E2
Which statement from the client with Guillain-Barré syndrome indicates that teaching about disease progression was effective? a . "I will have permanent muscle weakness and loss of sensation." b . "I will need a wheelchair for the rest of my life." c. "I may need a ventilator until the paralysis goes away." d . "I will have to wear a mask around other people to prevent exacerbations."
"I may need a ventilator until the paralysis goes away."
When reviewing the client's medical record, the experienced nurse discovers that the client's breast cancer is staged as T4 N3 M1. Which comment made by the experienced nurse to the new nurse is correct? a . "This client has a 3-cm breast tumor that has spread to only one lymph node." b . "The TNM system is used to classify solid tumors by size and degree of spread." c. "The higher the number in the TNM system, the better the chances are for a cure." d . "This TNM system helps to classify tumors as either well- or poorly differentiated."
"The TNM system is used to classify solid tumors by size and degree of spread."
The RN has just received change-of-shift report. Which of the assigned clients should be assessed first? a . A client with chronic kidney failure who was just admitted with shortness of breath. b . A client with kidney insufficiency who is scheduled to have an arteriovenous (AV) fistula inserted. c. A client with azotemia whose blood urea nitrogen and creatinine are increasing. d . A client receiving peritoneal dialysis who needs help changing the dialysate bag.
. A client with chronic kidney failure who was just admitted with shortness of breath.
The nurse's client with a T2 Spinal Cord Injury (SCI) is dysreflexic and has a BP of 170/90 mm Hg. Place the nurse's interventions in the order that these should be performed
1)Elevate the head of bed (HOB) to 90 degrees. 2)Lower the end of the bed so feet are dependent 3)Remove elastic stocking and other constricting devices 4)Retake the blood pressure 5)Administer a prn med for continued elevated BP. 6)Perform digital removal of impacted stool 7)Inform the HCP of the incident
The client is scheduled to receive hemodialysis (HD) for 4 hours this morning, and several medications for chronic diseases are scheduled to be given now. What is the best nursing action? a . Administer medications after dialysis. b . Withhold medications for today only. c . Give all medications as scheduled. d . Give double doses of all medications.
A. Administer medications after dialysis bc med will cleaned out during dialysis
A client has been admitted to the ED with fever, headache, nausea, photophobia, and nuchal rigidity. The CSF analysis revealed the following lab findings: What type of Meningitis will be confirmed as a final diagnosis based on the CSF laboratory values and the client's clinical manifestations? What type of isolation precautions would you implement as the most effective measure to prevent the spread of the disease. A) Viral Meningitis Airborne precautions b .Parasitic Meningitis Neutropenic precautions c. Bacterial Meningitis Droplet precautions d. Fungal Meningitis Contact precautions
Bacterial Meningitis Droplet precautions bc cloudy, decreased glucose under 40, increased protein and WBC
The client with chronic kidney disease (CKD) is prescribed drugs to be given at 10:00 AM, digoxin (Lanoxin), Metoprolol (Lopressor), and epoetin alfa (Epogen). He is complaining of nausea, vomiting, and blurred vision (visual disturbances). Which action will the nurse take first? "Now that I have had a mammogram, my risk for getting breast cancer is reduced." a Administers both medications. . b Call MD/NP for a dose of furosemide (Lasix) 40 . mg IV. c. Holds the dose of digoxin. d Checks the hemoglobin and hematocrit levels.
C hold the dose of digoxin Clients with renal failure are at risk for digoxin toxicity
Which clinical manifestation indicates the need for increased fluids in a client with kidney failure? a . Pale-colored urine b . Creatinine level = 1.2 mg/dL c. Blood urea nitrogen (BUN) = 47 mg/dL d . Serum sodium level= 146 mg/dL
Creatinine level = 1.2 mg/dL
A 55-year-old white man with a history of end-stage renal disease (ESRD) secondary to chronic uncontrolled hypertension (HTN) presents to the emergency department (ED) after sustaining a fall in his bathroom on to his right hip. He complains of pain with passive motion of the hip and on physical examination the hip has limited range of motion upon internal rotation. An x-ray of the right hip shows a fracture. Which of the below series of serum laboratory values are consistent with the underlying condition predisposing to this patient's fracture? a . Increased serum Calcium, Decreased serum Phosphate, and Increased serum PTH (PTH: Parathyroid Hormone). b . Decreased serum Calcium, Decreased serum Phosphate, and Increased serum PTH (PTH: Parathyroid Hormone). c. Decreased serum Calcium, Increased serum Phosphate, and Increased serum PTH (PTH: Parathyroid Hormone). d . Increased serum Calcium, Increased serum Phosphate, and Decreased serum PTH (PTH: Parathyroid Hormone)
Decreased serum Calcium, Increased serum Phosphate, and Increased serum PTH (PTH: Parathyroid Hormone).
