exam 3 practice questions
A nurse is caring for a client who has polycystic kidney disease (PKD). Which of the following findings should the nurse expect? A. Flank pain B. Hypotension C. Confusion D. Urinary retention
A. Flank pain
35. A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL/hr
125 mL/hr
A nurse is preparing to administer lactated Ringer's 400 mL IV bolus to infuse over 3 hr. 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/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ gtt/min
44 gtt/min
A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor? A. COPD B. Diabetes mellitus C. Anemia D. Osteoporosis
B. Diabetes mellitus
Using the parkland formula, calculate the hourly rate of fluid replacement with lactated ringers solution during the first 8 hours for a client weighing 75 kg with total body surface area burn of 40%. Record your answer using a whole number:
750 mL/hr
A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan? A. Administer antibiotics. B. Encourage increased fluid intake. C. Obtain weight weekly. D. Encourage frequent ambulation.
A. Administer antibiotics.
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. Airway obstruction B. Infection C. Fluid imbalance D. Paralytic ileus
A. Airway obstruction
A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? A. Protein B. Calcium C. Vitamin B1 D. Vitamin D
A. Protein
A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity? A. Omeprazole B. Vancomycin C. Ondansetron D. Diphenhydramine
B. Vancomycin
A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing? A. One cup of brown rice B. One cup of orange juice C. One cup of pureed avocado D. One cup of lentils
D. One cup of lentils
A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions? A. Mastoiditis B. Ménière's disease C. Acoustic neuroma D. Perforated tympanic membrane
D. Perforated tympanic membrane
A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values? A. RBC count B. Protein C. Calcium D. Potassium
D. Potassium
12. A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching? A. Renal function is reestablished. B. BUN and creatinine levels decrease. C. Urine output is less than 400 mL per 24 hr. D. The glomerular filtration rate (GFR) recovers.
C. Urine output is less than 400 mL per 24 hr.
A nurse is reviewing the provider's history and physical form for a client who has advanced multiple myeloma. Which of the following findings should the nurse expect? A. Ecchymoses B. Hypocalcemia C. Hypotension D. Polycythemia
A. Ecchymoses
A nurse is assessing a client who presents to the provider's office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy? A. Irregular borders B. Purulent drainage C. Uniform pigmentation D. Intense pruritus
A. Irregular borders
A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply? A. Transparent dressing B. Wet-to-dry gauze dressing C. Hydrogel dressing D. Alginate dressing
A. Transparent dressing
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority? A. Place the child on a no-salt-added diet. B. Check the child's daily weight. C. Educate the parents about potential complications. D. Maintain a saline-lock.
B. Check the child's daily weight.
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A. Urinary output 25 mL/hr B. Difficulty swallowing C. Heart rate 122/min D. Pain of 6 on a scale of 0 to 10
B. Difficulty swallowing
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? A. BP B. Heart rate C. Urine output D. Weight
B. Heart rate
A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect? A. Decreased creatinine level B. Hyperkalemia C. Hypomagnesaemia D. Increased glomerular filtration rate (GFR)
B. Hyperkalemia
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis? A. Hyperactive bowel sounds B. Nausea and vomiting C. Bradycardia D. Increased urinary output
B. Nausea and vomiting
A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take? A. Apply dry, sterile gauze dressings to affected areas. B. Prepare to administer acyclovir. C. Instruct family members with a history of chickenpox that they are still at risk for contracting the virus. D. Apply topical corticosteroids to the affected areas.
B. Prepare to administer acyclovir.
11.A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft? A. Measure the client's blood pressure to ensure it is higher in the left arm than the right. B. Check the brachial and radial pulses of the left arm simultaneously. C. Auscultate the site for a bruit. D. Auscultate the antecubital fossa using a Doppler stethoscope.
C. Auscultate the site for a bruit.
A nurse is caring for a client who is receiving mydriatic eye drops. Which of the following manifestations indicates to the nurse that the client has developed a systemic anticholinergic effect? A. Seizures B. Bradycardia C. Constipation D. Hypothermia
C. Constipation
A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Perform wound irrigation for a client. B. Evaluate pain relief for a client following the administration of a pain medication. C. Measure and record intake and output for a client. D. Teach a client about low-sodium foods.
