Clinical Questions
a nurse is caring for a client who has a prescription for one unit of packed RBC's. the nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?
The first 15 minutes
A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?
The lab results are prolonged
A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. The following lab tests of the nurse anticipate the provider to prescribe
Troponin I
a nurse is preparing to admin a unit of RBC's. the nurses responsibility is to compare and verify the information on the blood label with the client's information. the nurse should use which of the following as the priority source of verification?
identification wristband
a nurse is preparing to administer a unit of RBC's. the nurse's responsibilitity is to compare and verify the information on the blood label with the clients information. the nurse should use which of the following as the priorty source of verification?
identification wristband
a nurse is caring for a client who is scheduled for an exercise stress test. which of the following comments made by the client should indicate to the nurse that the client requires further teaching?
ill take my heart medication the morning of the test
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
increased respiratory rate
an acute care nurse receives shift report for a client who has increased ICP. the nurse is told that the client demonstrates decorticate posturing. which of the following findings should the nurse expect to observe when assessing the client?
plantar flexion of the legs
a nurse is caring for a female client who reports an increase in bruising. the nurse should expect which of the following laboratory values?
platelets 110,000
a nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. which of the following infection-control precautions should the nurse use while caring for this client?
protective
A nurse in a clinic is caring for a client who has a prescription for digoxin. which of the following statements indicates the client is experiencing digoxin toxicity
My vision seems yellow
A nurse is planning care for a client who is to receive packed RBC's. the nurse should plan for the total infusion time to not exceed which of the following?
4 hours
A nurse is caring for four clients for who she has to administer oral medications in the morning. the nurse should administer which of the following medications before breakfast?
Alendronate
a nurse is caring for a client who is 1 day postop following a subtotal thyroidectomy. the client reports a tingling sensation in the hands, the soles of the feet, and around the lips. for which of the following findings should the nurse assess the client?
Chvostek's sign
A nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following?
cabbage
a nurse is caring for a client who reports a throbbing headache after a lumbar puncture. which of the following actions is most likely to facilitate resolution of the headache?
increase fluid intake
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
"DIC is caused by abnormal coagulation involving fibrinogen."
a nurse is admitting a client who has acute HF following MI. the nurse recognizes that which of the following prescriptions by the provider requires clarification?
0.9% NS IV at 50 mL/hr continuous
a nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. after administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?
0745
a nurse is caring for a client who has diabetes and a new prescription for 14 units of regular insulin and 28 units NPH insulin SUBQ at breakfast daily. what is the total number of units of insulin that the nurse should prepare in the insulin syringe?
42 units
a nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels?
6.3%
a nurse is caring for a client who has HIV-1 infection and is prescribed zidovudine as part of antiretroviral therapy. the nurse should monitor the client for which of the following adverse effects of this medication?
Aplastic anemia
a nurse is caring for a client who has a fungal infection and has a new prescription for amphotericin B. which of the following laboratory values should the nurse report to the provider before initiating the medication?
BUN 55 mg/dL
a nurse in a medical clinic is caring for a client who has come in for their annual check-up. physical examination: BMI = 19 Client reports they started following a strict vegan diet one month ago. The nurse should recognize that which of the following 3 findings from the visit 6 months after the annual check-up require immediate follow-up?
Buccal mucosa paresthesia Hbg level
a nurse is caring for a client who has HIV. which of the following laboratory values is the nurse's priority?
CDT-T-cell count 180 cells/mm3
a nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD$-T cell count. the nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?
Candidiasis
A nurse is teaching a class at a community center to a group of young adults and older adult clients regarding regular screening recommendations for cancer prevention. which of the following information should the nurse include?
Clients should have a yearly test for fecal occult blood
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. additional data includes pulse 100, RR 24, BP 132/76, temp 98.2. which of the following actions should the nurse perform?
Complete a neurological check
A family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse noted the client flinches when she palpated his abdomen yet responds to questions only by nodding and smiling. The following factors should the nurse identify as likely explanation of the client's behavior
Confusion
a nurse is caring for a client who has Cushing's syndrome. which of the following interventions should the nurse expect to perform?
Cushing's syndrome affects blood glucose levels by causing increased release of glucose from the liver and decreased sensitivity of insulin receptors. this can result in elevated blood glucose levels.
A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrived for his first dialysis treatment, he tells the nurse "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." the nurse should identify that this client is demonstrating which of the following Kubler-Ross stages of grieving?
Denial
a nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include
Determine the client's level of fluency in his primary language
a nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and SOB. which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
Different apical and radial pulses
a nurse is caring for a client who has infective endocarditis. which of the following manifestations is the priority for the nurse to monitor for? / REPORT TO THE PROVIDER
Dyspnea
a nurse is teaching a female client who has a new diagnosis of SLE. the nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?