A 40-year-old African-American woman is newly diagnosed with mild chronic kidney disease (CKD). She is otherwise very fit and healthy, and no one in her family has CKD. She asks the nurse whether any of the following factors could have caused this problem. Which factor should the nurse indicate may have influenced the development of CKD? a . She drinks 3 liters of water daily. b . Her mother and older sister have type 2 diabetes. c. She has followed a vegetarian diet that includes eggs but no dairy products for the past 3 years. d . She has taken 220 mg of Naproxen (Aleve) twice daily for 3 years.
She has taken 220 mg of Naproxen (Aleve) twice daily for 3 years. longterm use can cause CKD
A 58-yr-old woman tells the nurse, "I understand that I have stage 2 breast cancer and I need to decide on a surgery, but I feel overwhelmed. What do you think I should do?" Which response by the nurse is best? a . "I would have a lumpectomy, but you need to decide what is best for you." b . "It would not be appropriate for me to make a decision about your health." c. "There is no need to make a decision rapidly; you have time to think about this." d . "Tell me what you understand about the surgical options that are available."
Tell me what you understand about the surgical options that are available.
The client who has experienced status epilepticus has been treated with IV diazepam (Ativan) and has been ordered to receive phenytoin (Dilantin) to prevent a recurrence. Which statement indicates that the client understands how to take this medication ( phenytoin )? a . "Even when my seizures stop, I will take this drug." b . "I must drink at least 2 L of water daily." c. "I will not be able to be employed while taking this medication." d . "This will stop me from getting an aura before a seizure."
a . "Even when my seizures stop, I will take this drug." to maintain theraputic range of drug if out of range pt can seize
Which comment made by the client with breast cancer indicates correct understanding regarding cancer causes and prevention? a . "I will have regular mammograms on my other breast to detect cancer early." b . "If I had breast-fed my children, this would not have happened to me." c. "I will cure my cancer by eating a low-fat diet from now on." d . "I hope this doesn't increase my risk for bone cancer or lung cancer."
a . "I will have regular mammograms on my other breast to detect cancer early."
The wife of a client with severe chronic kidney disease (CKD) who has a Kussmaul pattern of respiration asks the nurse about giving the client oxygen to ease his respirations. What is the nurse's best response? a . "Oxygen will not help his respirations and could make his acidosis worse." b . "The oxygen mask or tube may increase his risk for skin breakdown." c. "He will probably need a high flow of oxygen because he is also anemic." d . "That is a good idea and I will check with the physician right away."
a . "Oxygen will not help his respirations and could make his acidosis worse."
To determine the effectiveness of fluid restriction on a client in renal failure, the nurse will assess for which finding? a . Absence of lung crackles. b . Increased muscle strength. c. Decreased serum potassium level. d . Decreased serum creatinine level
a . Absence of lung crackles. if retaining fluid lungs a primary symptom in pt w/ renal failure is this
The client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? a . Assessing neurologic status at least every 2 to 4 hours. b . Strict monitoring of hourly intake and output. c. Decreasing environmental stimuli. d . Managing pain through drug and nondrug methods.
a . Assessing neurologic status at least every 2 to 4 hours
The nurse reviews the chart of the client, who had a T-12 Spinal Cord Injury (SCI) 13 years ago and is receiving baclofen (Lioresal) through an intrathecal infusion pump. Which chart information in the exhibit is most important for the nurse to discuss with the Health Care Provider (HCP)? a . Assessment findings:the patient is experiencing manifestations of critical side effects to Baclofen; which should be discussed with the HCP. b . Orthostatic hypotension: Severe orthostatic hypotension warrants calling the HCP. c. Prescribed medications: one medication should not be prescribed because its contraindicated to patients with SCI. d . Laboratory test results: Leukocytosis and Hyperglycemia should be reported to HCP immediately.
a . Assessment findings:the patient is experiencing manifestations of critical side effects to Baclofen; which should be discussed with the HCP.
