select all that apply. One, some, or all responses may be correct. Confusion Hyperactivity Excessive thirst Fruity-scented breath Decreased urinary output
Confusion Excessive thirst Fruity-scented breath
Which interventions would the nurse follow while dealing with family members after the death of the client who was critically injured in an earthquake? Select all that apply. One, some, or all responses may be correct. Expressing intense grief Avoiding concrete language Coordinating with crisis staff Avoiding words such as "death" or "died" Offering the option of speaking to a clergy
Coordinating with crisis staff Offering the option of speaking to a clergy
A health care provider prescribes a sigmoidoscopy for one client and a barium enema for another client. Which is a nursing responsibility common to preparing both of the clients for these procedures?
Ensuring an understanding of the procedure
Which nursing interventions enhance comfort in a dying client in the hospital? Select all that apply. One, some, or all responses may be correct. Frequently repositioning the client Maintaining oral hygiene in the client Limiting frequent visits of the family members Measuring the vital signs of client frequently Applying body lotion to the client's skin daily
Frequently repositioning the client Maintaining oral hygiene in the client Applying body lotion to the client's skin daily
The nurse is teaching a client about a sodium-restricted diet. Which foods should the nurse encourage the client to consume? Select all that apply. One, some, or all responses may be correct. Fruits Sliced deli meats Condiments Fresh vegetables Processed cheese
Fruits Fresh vegetables
Which sexually transmitted infection is caused by a virus?
Genital warts
A client with jaundice associated with hepatitis expresses concern over the change in skin color. Which does the nurse explain is the cause of this color change?
Inability of the liver to remove normal amounts of bilirubin from the blood
An adolescent is found to have type 1 diabetes. The nurse plans to teach the adolescent that dietary control and exercise can help regulate the disorder. Which additional information would the nurse include in the teaching plan? Select all that apply. One, some, or all responses may be correct. Insulin therapy Prophylactic antibiotics Blood glucose monitoring Oral hypoglycemic agents Adherence to the treatment regimen
Insulin therapy Blood glucose monitoring Adherence to the treatment regimen
A total parenteral nutrition (TPN) solution is prescribed to infuse at 1 liter every 12 hours. Which clinical findings are important for the nurse to monitor? Select all that apply. One, some, or all responses may be correct. Activity tolerance Intake and output Orthostatic vital signs Gucose eve s Serum electrolytes
Intake and output Glucose levels Serum electrolytes
The nurse is caring for a client who is terminally ill with cancer. The health care team meets and agrees to provide the client with information to help the client make decisions regarding treatment. Which ethical principles are applied in this situation? Select all that apply. One, some, or all responses may be correct. Justice Fidelity Veracity Autonomy Beneficence
Justice Fidelity Veracity Autonomy
A health care provider informs a client that a T-tube will be in place after an abdominal cholecystectomy and a choledochostomy. Which would the nurse include in the preoperative teaching for this client regarding the primary reason why a T-tube is necessary?
Keep the common bile duct patent
A client is diagnosed with cancer of the rectum and has surgery for an abdominoperinea resection and colostomy. Which nursing care would be implemented during the postoperative period?
Keeping the client's skin around the stoma clean
A client describes abdominal discomfort after ingestion of milk. Which enzyme, as a result of a genetic deficiency, would the nurse consider to be the cause of the client's discomfort?
Lactase
The nurse identifies which weight category as reflective of a client's body mass index (BMI) of 25.5 kg/m ?
Overweight
When the home health nurse is caring for a client with chronic occlusive arterial disease, which finding will be of most concern?
Pale and dry-appearing ulcer on great toe
The nurse understands that megestrol is most often used to treat which issue?
Palliative management of cancer
The registered nurse (RN) asks a client to rate their pain on a scale from 0 to 10, then instructs the nursing student to perform a physical assessment. Which steps by the nursing student would be included in a physical assessment for pain? Select all that apply. One,some, or all responses may be correct. Palpating for tenderness Observing nonverbal cues Inspecting any areas of discomfort Noticing if the pain is localized or radiates Noticing if the client gives nonverbal signs of pain
Palpating for tenderness Inspecting any areas of discomfort
Which condition contraindicates the use of ginseng herbal therapy?
Pregnancy
Which condition is due to decreased elasticity of the ocular lens?
Presbyopia
Which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery?
Prevent clot formation (DVT)
A client with Laënnec cirrhosis experiences ascites, jaundice, and confusion. Which is a nursing priority when caring for this client?
Providing for the client's physical safety
A client is admitted to the hospital with a history of cancer of the liver and jaundice. In relation to the jaundice, which symptom does the nurse expect the client to report?