Exercise
A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take
Explain to the client what is about to happen
a nurse in an ED is admitting a client. 0900: T: 98 HR: 48 RR: 28 BP: 106/55 select the 3 findings that require immediate follow-up
HR 12 lead EKG RR
a nurse in an ED is admitting a client. select the 3 findings that require immediate follow-up
HR 12 lead EKG Respiratory assessment
a nurse is caring for a client who has Cushing's syndrome. the nurse should recognize that which of the following are manifestations of Cushing's syndrome?
HTN Moon face purple striations buffalo hump
a nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postop. which of the following surgical procedures places the client at risk for DVT?
Hip arthroplasty
A nurse is caring for a client who has cancer and is receiving palliative care. which of the following statements by the client indicates they understand this type of tx
I am hoping this will limit my discomfort
A nurse is teaching a client about how to use her new hearing aids. Of the following statements should the nurse identify as an indication that the client needs further instruction
I will clean the hearing aids with alcohol wipes
A nurse is teaching a client who reports insomnia about promoting rest and sleep. which of the following statements should the nurse identify as an indication that the client understands the instructions
I will no longer have a glass of wine before bedtime
a nurse in an allergy clinic is caring for a client who has a hx of seasonal allergy symptoms. the client had a radioallergosorbent test (RAST) completed on a previous visit. the nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result?
IgE
a nurse is caring for a client who has PAD. which of the following symptoms should the nurse expect to find in the early stage of the disease?
Intermittent claudication
A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching
It's unfortunate that I have to be in the hospital for this treatment
a nurse is reviewing the lab results of male adult client who is at risk for peripheral arterial disease from atherosclerosis. the nurse should identify that which of the following results places the client at risk?
LDL 172 mg/dL
A nurse's planning care for a client who has leukemia and a platelet count of 130,000/mm3. which of the following interventions should the nurse include in the plan of care
Limit IM injections
a nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. which of the following medications should the nurse plan to administer?
Mannitol 25%
a nurse is caring for a client who is postop following a laminectomy with spinal fusion. which of the following actions should the nurse take?
Monitor sensory perception of the lower extremities
A nurse is caring for an older adult client who was alert and oriented added admission but now seems increasingly restless and intermittently confused. which of the following action should the nurse take to address the client's safety needs
Move the client to a room closer to the nurses station
A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Following action should the nurse take
Place a seat alarm in the client's chairs
a nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. the nurse suspects air embolism and clamps the catheter immediately. what other action should the nurse take at this time?
Place the client on his left side in Trendelenburg position
A nurse is carrying fray client who has had an allogenic hematopoietic stem cell transplant. Which of the following infection control precautions should the nurse use while caring for the client?
Protective
a nurse is providing dietary teaching for a client who has just learned that she has type 2 diabetes mellitus. the nurse should explain that which of the following sweeteners will add calories to the client's carbohydrate count?
Sorbitol
a nurse in a clinic is reviewing the lab values of a client who has primary hypothyroidism. the nurse should anticipate an elevation of which of the following lab values?
TSH
A nurse is teaching a group of middle adult clients about early detection of colorectal cancer. The nurse should include the American Cancer Society recommendation that men and women beginning at age 50 who are at average risk should have a fecal occult blood test and a colonoscopy at which of the following intervals
Ten years
A nurse is caring for a client who is receiving cisplatin for treatment of ovarian cancer. The client's most recent CBC is shown in the table below. Important for the nurse to consider which of the following for the client
The client has an increased risk of infection
A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses. The following information should the nurse include?
The nurse may serve as a witness to informed consent for organ donation
a nurse is caring for a client who is scheduled for surgery a nurse is Providing preoperative teaching to a client about Pain management using a APCA system. Which of the following statements should the nurse include
There's a minimal risk of an overdose of pain medication using the PCA regularly will provide a consistent level of pain relief push the button on the PCA prior to your pain level becoming severe so ...
A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative Care. Family asked the nurse for information about this type of care. Which of the following explanations should the nurse provide
This service began with the client's admission to the hospital
a nurse is caring for a client who came to the emergency department reporting chest pain. the provider suspects a myocardial infarction. while waiting for the troponin levels report, the client asks what this blood test will show. which of the following explanations should the nurse provide the client?
Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart
When a nurse is caring for a client who has a Seizure disorder. Select all that apply
Turn the client to the side Time the duration of the seizure administer supplemental oxygen to the client
a nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. which of the following findings should the nurse report to the provider?