Which teaching by the nurse will help the client prevent renal osteodystrophy? a . Avoiding peas, nuts, and legumes b . Low-calcium diet c. Drinking cola beverages only once daily d . Avoiding dairy enriched with vitamin D
a . Avoiding peas, nuts, and legumes these foods are high in phosphorus and kidney failure has hyperphosphatemia and hypocalcemia
When performing an hourly assessment of a client who had a subclavian catheter placed 6 hours ago for continuous arteriovenous hemofiltration with dialysis (CAVHD), the nurse observes these findings. For which finding does the nurse stop the CAVHD? a . Blood pressure has decreased from 148/90 to 90/60. b . The client reports 2/10 pain level and cramps in the calf muscle bilaterally. c. Pulse oximetry is increased from 89% to 91%. d . The right foot and ankle appear slightly more edematous than the left foot and ankle
a . Blood pressure has decreased from 148/90 to 90/60. bc indicates sign of infection
Which of the following clients is most at risk for developing postrenal renal failure? a . Client diagnosed with renal calculi. b . Client with congestive heart failure. c. Client recovering from glomerulonephritis. d . Client with EF= 45% and severe hypotension e . Client taking nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritis pain.
a . Client diagnosed with renal calculi. bc obstruction
Which client should be assigned to the experienced registered nurse on a neurologic floor? a . Client with traumatic injury to the cervical spinal cord who was admitted today from the emergency department. b . Client with Bell's palsy with unilateral facial droop. c. Client with trigeminal neuralgia reporting facial pain rated at 10. d . Client after surgical removal of a spinal cord tumor who is scheduled for discharge tomorrow.
a . Client with traumatic injury to the cervical spinal cord who was admitted today from the emergency department.
The nurse monitors for which complication in the client with Guillain-Barré syndrome who is undergoing plasmapheresis? a . Hypovolemia and hypotension. b . Hyperkalemia and hyponatremia. c. Increased INR and elevated aPTT. d . Hypertension and fluid overload.
a . Hypovolemia and hypotension. bc removes plasma from blood so blood has to removed for procedure
A client complains of a tight, band-like feeling around the trunk and sensations of numbness and tingling in both legs after a motor vehicle crash. Which is the nurse's priority action? a . Immobilizing the client and notify the health care provider. b . Medicating the client for pain and provide oxygen. c. Assessing proprioception while massaging both legs. d . Performing ROM exercises on the extremities.
a . Immobilizing the client and notify the health care provider.
Which statement made by the client who has just had a mammogram indicates a need for clarification regarding the importance or purpose of this procedure? a . Now that I have had a mammogram, my risk for getting breast cancer is reduced." b "Even though I have had a mammogram, I should still perform a breast . self-examination monthly." c. "The amount of radiation exposure from a mammogram is low." d "Yearly mammograms can reduce my risk of dying from breast cancer."
a . Now that I have had a mammogram, my risk for getting breast cancer is reduced." Regular or yearly mammography does not decrease the incidence of breast cancer. It only assists in early detection and diagnosis
The client arrives in the emergency department from a motor vehicle crash, during which the car ran into a tree. The client was not wearing a seat belt, and the windshield is shattered. What action is most important for you to do? a . Use a logroll technique when transferring the patient. b . Assess the Glasgow Coma Scale (GCS) score. c. Determine if the patient lost consciousness. d . Obtain vital signs and assess pain level.
a . Use a logroll technique when transferring the patient.
A client is concerned about her steadily worsening chronic kidney disease and asks the nurse at what point she will require hemodialyis (HD) treatment. Which of the following should the nurse mention? When the client's bleeding tendency increases, uremic manifestations are present, AND:_____________ a . When your urine osmolality is greater than 500 mOsm/kg H2O. b . When your urine output is less than 0.5 mL/kg/h × 6 h. c. When your urine albumin-to-creatinine ratio is greater than 25 mg/g. d . When your glomerular filtration rate (GFR) falls below 15 mL/min/1.73 m2.