C. Measure and record intake and output for a client.
A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? A. Stress incontinence B. Urge incontinence C. Overflow incontinence D. Reflex incontinence
C. Overflow incontinence
A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication? A. The leukocyte count B. The platelet count C. The hematocrit (Hct) D. The erythrocyte sedimentation rate (ESR)
C. The hematocrit (Hct)
10. A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching? A. "The procedure will be cancelled if the urinalysis indicates the presence of red blood cells." B. "High frequency sound waves will be used to identify renal system structures." C. "You will be able to resume your regular diet as soon as the test is complete." D. "After the procedure you will be encouraged to drink plenty of fluids."
D. "After the procedure you will be encouraged to drink plenty of fluids."
A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)? A. 9 percent B. 18 percent C. 36 percent D. 54 percent
D. 54 percent
A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client? A. Urinary retention B. Low back pain C. Incontinence D. Confusion
D. Confusion
A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching? A. "All recently used clothing, bedding, and towels must be washed in hot water." B. "My child must be free from nits before returning to school." C. "I will treat all the family members to be on the safe side." D. "Toys that can't be dry cleaned or washed must be thrown out."
A. "All recently used clothing, bedding, and towels must be washed in hot water."
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? A. Electrical cords are placed along the walls. B. Scatter rugs are present in the kitchen. C. Handrails are present in the bathroom. D. Uses a microwave for cooking.
B. Scatter rugs are present in the kitchen.
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report A. loss of central vision. B. having a loss of peripheral vision. C. seeing bright flashes of light and floaters. D. having a decreased ability to perceive colors.
D. having a decreased ability to perceive colors.
The nurse is discharging a client who just had cataract removal and intraocular lens implantation. The nurse is condiment the client understands discharge instructions when the client states the following. Select all that apply a. I understand the schedule for my eyedrops and will use the medications b. I feel good and am ready to drive home now c. I will call in the morning if I cannot see clearly d. I will wear the eye shield at night to protect my eye e. I will avoid lifting or pulling anything over 15 lbs f. I will call if I still have eye pain after taking acetaminophen
a. I understand the schedule for my eyedrops and will use the medications e. I will avoid lifting or pulling anything over 15 lbs f. I will call if I still have eye pain after taking acetaminophen
A nurse is teaching a client who has pre-dialysis end-stage kidney disease about diet. Which of the following instructions should the nurse include? A. "Increase intake of dietary phosphorous." B. "Eliminate foods high in protein from your diet." C. "Reduce intake of foods high in potassium." D. "Increase intake of sodium-containing food."
C. "Reduce intake of foods high in potassium."
A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have? A. pH 7.49, HCO3 24, PaCO2 30 B. pH 7.49, HCO3 30, PaCO2 40 C. pH 7.26, HCO3 24, PaCO2 46 D. pH 7.26, HCO3 14, PaCO2 30
D. pH 7.26, HCO3 14, PaCO2 30
A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction? A. "I will clean the hearing aids with alcohol wipes." B. "I will not use hairspray if I am wearing the hearing aids." C. "I will change the batteries once a week." D. "I will expect the hearing aids to whistle when I cup my hand over them."
A. "I will clean the hearing aids with alcohol wipes."
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching? A. "I will need to wipe my perineal area from back to front after urination." B. "I will need to empty my bladder regularly and completely." C. "I will need to drink apple cider vinegar each day." D. "I need to drink 8 cups of liquid each day."