WBC 2300
A nurse is caring for a client who has lung cancer in his scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure
a chest tube
a nurse is admitting a child who has leukemia. which of the following clients should the nurse place in the same room with this child?
a child who has nephrotic sundrome
a nurse is instructing a client who is newly diagnosed with pulmonary TB about the use of antitubercular medications. which of the following information should the nurse include in the teaching?
a typical course of tx involves 6 to 9 months of consistent medication use
a nurse is providing discharge teaching to a client who has PAD. which of the following instructions should the nurse include in the teaching?
adjust the thermostat so that the environment is warm
a nurse in the ED is caring for a client who has an epidural hematoma following a motor-vehicle crash. which of the following is an expected finding in this client?
alternating periods of alertness and unconsciousness
a nurse is reviewing the lab results of an adolescent female client and notes a WBC count of 16,000 with increased immature neutrophils (bands) and normal monocytes. which of the following is the appropriate analysis of the results?
an acute infectious process
a client who has a hx of MI is prescribed aspirin 325 mg. the nurse recognizes that the aspirin is given due to which of the following actions of the medication?
antiplatelet aggregate
a nurse is preparing to perform hand hygiene. which of the following actions should the nurse take?
apply 4-5 mL of liquid soap on the hands
a nurse is caring for a client who has HTN and develops epistaxis. which of the following actions should the nurse take?
apply pressure to the nares place ice to the bridge of the clients nose move the client into high-fowlers position
a nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. the nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia?
blurred vision tachycardia moist, clammy skin
a nurse is caring for a client who has HF. a nurse is reviewing the assessment finding for the client on day 4. which of the following findings requires further action?
breath sounds weight oxygen saturation BP
A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority actions the nurse should take
check the patency of the clients to airway
a nurse is assessing a client's cranial nerves as part of a neurological examination. The following actions showed the nurse take to assess cranial nerve 3
check the pupillary response to light
a nurse in a provider's clinic is assessing a client who has cancer and a prescription for methotrexate PO. which of the following actions should the nurse take when the client reports bleeding gums?
check the value of the clients current platelet count
a nurse is reviewing the medical record of a client who has been on levothyroxine for several months. which of the following findings indicates a therapeutic response to the medication?
decrease in level of TSH
a nurse is assessing for paradoxical BP on a client who has constrictive pericarditis. which of the following findings should the nurse expect?
decrease in systolic pressure by more than 10 mm Hg during inspiration
a nurse is caring for a client who has sustained a TBI. the nurse should monitor the client for which of the following manifestations of increased ICP
decreased LOC
a nurse is assessing a client who has diabetes insipidus. which of the following findings should the nurse expect?
dehydration
a nurse is talking with a client who is about to undergo radionuclide imaging. the nurse should explain that the procedure will help do which of the following?
detect damage to the heart muscle
A nurse is assessing a client who has insomnia. Following questions is the highest priority for the nurse to ask the client
do you have difficulty staying awake when you are driving
a nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. for which of the following findings should the nurse identify that the client exhibits babinski's sign?
dorsiflexion of the great toe
a nurse is caring for a client who is postop following vascular surgery. which of the following signs should indicate to the nurse that the client has developed a thrombus?
dull, aching calf pain
a nurse is assessing a client who has chronic venous insufficiency. which of the following findings should the nurse expect?
edema
a nurse is planning care for a client who has a decreased level of consciousness. the client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. which of the following is the priority action by the nurse?
elevate the HOB 30-45 degrees
a nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. which of the following actions should the nurse include in the clients plan of care?
encourage fluid intake at and between meals
a nurse at a rehab center is planning care for a client who had a left hemispheric cerebrovascular accident 3 weeks ago. which of the following goals should the nurse include in the clients rehab program?
establish the ability to communicate effectively
a nurse is teaching a client who has diabetes mellitus and receives 25 units of NPH insulin every morning if her blood glucose is above 200 mg/dL. which of the following information should the nurse include?
expect the NPH insulin to peak in 6 to 14 hr
A nurse is teaching a client about the physical effects of chemotherapy. Following the teaching the nurse asked the client to describe one physical effect. Nurses focusing on which of the following elements of the communication process
feedback
a nurse is assessing a client who is in skeletal traction. which of the following findings should the nurse identify as an indication of infection at the pin sites?
fever
a nurse is teaching a client who takes aspirin daily for coronary artery disease about herbal supplements. the nurse should instruct the client that which of the following herbal supplements may interact adversely with aspirin?
feverfew
a nurse is assessing a client who has hyperthyroidism. the nurse should expect the client to report which of the following manifestations?
frequent mood changes
a nurse is planning care for a client who is being treated with chemo and radiation for metastatic breast cancer, and who has neutropenia. the nurse should include which of the following restrictions in the clients plan of care?