a . When your urine osmolality is greater than 500 mOsm/kg H2O. bc measures osmolality measures urine concentration
The nurse has just received the shift report. Which client should the nurse assess first? a. The client with a C-6 spinal cord injury who has autonomic dysreflexia. b. The client with Huntington's disease who has writhing, twisting movements of the face. c. The client with Guillain-Barré syndrome who has ascending paralysis to the knees. d. The client with Parkinson's disease who is experiencing "pill rolling." e. The client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia
a. The client with a C-6 spinal cord injury who has autonomic dysreflexia. pts is experencing massive uncompensated cardiovascular response
Which statement indicates that the family has a good understanding of the changes in motor movement associated with Parkinson's disease? a . "I think this disease makes him nervous. He perspires all the time." b . "I can offer smaller meals with bite-size portions and a liquid supplement." c. "I can never tell what he's thinking. He hides behind a frozen face." d . "She drools all the time just so I can't take her out anywhere."
b . "I can offer smaller meals with bite-size portions and a liquid supplement." give small frequent meals/thickened liquids bc swallowing dysfunction
Which response by the client indicates an understanding of measures to facilitate the flow of peritoneal dialysate fluid? a . "Flushing the catheter once a week is needed." b . "I will take my stool softeners every day." c. "Warmed dialysate infusion increases the speed of flow." d . "I will keep the drainage bag at the level of my abdomen.
b . "I will take my stool softeners every day." pts are at risk for constipation
The nurse is evaluating whether treatment is effective for the 28-year-old with Chronic Renal Failure (CRF) who is receiving sevelamer hydrochloride (Renagel, Renvela) . Identify the laboratory test results which indicate that the medication is effective (see chart be a . Hemoglobin and Hematocrit b . Calcium and phosphorus c. Potassium and RBCs d . WBCs and Albumin
b . Calcium and phosphorus
The nurse is caring for a client with a spinal cord injury (SCI) resulting from a diving accident, who has a halo fixator and an indwelling catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the health care provider will request which medication? a . Methylprednisolone (Solu-Medrol). b . Hydralazine (Apresoline). c. Dopamine hydrochloride (Inotropin). d . Metronidazole (Flagyl).
b . Hydralazine (Apresoline).
Clients with spinal cord injury (SCI) may experience both spinal shock and neurogenic shock, and differentiating between the two is essential. What symptoms are unique to neurogenic shock? a . Presence of poikilothermia (inability to regulate core body temperature). b . Hypotension and bradycardia. c. Flaccid paralysis below the lesion. d . Loss of motor and sensory function
b . Hypotension and bradycardia.
Which precautions will the nurse institute to ensure the safety of a client with epilepsy who has been hospitalized? (Select all that apply.) a . Place a padded tongue at bedside. b . Keep bed rails up at all times while in bed (per institution policy). c. Permit only clear oral fluids. d . Maintain the client on strict bedrest with 2-point restraint while in the hospital. e . Have suction equipment at the bedside. f. Ensure that the client has IV access.
b . Keep bed rails up at all times while in bed (per institution policy). e . Have suction equipment at the bedside. f. Ensure that the client has IV access.
The nurse is assessing the client following a closed head injury. When applying nailbed pressure, the client's body suddenly stiffens, the eyes roll upward, and there is an increase in salivation and loss of swallowing reflex. Which observation should the nurse document? a . Decorticate posturing observed. b . Seizure activity observed. c. Decerebrate posturing observed. d . Positive Kernig's sign observed.
b . Seizure activity observed.
The ICU nurse manager is making shift assignments. Which client should be assigned to the most experienced nurse? a . The client diagnosed with Parkinson's who has a mask-like face and has pill rolling. b . The client diagnosed with bacterial meningitis who is experiencing photophobia. c. The client with an L-4 SCI who has spastic muscle spasms of the lower extremities. d . The client with amyotrophic lateral sclerosis (ALS) who is having respiratory distress.
b . The client diagnosed with bacterial meningitis who is experiencing photophobia.
The nurse is providing medication instructions to a client diagnosed with amyotrophic lateral sclerosis (ALS) who has been prescribed riluzole (Rilutek). Which statement indicates to the nurse that the client understands the instructions? a . "I plan to take riluzole once daily." b . "I will need frequent checks of my liver enzymes." c. "Riluzole should be taken with food." d . "I will call the health care provider if my pulse goes below 50."
b."I will need frequent checks of my liver enzymes."
A client with Bell's palsy asks the nurse why artificial tears were ordered by the health care provider. Select the best reply by the nurse. a . "When your affected eye fails to make tears, the eye can become irritated and ulcerated." b . "Because your eye remains closed, foreign matter can be trapped beneath the lid." c. "Because you cannot blink the affected eye, it can become dry and irritated." d . "Artificial tears will remove the purulent drainage from your eye, which speeds healing."
c. "Because you cannot blink the affected eye, it can become dry and irritated."