A. "I will need to wipe my perineal area from back to front after urination."
A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect? A. Tugging on the affected ear lobe B. Clear drainage from the affected ear C. Pain when manipulating the affected ear lobe D. Erythema and edema of the affected ear
A. Tugging on the affected ear lobe
The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. What is the most appropriate nursing action? a. Reposition the client off the reddened skin and reassess in a few hours b. Apply a moist to moist dressing, being careful to pack just the wound bed c. Consult with a wound-ostomy-continence nurse specialist Complete and document a Braden skin breakdown risk score for the client
a. Reposition the client off the reddened skin and reassess in a few hours
In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? a. Oral analgesics such as ibuprofen or acetaminophen b. Intravenous opioids c. Intramuscular opioids d. Oral antianxiety agents such as lorazepam
b. Intravenous opioids
Eardrops have been prescribed to be instilled in the adult client's left ear to soften cerumen. To position the client, what should the nurse do? a. Have the client lie on the left side b. Pull the auricle lobe up and back c. Pull the ear lobe down and back d. Chill the eardrops prior to administering
b. Pull the auricle lobe up and back
A client uses timolol maleate eyedrops. The expected outcome of this drug is to control glaucoma by: a. Constricting the pupils b. Dilating the canals of Schlemm c. Reducing aqueous humor formation d. Improving the ability of the ciliary muscle to contract
c. Reducing aqueous humor formation
The nurse is assessing an 80-year-old client who has scald burns on the hands and both forearms (first and second degree burns on 10% of the body surface area). What should the nurse do first? a. Clean the wounds with warm water b. Apply antibiotic cream c. Refer the client to a burn center d. Cover the burns with a sterile dressing
c. Refer the client to a burn center
The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which finding indicates that the client is responding? a. Pulse rate of 112 bpm b. Blood pressure of 94/64 mm Hg c. Urine output of 30 mL/h Serum sodium level of 136 mEq/L
c. Urine output of 30 mL/h
The risk for injury during an attack of Meniere's Disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo? a. Place you r head between your knees b. Concentrate on rhythmic deep breathing c. Close your eyes tightly d. Assume a reclining or flat position
d. Assume a reclining or flat position
To approach a deaf client, what should the nurse do first? a. Knock on the room's door loudly b. Close and open the vertical blinds rapidly c. Talk while walking into the room d. Get the client's attention
d. Get the client's attention
After cataract removal surgery, the client is instructed to report sharp pain in the operative eyes because this could indicate which postoperative complication? a. Detached retina b. Prolapse of the iris c. Extracapsular erosion d. Intraocular hemorrhage
d. Intraocular hemorrhage
The client is diagnosed with a detached retina in the right eye. What should the nurse do first? a. Apply compresses to the eye b. Instruct the client to lie prone c. Remove all bed pillows d. Promote measures that limit mobility
d. Promote measures that limit mobility
A nurse is completing the 8-hr I&O record for a client who consumed 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The client also received 300 mL of 0.9% sodium chloride IV. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL
1,140 mL
A nurse is preparing to administer 0.9% sodium chloride (NSS) 3000 mL IV to infuse over 24 hr. The drop factor on the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ gtt/min
21 gtt/min
A nurse is preparing to administer cefazolin IVPB over 20 min. Available is cefazolin 1 g in 100 mL of dextrose 5% in water (D5W). The drop factor of the manual IV tubing is 15gtt/mL. The nurse should set the IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ gtt/min
75 gtt/min
26. A nurse is teaching a client who has herpes simplex virus type 2 about disease transmission. Which of the following statements by the client indicates understanding of the teaching? A. "Itching or tingling occurs at the site where a blister forms." B. "It is okay to share towels as long as it belongs to a family member." C. "It is not contagious after the blisters rupture." D. "I will take medication daily to prevent more sores."
A. "Itching or tingling occurs at the site where a blister forms."
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? A. Sleep on the abdomen to facilitate wound healing. B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. C. Bend at the waist to pick objects up from the floor. D. Notify the surgeon if white drainage develops on the eyelids.
B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
18.During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer? A. Squamous cell carcinoma B. Basal cell carcinoma C. Malignant melanoma D. Actinic keratosis
B. Basal cell carcinoma
A nurse is caring for a client who has shingles with multiple skin lesions. Which of the following actions by the nurse require intervention by the nurse's supervisor? A. The nurse wears an N95 respirator mask. B. The nurse admits another client who has shingles to the client's double room. C. The nurse wears gloves when providing direct care to the client. D. The nurse wears a gown when bathing the client.
B. The nurse admits another client who has shingles to the client's double room.
3. A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.) A. Green Beans B. Tomatoes C. Bananas D. Asparagus E. Raisins
B. Tomatoes C. Bananas E. Raisins
A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury? A. Initiate fluid resuscitation. B. Medicate for pain. C. Insert an indwelling urinary catheter. D. Maintain the airway.