fresh flowers and potted plants in the room
a nurse is providing teaching for a client who is newly diagnosed with type 2 diabetes mellitus and has a prescription for glipizide. which of the following statements by the nurse best describes the action of glipizide?
glipizide stimulates your pancreas to release insulin
a nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. when the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following?
graham crackers
a nurse is caring for a client 4 hr following a cardiac catheterization. which of the following actions should the nurse take?
have the client lie flat in bed
a nurse is caring for a client who has active TB. the client requires airborne precautions and is receiving multidrug therapy. which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest xray?
have the client wear a mask
a nurse is assessing an adolescent who has an exacerbation of Graves' disease. which of the following findings should the nurse expect?
heat intolerance
a nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. which of the following findings should the nurse expect?
hyperpigmentation
A nurse in the ED is monitoring a client who has cervical spine injury from a fall. the nurse should monitor the client for which of the following complications?
hypotension absence of bowel sounds weakened gag reflex
a nurse is reviewing discharge teaching instructions with a client who has Raynaud's disease. which of the following client statements indicates an understanding of the teaching?
i am going to take a stress management class
a nurse is caring for a client who has a new diagnosis of chronic kidney disease. which of the following statements should the nurse identify as an indication of anticipatory grieving?
i just can't believe that this dialysis is going to ruin my whole life
a nurse is reinforcing teaching with a client regarding of risk factors for coronary artery disease. which of the following statements by the client indicates an understanding of the teaching?
i must stop smoking i need to monitor my weight i am limiting my intake of fast foods
a nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. the client says "go away; no one can help me." which of the following responses should the nurse make
i will come back later and we can talk
a nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. which of the following statements by the client indicates a need for further teaching?
i will reduce my exercise schedule to 3 days a week
a nurse is teaching a client who has type 1 diabetes mellitus about foot care. which of the following statements by the client indicates an understanding of the teaching?
ill check my feet everyday for sores and bruises
a nurse is teaching a client who is pre-op how to do deep-breathing exercises and cough effectively after surgery. which of the following statements by the client indicates an understanding of the teaching?
ill splint my incision with a pillow to cough
a nurse is caring for a client who has had a stroke involving the right hemisphere. which of the following alterations in function should the nurse expect
inability to recognize his family members
a nurse is assessing a client who is taking levothyroxine. the nurse should recognize that which of the following findings is a manifestation of levothyroxine overdose?
insomnia
a nurse is performing a neurological assessment for a client who has head trauma. which of the following assessments will give the nurse information about the functioning of cranial nerve III
instruct the client to look up and down without moving his head
a nurse is caring for several clients who are at various developmental stages. the nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of psychosocial development?
integrity vs despair
a nurse is monitoring a client who had a cerebral aneurysm rupture. which of the following findings should the nurse identify as a manifestation of increased ICP
irritability
a nurse is teaching a client who has a new prescription for regular insulin and NPH insulin. which of the following instructions should the nurse include in the teaching?
keep the open vial of insulin at room temperature
A nurse is caring for an older adult client who states, "I am afraid that I may be fall while walking to the bathroom during the night." which of the following actions should the nurse take?
leave a night light on in the client's room
a nurse is assessing a male client who has advanced peripheral artery disease (PAD). which of the following findings should the nurse expect?
leg pain at rest
a nurse is planning care for a client who has immunosuppression following chemo. which of the following interventions should the nurse include in the plan of care?
limit the number of health care workers entering the room
a nurse is caring for a client who is being evaluated for acromegaly. which of the following manifestations should the nurse expect to find during assessment?
loss of color discrimination
a nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. which of the following actions should the nurse perform?
maintain constant observation while the balloons are inflated
a nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. which of the following instructions should the nurse include?
maintain stable glucose levels
a nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. the nurse should recognize confabulation when the client
makes up stories when he is unable to remember actual events
a nurse is planning care for a 6 yer old child who has bacterial meningitis. which of the following nursing interventions is unnecessary in the clients plan of care?
measure head circumference every shift
a nurse in a providers office is assessing a client who reports occasional atypical chest pain, palpitations, and exercise intolerance. on auscultation, the nurse notes a systolic click. the nurse should recognize this finding as a manifestation of which of the following conditions?
mitral valve prolapse
a nurse is caring for a client who has type 1 diabetes mellitus. the nurse misread the clients morning blood glucose level as 210 instead of 120 and administered the insulin dose appropriately for a reading over 200 before the clients breakfast. which of the following actions is the nurses priority?
monitor the client for hypoglycemia
a nurse is teaching a class of older adult about the expected physiologic changes of aging. which of the following changes should the nurse include in the discussion?