The nurse has presented information about amyotrophic lateral sclerosis (ALS) to a newly diagnosed client. Which question by the client indicates that he understands the nature of the disease? a . "How can I avoid infecting my family with the virus?" b . "How many people achieve remission with chemotherapy?" c. "How can I execute a living will?" d . "How can I prevent an exacerbation of the disease?
c. "How can I execute a living will?" bc no cure
You have just received report on a group of clients. Which client would require your attention first? a. A 60-year-old client with a history of seizure disorder who has a reported temperature of 40.0° Celsius (104 F°) b. A 44-year-old client with a diagnosis of complex partial seizures who is agitated and picking at clothing c. A 30-year-old client who has just been reported to have a fourth seizure in the last 30 minutes d. A 28-year-old client admitted with a diagnosis of generalized tonic-clonic seizure who describes the presence of an aura
c. A 30-year-old client who has just been reported to have a fourth seizure in the last 30 minutes can become a crisis
The nurse in a long-term care facility is administering medications to a group of clients. Which medication should the nurse administer first? a . Acetylsalicylic acid (aspirin) to a client diagnosed with cerebrovascular disease. b . Neostigmine (Prostigmin) to a client diagnosed with myasthenia gravis. c. Acyclovir (Zovirax) to a client diagnosed with Bell's palsy. d . Cephalexin (Keflex) to a client diagnosed with an acute urinary tract infection
c. Acyclovir (Zovirax) to a client diagnosed with Bell's palsy.
The client has a spinal cord lesion at T1-T2. About an hour after being turned, the client experiences a sudden throbbing headache accompanied by extreme blood pressure elevation and profound bradycardia. The client has a very flushed face. What is the nursing priority? a . Administer pain medication immediately. b . Turn on the fan and open the window. c. Check Foley catheter for twisting or kinks. d . Give intravenous beta-antagonist medication.
c. Check Foley catheter for twisting or kinks. bc pt has autonomic dysreflexia
What instruction should the nurse include in the discharge-teaching plan of a client who has been diagnosed with multiple sclerosis (MS)? a . It is very important to engage in a progressive exercise program to build strength and endurance. b . It is important to engage in social activity, and volunteering to read to schoolchildren will keep you active. c. It is very important to develop a daily schedule that reduces fatigue and conserves energy. d . It is important with this disease to relax muscles; a hot tub spa is a good form of relaxation.
c. It is very important to develop a daily schedule that reduces fatigue and conserves energy. bc of weakness
Which nursing intervention will assist in preventing respiratory complications in the client with Parkinson's disease? a . Teaching the client pursed-lip breathing techniques. b . Keeping an oral airway at the bedside. c. Maintaining the back rest elevation at greater than 30 degrees. d . Ensuring a fluid intake of at least 3 L/day.
c. Maintaining the back rest elevation at greater than 30 degrees. to prevent aspirations
A client with Parkinson's disease is prescribed levodopa/carpidopa (Sinemet) therapy. Improvement in which of the following indicates effective therapy? a . Flaccid and weak muscles of lower extremities. b . Alertness and fatigue c. Muscle rigidity and stiffness d . Appetite and swallowing difficulty e . Mood and cognitive function
c. Muscle rigidity and stiffness
Which nursing action should be included in the plan of care for a patient returning to the surgical unit after a left modified radical mastectomy with dissection of axillary lymph nodes? a . Insist that the patient examine the surgical incision when the initial dressings are removed. b . Teach the patient to use the ordered patient-controlled analgesia every 10 minutes. c. Post a sign at the bedside warning against venipunctures or blood pressures in the left arm. d . Obtain a permanent breast prosthesis before the patient is discharged from the hospital.
c. Post a sign at the bedside warning against venipunctures or blood pressures in the left arm. puts pt at risk for lymphedema
You recognize that status epilepticus is a medical emergency because a. Heart rate becomes bradycardic and may lead to syncope. b.Urinary fecal incontinence may occur. c. Seizures continue without a return of consciousness. d.Fractures of a limb may occur.
c. Seizures continue without a return of consciousness.