D. Maintain the airway.
A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching? A. Take ibuprofen for eye discomfort. B. Creamy white drainage is an indication of infection. C. Notify the provider immediately if the operative eye itches. D. The client should wear dark glasses while outdoors.
D. The client should wear dark glasses while outdoors.
A nurse is caring for a client is who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL/hr
24 mL/hr
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention? A. Daily weight B. Sodium level C. Tissue turgor D. Intake and output
A. Daily weight
A nurse is teaching a client who has a new prescription for ciprofloxacin to treat an uncomplicated UTI. Which of the following instructions should the nurse include? A. "Take this medication with an antacid." B. "Monitor for tendon pain." C. "Drink 1,000 milliliters of fluid daily." D. "Expect urine to turn dark orange."
B. "Monitor for tendon pain."
A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make? A. "Yes, you are free to move around as you wish." B. "No, you are on strict bedrest and must not be up." C. "Please ring for assistance when you wish to get out of bed." D. "We will have to get a prescription from your provider."
C. "Please ring for assistance when you wish to get out of bed."
A nurse is caring for a client who has malignant melanoma. Which of the following findings should the nurse expect when assessing the lesion? A. Pain B. Pruritus C. Purplish in color D. Purulent drainage
C. Purplish in color
A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown? A. An adolescent who has a cervical fracture and is in a halo brace B. A young adult who has a femur fracture and is in skeletal balanced suspension traction C. A middle adult who has a fractured radius and an arm cast D. An older adult who has a hip fracture and is in Buck's traction
D. An older adult who has a hip fracture and is in Buck's traction
A nurse is discussing laboratory values associated with the renal system with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the values? A. Potassium levels are increased in clients who have polyuria. B. Specific gravity is decreased in clients who have hypovolemia. C. BUN is decreased in clients who have dehydration. D. Creatinine levels are increased in clients who have acute kidney injury.
D. Creatinine levels are increased in clients who have acute kidney injury.
A nurse is assessing a client at a dermatology clinic. Which of following findings places the client at risk for developing malignant melanoma? A. Female gender B. Age 19 to 30 years C. Dark hair D. History of chronic skin irritation
D. History of chronic skin irritation
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury? A. Dextrose 5% in water B. Dextrose 5% in 0.9% sodium chloride C. 0.9% sodium chloride D. Lactated Ringer's
D. Lactated Ringer's
The nurse is instructing the client about postoperative care following cataract removal. What position should the nurse teach the client to use? a. Remain in a semi-fowlers position b. Position the feet higher than the body c. Lie on the operative side d. Place the head in a dependent position
a. Remain in a semi-fowlers position
A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching? A. "Pyelonephritis increases a pregnant woman's risk for preterm labor." B. "Pyelonephritis is most often caused by Staphylococcus saprophyticus." C. "Pyelonephritis is an infection of the lower urinary tract." D. "Pyelonephritis often causes no symptoms in affected clients."
A. "Pyelonephritis increases a pregnant woman's risk for preterm labor."
A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. "Your provider might prescribe anticholinergic medications." B. "You should limit fluids in the evening." C. "You should restrict your intake of caffeine." D. "You might require intermittent urinary catheterization." E. "You might require an anterior vaginal repair."
A. "Your provider might prescribe anticholinergic medications." B. "You should limit fluids in the evening." C. "You should restrict your intake of caffeine."
A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? A. Auscultate breath sounds at least every 2 hr. B. Perform range-of-motion (ROM) exercises at least two to three times daily. C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day. D. Apply antiembolic stockings.
A. Auscultate breath sounds at least every 2 hr.
A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include? A. Basal cell carcinoma has a low incidence of metastasis. B. Basal cell carcinoma has a high mortality rate. C. Basal cell carcinoma is aggressive and rapid growing. D. Basal cell carcinoma develops from a nevi or mole.