more difficulty seeing due to a greater sensitivity to glare decreased cough reflex decreased bladder capacity dehydration of interverbal discs
a nurse is completing a clients hx and physical examination. which of the following information should the nurse consider subjective data?
nausea
a nurse is carrying fright client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?
observe for signs of infection
a nurse is giving a presentation about preventing DVT. which of the following should the nurse include as a risk factor for this disorder?
oral contraceptive use immobility
a nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. when planning care, the nurse should anticipate which of the following types of disability?
paraplegia
a nurse is caring for a client who reports a new onset of severe chest pain. which of the following actions should the nurse take to determine if the client is experiencing a MI?
perform a 12-lead ECG
a nurse is assessing a client who has ataxia. which of the following actions should the nurse talk to evaluate the clients ability to safely ambulate?
perform a rombergs test
a nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. which of the following actions should the nurse take?
place suction equipment at the clients bedside
a nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. the nurse obtains a bp of 210/108 and suspects the client is experiencing autonomic dysreflexia. which of the following actions should the nurse take first
place the client in a high-fowlers position
a nurse is assessing a client who is admitted with hyperthyroidism. the client reports a weight loss of 5.4 kg (12 lbs) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. which of the following actions should the nurse take to prevent a thyroid crisis?
provide a quiet, low-stimulus environment
the nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. which of the following pulses should the nurse palpate?
radial pulse in the left arm
a nurse is preparing to administer an osmotic diuretic IV to a client with increased ICP. which of the following should the nurse identify as the purpose of the medication
reduce edema of the brain
a nurse is caring for an adolescent client who has a long hx of diabetes mellitus and is being admitted to the ED confused, flushed, and with an acetone odor on the breath. DKA is suspected. the nurse should anticipate using which of the following types of insulin to treat this client?
regular insulin
a nurse is caring for a client 4 hr following evacuation of a subdural hematoma. which of the following assessments is the nurse's priority?
respiratory status
a nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. which of the following instructions should the nurse provide?
rinse the mouth after administration
a nurse is caring for a male client who has peripheral vascular disease (PVD), is taking dietary supplements, and has a new prescription for warfarin. the nurse should instruct the client to stop which of the following supplements prior to starting warfarin?
saw palmetto glucosamine gingko biloba
a nurse is performing a pain assessment for a client who is alert the nurse should recognize that which of the following measures is the most reliable indicator of pain
self report
a nurse is caring for a client who is 8 hr postop following a subtotal thyroidectomy. in which of the following positions should the nurse keep the client?
semi-fowlers with neck in a neutral position
a nurse is caring for a client who has a hx of exposure of TB and symptoms of night sweats and hemoptysis. which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?
sputum culture for acid-fast bacillius
a nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?
suction saliva from the clients mouth
a nurse is caring for an older adult client who just returned from PACU after receiving a spinal anesthetic during knee surgery. for which of the following findings should the nurse notify the provider?
systolic BP changed from 140 to 120
a nurse is caring for a child who has Addison's disease. which of the following actions should the nurse take?
teach the parents about cortisol replacement therapy
a nurse is caring for a client who has a central venous access device (CVAD)
the client is most likely experiencing catheter dislodgement the nurse should stop the infusion
a nurse is establishing health promotion goals for a female client who smokes cigarettes, has HTN, and has a BMI of 26. which of the following goals should the nurse include?
the client will walk for 30 min 5 days a week
a nurse is caring for a client who reports fatigue and had a syncopal episode at home. the nurse has completed an assessment on the client after the syncopal episode.
the nurse should first address the client's oxygen saturation followed by the client's hypotension
a nurse in a medical clinic is caring for a client who has come in for their annual check-up
the nurse should recognize that which of the following 3 findings from the visit 6 months after the annual check-up require immediate follow-up buccal mucosa paresthesia Hgb
A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. which of the following findings should the nurse identify as indicating a therapeutic response?
the shoulders drop the facial muscles relax the pulse is within the expected range
a nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn from the client. which of the following statements should the nurse make regarding cardiac enzymes studies?
these tests help determine the degree of damage to the heart tissues
a nurse is talking with a client whose thyroid-stimulating hormone (TSH) level will be measured. which of the following statements by the nurse explains the purpose of this test?
this test determines whether your thyroid gland is overactive, appropriately active, or underactive
a nurse is caring for a child who was admitted with suspected rheumatic fever. the provider prescribes an anti-streptolysin O (ASO) titer. the parent asks the nurse the purpose of the test. which of the following responses should the nurse make?
this test will confirm if your child had a recent streptococcal infection
a nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. before administering the medication, the nurse should check to see that which of the following tests have been completed?