A client on peritoneal dialysis (PD) develops a low-grade fever and complains of abdominal pain when fluid is being inserted/infused. The nurse also observes that the peritoneal drainage fluid is cloudy. What intervention should the nurse make? a . Assess the patient for signs of pulmonary congestion. b . Measure the patient's blood pressure. c. Send a specimen of the dialysate outflow for culture and sensitivity study. d . Turn the patient from side to side
c. Send a specimen of the dialysate outflow for culture and sensitivity study. bc sign of peritonitis
A patient diagnosed with chronic kidney disease is told he must start hemodialysis. During patient teaching, the nurse should instruct the patient to: a . Eat food high in dairy such as cheese and ice cream. b . Use alcohol to clean the skin because of integumentary changes. c. Strictly follow the hemodialysis schedule. d . Follow a high-potassium diet.
c. Strictly follow the hemodialysis schedule. noncompliance can lead to a crisis like fluid overload
Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action? a . The patient's sacral area skin is reddened. b . The patient's blood pressure (BP) is 140/82 mm Hg. c. The patient is continuously drooling saliva. d . The patient reports severe pain in the feet.
c. The patient is continuously drooling saliva. bc pt can aspirate
What will the nurse teach a patient with metastatic breast cancer who has a new prescription for trastuzumab (Herceptin)? a . The patient will need frequent eye examinations. b . Serum electrolyte levels will be drawn monthly. c. The patient should call if she notices ankle swelling. d . Hot flashes may occur with the medication.
c. The patient should call if she notices ankle swelling.
The nurse is providing care for a patient with a seizure disorder. What is the best explanation for the patient's statement, "I see flashing lights that are not there before I have a seizure." a . This prodromal symptom indicates that the seizure will be worse than the last. b . This is the initial part of the ictal phase of the seizure. c . This is an aura and is a normal part of the initial phase of a seizure. d . This is an abnormal finding and should be reported to the provider.
c.This is an aura and is a normal part of the initial phase of a seizure.
The client with myasthenia gravis (MG) is receiving cholinesterase inhibitor drugs to improve muscle strength. The nurse is educating the family about this therapy. Which statement by a family member indicates correct understanding of the nurse's instruction? a . "I should increase the dose if a sudden increase in weakness occurs." b . "The medication should be taken on an empty stomach." c. "The medication should be taken with a large meal." d . "I should call 911 if a sudden increase in weakness occurs.
d . "I should call 911 if a sudden increase in weakness occurs. bc this shows understanding of crisis
Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? a . Cardiac monitoring for bradycardia. b . Application of pneumatic compression devices to legs. c. Administration of low-molecular-weight heparin. d . Assessment of respiratory rate and effort.
d . Assessment of respiratory rate and effort. edema around injury leads to above c4 damage
The occurrence of which condition warrants the nurse immediately discontinuing a peritoneal dialysis exchange? a . Poor dialysate flow b . Outflow less than inflow c. Pain during dialysate inflow d . Brown color effluent
d . Brown color effluent
During hemodialysis, a client with chronic kidney disease develops headache, nausea, vomiting, and restlessness. After notifying the MD/NP, which action by the nurse is most appropriate? a . Preparing to administer an anticonvulsant b . Administering an intravenous bolus of dextrose solution c. Ordering a blood urea nitrogen (BUN) level STAT d . Discontinuing the hemodialysis after administering heparin
d . Discontinuing the hemodialysis after administering heparin bc if dialysis continues after administration the med will get flushed out of body
A 51-yr-old patient with a small immobile breast lump is considering having a fine-needle aspiration (FNA) biopsy. What should the nurse explain as an advantage to this procedure? a . If the biopsy results are negative, no further diagnostic testing will be needed. b . Only a small incision is needed, resulting in minimal breast pain and scarring. c. FNA is guided by a mammogram, ensuring that cells are taken from the lesion. d . FNA is done in the outpatient clinic, and results are available in 1 to 2 days
d . FNA is done in the outpatient clinic, and results are available in 1 to 2 days
The nurse is caring for a patient with acute kidney injury. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: a . Hypernatremia. b . Hyponatremia. c. Hypokalemia. d . Hyperkalemia
d . Hyperkalemia insulin w/ glucose temporarily push k+ outside cell sodium bicarb helps w/acidosis which is caused by hyperkalemia
Which patient assessment would help the nurse identify potential complications of trigeminal neuralgia? a . Have the patient clench the jaws. b . Identify trigger zones by lightly touching the affected side. c. Palpate the face to compare skin temperature bilaterally. d . Inspect the oral mucosa and teeth.