A. Basal cell carcinoma has a low incidence of metastasis.
A nurse is assessing a client who reports a nevus that has increased in size and an irregularly shaped lesion that varies in color. These findings are consistent with which of the following medical diagnoses? A. Malignant melanoma B. Basal cell carcinoma C. Squamous cell carcinoma D. Kaposi's sarcoma
A. Malignant melanoma
A nurse is planning care for a client who has a detached retina and is preoperative for a surgical repair. The nurse should prepare to administer which of the following medications? A. Phenylephrine B. Latanoprost C. Pilocarpine D. Timolol
A. Phenylephrine
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? A. Place suction equipment at the client's bedside. B. Apply an eye patch to the client's right eye. C. Avoid the use of warm water to wash the client's face. D. Provide range-of-motion exercises to the client's neck and shoulders.
A. Place suction equipment at the client's bedside.
A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD).The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.) A. Protein B. Calcium C. Calories D. Phosphorous E. Sodium
A. Protein D. Phosphorus E. Sodium
A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing? A. Serum albumin 3.2 g/dL B. Hemoglobin 16 g/dL C. WBC count 8,000/mm3 D. PTT 1.8
A. Serum albumin 3.2 g/dL
A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? A. Sodium 126 mEq/L B. Potassium 3.6 mEq/L C. Magnesium 1.9 mEq/L D. Chloride 99 mEq/L
A. Sodium 126 mEq/L
A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload? A. The client has a 5 lb weight gain since yesterday. B. Flattened neck veins C. Oxygen saturation 93% D. Return of skin to previous position when the client's shin is palpated
A. The client has a 5 lb weight gain since yesterday.
A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include? A. "Take aspirin for discomfort." B. "Restrict lifting objects greater than 10 pounds." C. "Expect reduced vision for 48 hours after procedure." D. "Apply warm compresses for discomfort."
B. "Restrict lifting objects greater than 10 pounds."
A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene? A. The nurse separates the client's labia with her dominant hand. B. The nurse coats the indwelling urinary catheter with lubricant. C. The nurse provides perineal care prior to inserting the urinary catheter. D. The nurse applies the sterile drape prior to inserting the urinary catheter.
A. The nurse separates the client's labia with her dominant hand.
A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Use a transfer device to lift the client up in bed. B. Apply cornstarch to keep sensitive skin areas dry. C. Massage the skin over the client's bony prominences. D. Elevate the head of the bed no more than 45°.
A. Use a transfer device to lift the client up in bed.
A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect? A. Vertigo B. Dysphagia C. Diplopia D. Apraxia
A. Vertigo
9. A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? A. "I'll urinate a little then stop." B. "I'll use the cleansing wipe from front to back." C. "I'll clean the inside of the container with a wipe." D. "I'll use each cleansing wipe twice."
B. "I'll use the cleansing wipe from front to back."
A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma? A. Painless, raised purple nodules on the hard palate B. A firm nodule with a hard crust C. A small macule with a yellow-brown scale D. Yellow-white patches of growth on the tongue
B. A firm nodule with a hard crust
A client has a wound on the ankle that is not healing. The nurse should assess the client for which risk factors for delayed wound healing? Select all that apply. a. Atrial fibrillation b. Advancing age c. Type 2 diabetes mellitus d. Hypertension e. Smoking
B. advancing age c. type 2 DM e. smoking
A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take? A. Speak loudly and into the client's good ear. B. Use sign language when communicating with the client. C. Speak directly to the client in a normal, clear voice. D. Sit by the client's side and speak very slowly.
C. Speak directly to the client in a normal, clear voice.
A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture? A. Green-blue discharge in the ear canal B. Increased temperature C. Sudden pain relief D. Popping sensation when swallowing
C. Sudden pain relief
A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn? A. The burned area is black in color and pain is absent. B. The burned area is pink in color with blisters present. C. The burned area is red in color with eschar present. D. The burned area is yellow in color with severe edema.
C. The burned area is red in color with eschar present.
A 75-year-old client who has been taking furosemide regularly for 4 months tells the nurse about having trouble hearing. What should the nurse do? a. Tell the client that at age 75 years, it is inevitable that there will be hearing loss b. Report the hearing loss to the healthcare provider c. Schedule the client for audiometric testing and a hearing aid d. Tell the client that the hearing loss is only temporary; when the body adjusts to the furosemide, hearing will improve
b. Report the hearing loss to the healthcare provider