thyroid hormone assay
a nurse is caring for a client who has chemo-induced peripheral neuropathy. the nurse should expect the client to report having experienced which of the following symptoms
tingling feeling in the extremities
a nurse is preparing a client for a hip arthroplasty. for which of the following reasons should the nurse assess the clients vital signs?
to establish a baseline for postop assessment
a nurse is teaching a client who has a new diagnosis of venous insufficiency. which of the following instructions should the nurse include?
use elastic stockings
a nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. which of the following actions should the nurse take?
weigh the client daily
A nurse is admitting a client from a long term care facility The nurse should used closed ended questions when assessing which of the following factors
when asking if the client took his medication this morning
a nurse is assisting a client who has hypothyroidism with meal planning. which of the following foods should the nurse recommend that the client add to her diet?
whole grains
a nurse is assisting a client who has hypothyroidism with meal planning. which of the following should the nurse recommend that the client add to her diet?
whole grains
a nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. which of the following statements should the nurse include in the teaching?
you may experience drowsiness while taking this medication
a nurse is monitoring a client who is on telemetry. which of the following findings on the ECG strip should the nurse recognize as NSR
The P wave falls before the QRS complex
A nurse is caring for a client in the emergency department. 1030: the client complains of fatigue, vertigo, and sob with daily activities. current vital signs are: BP 86/46 mm Hg, PR 100/min, RR 28, O2 94% on 2 L NC Client has an 18 g capped IV in the right antecubital space. there is a new prescription for the transfusion of 2 units of PRBC's; the first unit has been ordered from the blood bank. o2 is to be titrated to maintain an o2 stat of 92% A nurse has received the following report about a client that they will be admitting to the medical-surgical unit. Click to highlight the findings in the transfer report that require immediate action by the nurse when the client arrives.
The clients BP, PR, RR 0.9& sodium at 125 mL/hr should be started immediately.
A nurse is giving a presentation to a community group about of the following should the nurse include as a modifiable risk factor for modifiable risk factor for this disorder
hypercholesterolemia hypertension obesity smoking
a nurse is caring for a client 1 day postop who has developed atelectasis. which of the following manifestations is an expected finding for this condition?
hypoxemia
A nurse is teaching a client who takes warfarin daily. which of the following statements by the client indicates a need for further teaching?
i have started taking ginger root to treat my joint stiffness
A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicate they need for further teaching?
i will apply heat
A nurse is caring for a 33-year-old client on a med-surg unit.
place client NPO Obtain prescription for a glucocorticoid Ulcerative collitis ESR & WBC count levels
a nurse is monitoring a client who is on telemetry. which of the following findings on the ECG strip should the nurse recognize as NSR?
the P wave falls before the QRS complex
a nurse is monitoring the cardiac output of a client who has left-sided HF using pulse pressure analysis. which of the following findings can compromise the readings?
the client is experiencing premature atrial contractions
a nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). which of the following information should the nurse include?
the client should hold his cell phone on the side opposite the ICD
a nurse is caring for a client who was admitted for pain between their shoulder blades.
the nurse has completed the clients admission hx. the client is most likely suffering from angina as evidenced by the clients serum lipids
A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed red blood cells. The nurse suspects a possible hemolytic reaction. after stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse?
the nurse starts the transfusion of another unit of blood product
a nurse is providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker check. which of the following client statements should the nurse recognize as an understanding of the teaching?
the pacemaker can be checked from home by using the telephone
a nurse is preparing to administer dabigatran to a client who has atrial fibrillation. the nurse should explain that the purpose of this medication is which of the following?
to reduce the risk of stroke in clients who have atrial fibrillation
a nurse is preparing to perform a 12-lead electrocardiogram. which of the following instructions should the nurse provide to the client?
try to remain still once i have attached the gel pads
a nurse is providing discharge teaching for a client who has a new prescription for warfarin. which of the following instructions should the nurse include in the teaching?
use an electric razor while on this medication
A nurse is caring for a client who has a new diagnosis of essential hypertension. the nurse Should monitor the client for which of the following findings that it's consistent with this diagnosis
vertigo
A nurse is caring for a client who has sepsis and a prescription for vancomycin 1 g in 250 mL dextrose 5% (D5W) over 2 hr by IV intermittent bolus. The nurse should set the IV pump to deliver how many mL/hr?
125
A nurse is caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 unit/hr. Available is heparin 25,000 units in 500 ml D5W. the nurse should set the IV pump to deliver how many mL/hr?
24 mL/hr
A nurse is calculating the intake of a client during the past 9 hr. the clients intake includes lacteral ringers iv at 150ml/hr, cefazolin 2 g IV intermittent bolus in 100 ml of the 0/9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, famotidine 20 mg IV intermittent bolus in 50 mL of 0.9% sodium chloride. how many mL of intake should the nurse record?