d . Inspect the oral mucosa and teeth. caused by infection or trauma of teeth/jaw
A client who experienced a spinal cord injury (SCI) 1 hour ago is brought to the emergency room. Which medication will the nurse prepare to administer to this client? a . Atropine sulfate b . Intrathecal baclofen c. Epinephrine d . Methylprednisolone
d . Methylprednisolone bc gretaer recovery w/ early admin of drug
A client is scheduled to have a series of diagnostic studies for myasthenia gravis (MG), including a Tensilon test. The nurse should explain to the client that the diagnosis of myasthenia gravis will be confirmed if the administration of the Tensilon produces a: a . Brief exaggeration of symptoms. b . Prolonged decrease in the strength of swallowing and eyelid muscles. c. Prolonged and permanent symptomatic improvement. d . Rapid but brief symptomatic improvement.
d . Rapid but brief symptomatic improvement.
Which conditions or factors in a middle-aged woman diagnosed with Guillain-Barré syndrome are most likely to have contributed to this problem? a . She has a history of chronic atrial fibrillation. b . The results of her endometrial biopsy is positive for endometriosis. c. She works with oil paints and paint thinner as an artist. d . She had a viral infection about 9 days ago. e . Her husband also had Guillain-Barré syndrome 2 months ago.
d . She had a viral infection about 9 days ago. viruses can trigger/associated with GBS
The nurse is caring for multiple clients. Which client would be most appropriate for the nurse to plan to instruct on the use of intermittent self-urinary catheterization (straight cath)? a . The 16-year-old who is 8 months pregnant and reports dribbling. b . The 15-year-old preparing to have a cesarean section. c. The 18-year-old newly diagnosed with multiple sclerosis. d . The 13-year-old with an SCI and no awareness of urge to void.
d . The 13-year-old with an SCI and no awareness of urge to void.
The nurse is caring for a client who is receiving peritoneal dialysis. Which nursing intervention has the greatest priority when performing a dialysis exchange? a . Positioning the client on his side. b . Warming the dialysate fluid in a microwave oven. c. Adding potassium and antibiotic to the dialysate bags. d . Using sterile technique when hooking up dialysate bags.
d . Using sterile technique when hooking up dialysate bags.
The nurse in the ED documents that the newly admitted client is "postictal upon transfer." What did the nurse observe? (Post-ictal= post seizure attack) a. Abnormal sensations including tingling of the skin. b. Severe itching of the eyes from an allergic reaction. c. Yellowing of the skin due to a liver condition. d. Drowsy or confused state following a seizure.
d. Drowsy or confused state following a seizure. pts are fatigued
A nurse has instructed the client with myasthenia gravis (MG) to take drugs on time and to eat meals 45 to 60 minutes after taking the anticholinesterase (ChEI) drugs. The client asks why the timing of meals is so important. Which is the nurse's best response? a . "These drugs are very irritating to your stomach and could cause ulcers if taken too long before meals." b . "These drugs cause nausea and vomiting. By waiting for a while after you take the medication, you are less likely to vomit." c. "This timing prevents your blood sugar level from dropping too low and causing you to be at risk for falling." d . "This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke."
d."This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke." at risk for aspiration during meals
A client with chronic renal failure has an arteriovenous (AV) fistula in her right (R) forearm for dialysis access. What intervention or interventions should the nurse make in working with this client? (Select all that apply). a . Take the patient's blood pressure on the right forearm. b . Draw blood samples from the vein that forms the fistula. c. Elevate the right arm above the heart level at all times. d . Avoid placing any restraints on the access site (the fistula). e . Check frequently the distal pulses and capillary refill in the right arm. f. Palpate the fistula for thrill every 8 hours
d.Avoid placing any restraints on the access site (the fistula). f. Palpate the fistula for thrill every 8 hours
A client who suffered a spinal cord injury (SCI) at level T5 several months ago develops a flushed face, severe headache, and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 204/115 mm Hg. Which is the nurse's first action? a. Immediately turn the client to the side to prevent aspiration b. Placing the client in the Trendelenburg position c. Performing carotid massage after obtaining an order d. Administering oxygen via a nasal cannula e. Palpating the area over the bladder for distention
e. Palpating the area over the bladder for distention manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing,