Pruritus
Five days after a client has abdominal surgery the nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports that the client is experiencing wound dehiscence?
Serosanguineous drainage
Which clinical finding would the nurse expect for a client with hypertensive emergency?
Severe pounding headache
The nurse assesses the client's incision site after bariatric surgery for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence?
Sharp increase in serosanguineous drainage
The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema?
Shift of fluid into the interstitial spaces
Which describes the focus of hospice care?
To ease the pain from illness
Which action would the nurse take when a confused and anxious client voids on the floor in the sitting room of the mental health unit?
Toilet the client more frequently with supervision.
An older adult client is diagnosed with cancer and fears death. Which nursing intervention would demonstrate caring?
Touch
Which action by a client with peripheral arterial disease indicates that more teaching about how to manage the disease is needed?
Using a heating pad to warm the extremities
A client arrives at the emergency department reporting minimal urinary output despite drinking adequate fluid. The client's blood pressure is 190/94 mm Hg. Which additional clinical manifestation would the nurse assess the client for?
Weight gain
An older client with Alzheimer type dementia, consistently sleeps in a semi-Fowler position in bed. Which area of the client's body would the nurse consider a high risk for developing a pressure injury?
sacrum
Six hours after major abdominal surgery, a client reports severe abdominal pain and faintness. The nurse identifies a thready, rapid pulse. The nurse checks the medication administration record (MAR) and determines that the client can receive another injection of pain medication in an hour. Which action would the nurse take?
• Notify the health care provider about the client's symptoms.
The client with a permanent sigmoid colostomy has colostomy irrigations prescribed and inquires as to why they are prescribed. Which response would the nurse use?
"The irrigations help establish an elimination schedule."
When admitting an older client, the stool specimen confirmed a diagnosis of a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse inquires about potentially assigning Room 2010, Bed B, the same isolation room as another client (2010, Bed A) who has MRSA. Which response would the nurse receive?
"Placing clients with the same infection in 1 room is safe."
Which client would be appropriate for home health care services? Select all that apply. One, some, or all responses may be correct. A client with a new ostomy A client requiring wound care A client receiving intravenous antibiotics A client receiving intravenous chemotherapy A client recently diagnosed with diabetes requiring insulin A client needing physical therapy after a total knee replacement
A client with a new ostomy A client requiring wound care A client receiving intravenous antibiotics A client receiving intravenous chemotherapy A client recently diagnosed with diabetes requiring insulin A client needing physical therapy after a total knee replacement
A client has been receiving digoxin. The client calls the clinic and complains of "yellow vision." Which response would the nurse provide?
"The medication may need to be discontinued. Come to the clinic this afternoon.
A client is admitted to the hospital with Laënnec cirrhosis and chronic pancreatitis. Bile salts (bile acid factor) are prescribed, and the client asks why they are needed. How would the nurse respond?
"They aid in the absorption of fat-soluble vitamins."
A client who had a severe weight loss is told the importance of eating more protein to provide the essential amino acids. The client asks the nurse why these substances in protein foods are essential. How should the nurse respond?
"They must come from your food because your body cannot make them.
The nurse is providing education about care of the residual limb to a client who had a below-the-elbow amputation. Which information will the nurse include in the teaching session?
"Wash and dry the residual limb at least once a day."
A client had a colon resection and formation of a colostomy 2 days ago. Which color indicates to the nurse that the stoma is viable?
Brick red
Which initial nursing intervention would the nurse take for an older adult with delirium who begins acting out while in the dayroom?
Giving the client one simple direction at a time in a firm, low-pitched voice
Which intervention is most important to assist a couple to cope with their feelings about the husband's terminal illness?
Helping the couple express to each other their feelings about his terminal illness
The nurse is assisting a health care provider to perform a sigmoidoscopy. In which position would the nurse place the client for this procedure?
Knee-chest
The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief is the client communicating?
Magicoreligious belief
The nurse is obtaining a health history from the newly admitted client who has chronic pain In the right knee. Which would the nurse include in the pain assessment? Select all that apply. One, some, or all responses may be correct. Pain history, including location, intensity, and quality of pain Client's purposeful body movement in arranging the papers on the bedside table Pain pattern, including precipitating and alleviating factors Vital signs, such as increased blood pressurê and heart rate The client's family statement about increases in pain with ambulation
Pain history, including location, intensity, and quality of pain Pain pattern, including precipitating and alleviating factors
Which member of the interprofessional team is appropriate for the nurse to ask for support in informing and consoling the family of a terminally ill client who has died?
Social worker