2525 mL
a nurse is caring for a client who is postoperative following an appendectomy and is prescribed D5 lactated ringers at 150mL/hr by continuous IV infusion for 12 hours. the drop factor of the manual IV tubing is 20 gtt/mL. the nurse should set the manual IV infusion to deliver how many gtt/mL?
50 (gtt/mL)
A nurse is reviewing data for four children. The following children for the nurse assess first?
A 10 year old child who has sickle cell anemia who reports severe chest pain
a nurse is reviewing the EKG strip of a client who has prolonged vomiting. which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
Abnormally prominent U wave
a nurse is admitting a client to a medical-surgical unit following a fall at home.
Anticipated: obtain an xray of the right hip-obtain weight-administer an IV fluid bolus Nonessential: administer supplemental o2-administer iron supplement Contraindicated: administer spironolactone
A nurse is caring for a client in the primary care provider's office. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing
Aortic Stenosis educate on risk factors to decrease inflammatory response and inform client they will require ECG every 6 to 12 months. monitor the client HR and rhythm & pulse pressure
A nurse is caring for a client in the primary care provider's office.
Aortic Stenosis educate the client on risk factors to decrease inflammatory response inform client they will require ECG every 6 to 12 months monitor the HR and rhythm pulse pressure
when checking A client's capillary refill, the nurse finds that the color returns in 10 seconds. the nurse Should understand that this finding indicates which of the following?
Arterial insufficiency
a nurse is interpreting the ECG strip of a client who has bradycardia. which of the following cardiac components should the nurse identify as the role of the P wave?
Atrial Depolarization
a nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. the nurse finds a rapid and irregular HR with a significant pulse deficit. which of the following dysrhythmias should the nurse expect to find on the ECG?
Atrial fibrillation
a nurse is caring for a client who reports heart palpitations. an ECG confirms the client is experiencing ventricular tachycardia (VT). the nurse should anticipate the need for taking which of the following actions?
Elective Cardioversion
a nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. which of the following findings should the nurse expect?
Elevated central venous pressure (CVP)
a nurse is caring for an older adult client who has left-sided heart failure. which of the following assessments findings should the nurse expect?
Frothy Sputum
A nurse is caring for a client who is receiving a unit of PRBC's 15 minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. which of the following transfusion reactions should the nurse expect?
Hemolytic
A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?
Heparin does not dissolve clots. It stops new clots from forming.
a nurse is assessing a client who has right ventricular failure. which of the following findings should the nurse expect?
Hepatomegaly
a nurse is providing discharge instructions for a client who has CHF. which of the following client statements indicates to the nurse that the teaching was effective?
I plan to slow down if i am tired the day after exercising
a nurse is caring for a client in the outpatient cardiologist's office.
Improved: BP-JVD-Lung sounds-serum potassium- weight No change: dyspnea-oxygen saturation
a nurse is assessing a client who has fluid overload. which of the following findings should the nurse expect?
Increased HR-BP-RR
A charge nurse is teaching a group of nurses about clients who report using garlic, ginger, and ginkgo biloba. The charge nurse should identify which of the following as an adverse effect of these supplements
Increased effects of oral anticoagulants
A nurse in the ICU is caring for a client who has heart failure and is receiving a dopamine drip. The nerve should identify that which of the following findings indicates that the medication is effective
Increased urine output
a nurse is reviewing the lab results of four children. which of the following values should the nurse report to the provider?
Iron 38 mcg/dL
a nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). while sitting in a chair, the client feeling reports feeling lightheaded. if the client is having PVCs, which of the following findings should the nurse expect when auscultating the clients apical pulse?
Irregular pulsations
a nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. which of following veins should the nurse select?
Median vein in the forearm
a nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. the nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?
Pacemaker spikes before each QRS complex
a nurse is planning to administer digoxin to a client who has HF. which of the following lab results is the priority for the nurse to review prior to administering the medication?
Potassium
a nurse is caring for a client who is receiving heparin by continuous IV infusion. which of the following medications should the nurse plan to administer in the event of an overdose?
Protamine
a nurse is interpreting a clients ECG strip. which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?
QT interval
A nurse is creating a dietary plan for an adult female client who has a hemoglobin level of 9.9 g/dL. which of the following foods should the nurse recommend?
Raisins
A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extraction. Prior to the procedure, the nurse should anticipate that the client will receive which of the following?
Recombinant
a nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. the provider prescribes polystyrene sulfonate. if this medication is effective, the nurse should expect which of the following changes on the clients ECG?
Reduction of T-wave amplitude
A nurse is teaching a client who has a vitamin K deficiency about the effects of vitamin K. Which of the following information should the nurse include in the teaching?
Vitamin K reverses warfarin toxicity
a nurse is teaching A client who has a vitamin K deficiency about the effects of Vitamin K. Which of the following information should the nurse include in the teaching?
Vitamin K reverses warfarin toxicity
A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first
a client who has renal failure, a serum potassium of 5.8/mEq/L, and is prescribed sodium polystyrene sulfonate
a nurse is caring for a client in the ED> The nurse is planning care for the client. for each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.
anticipated: apply continuous ECG monitoring-administer O2 to maintain o2 higher than 90%-obtain vascular access Non-essential: obtain family hx Contraindicated: administer furosemide IV-prepare the client for intubation
the nurse receives a unit of PRBC's from a blood bank and notes that the time is 1130. the nurse should begin the infusion at which of the following times?
as soon as the nurse can prepare the client and the administration set
A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side.
bottom right box (his left ankle)
A nurse enters a clan's room and finds him unresponsive. Notifying the rapid response team which of the following actions should the nurse take
check for a carotid pulse
a nurse is teaching a client who is postop following the insertion of a permanent pacemaker. which of the following instructions should the nurse include?
count your pulse for 1 minute each morning do not wear tight clothing over the insertion area
a nurse is caring for a client who develops a ventricular fibrillation rhythm. the client is unresponsive, pulseless, and apneic. which of the following actions is the nurses priority?
defibrillation
a nurse is monitoring a client who is receiving a unit of packed RBC's following surgery. which of the following assessments is an indication that the client might be experiencing circulatory overload?
dyspnea
A charge nurse is teaching a group of nurses about agonists and antagonists. Should include in the teaching that which of the following agonist medications binds to receptors and causes activation that affects the cardiovascular system
epinephrine
a nurse is providing discharge teaching to a client who has a new diagnosis of HF. which of the following instructions should the nurse include in the teaching?
exercise at least 3x per week
a nurse is preparing an in-service about the various supplements clients might use. which of the following herbal supplements should the nurse include as potentially increasing the anticoagulant effects of aspirin and other oral anticoags?
feverfew
a nurse is assessing a client who has left-sided HF. which of the following findings should the nurse expect?
hacking cough
a nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. which of the following statements by the client should indicate to the nurse the need for further teaching?
increasing my intake of foods containing trans-fatty acids can lower my risk
a client tells the nurse that he is concerned because his provider told him he has a heart murmur. the nurse should explain to the client that a murmur is
indicates turbulent blood flood through a valve
A nurse is completing a physical examination of a client and notes that lab values indicate leukocytosis. the nurse should recognize that which of the following manifestations is associated with leukocytosis?
inflammation
a nurse is assisting with obtaining an ECG for a client who has atrial fibrillation. which of the following actions should the nurse take?
inspect the electrode pads instruct the client not talk during the test
A nurse is preparing a client who is scheduled for an echocardiogram the following day. Which of the following instructions should the nurse include about the test?
it requires lying quietly on one side
a nurse is preparing a client for MRI of the heart and great vessels. which of the following instructions should the nurse include about this test?
it requires removing metal objects like jewelry
A nurse is preparing to obtain a blood specimen from a client by ventpuncture. the client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. which of the following sites should the nurse plan to use to obtain the blood specimen?
left forearm
a nurse is preparing educational material for a client who has a thrombocytopenic disorder. Which of the following information should the nurse include?
notify the dentist of your condition prior to invasive procedures
a nurse is discharging a child who has sickle cell anemia after an acute crisis episode. which of the following instructions should the nurse include in the teaching?
offer fluids to your child multiple times every day
a nurse is preparing to administer a unit of PRBC's to a client. which of the following actions should the nurse plan to take?
remain with the client for the first 15 minutes of the transfusion
a nurse is caring for a client on the medical-surgical unit. action 1 &2 potential diagnosis parameter to monitor 1 &2
request a 12-lead ekg prepare for cardioversion ventricular tachycardia cardiac rhythm serum potassium
A nurse is assessing a client who is receiving one unit of packed red blood cells to treat intraoperative blood loss. The client reports chills and back pain and the clients blood pressure is 80/64. which of the following actions should the nurse take first?
stop the infusion of blood
a nurse is assessing a client who is receiving a unit of packed RBC's. the client appears flushed and reports low-back pain. which of the following actions is the nurses priorty?
stop the transfusion
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following action is the nurse's priority?
stopping the infusion
a nurse enters an adult clients room and finds him unresponsive. after determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take?
summon the code team
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
temperature
a nurse is auscultating a clients heart sounds and hears an extra sound before what should be considered the first heart sound S1. the nurse should document this finding as which of the following heart sounds?
the 4th heart sound (S4)
