exit K 4
An adult client is receiving lactated Ringers (LR) for burns to the genitalia. The nurse calculates which total body surface area (TBSA) for the burn?
1%
A nurse is caring for a client with right-sided heart failure. Which are key features of right-sided heart failure? Select all that apply.
1.Dependent edema 2.Distended abdomen 3.Polyuria at night
A client rescued from a burning building has partial- and full-thickness burns over 40% of the body. Which is the initial physiologic change that the nurse can expect?
An increase in serum potassium,
A client's laboratory report indicates the presence of hypokalemia. For which clinical manifestations associated with hypokalemia should the nurse assess the client? Select all that apply.
Anorexia Leg cramps
A client, admitted to the cardiac care unit with a myocardial infarction, complains of chest pain. The nursing intervention most effective in relieving the client's pain is to administer the prescribed:
Morphine sulfate 2 mg intravenously (IV)
A nurse is caring for a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). The IV infiltrates and needs to be restarted. What is necessary to protect the nurse when restarting the IV? Select all that apply.
Gloves Hand hygiene
A nurse is reviewing the physical examination and laboratory tests of a client with malaria. For which important clinical indicators should the nurse be alert when reviewing data about this client? Select all that apply.
Hyperthermia Splenomegaly
A client with a diagnosis of acquired immunodeficiency syndrome (AIDS) has a protozoal infection and is receiving pentamidine (NebuPent). The nurse should monitor the client for which common side effects? Select all that apply.
Hypoglycemia Decreased blood pressure
A nurse is providing postoperative care for a client one hour after the client had an adrenalectomy. Maintenance steroid therapy has not begun yet. The nurse should monitor the client for which complication?
Hypotension
A nurse concludes that a client has a hypoglycemic reaction to insulin. Which clinical findings support this conclusion? Select all that apply.
Irritability Heart palpitations
What should a nurse do immediately when a client returns from the postanesthesia care unit following a subtotal thyroidectomy?
Place a tracheostomy set at the bedside.
The nurse is caring for a client who returns from surgery with a catheter that is attached to a portable wound drainage system exiting from the surgical site. The principle underlying the function of a portable drainage system is:
Negative pressure
Which common initial clinical effects should the nurse expect a client with multiple sclerosis to exhibit? Select all that apply.
Nystagmus Scanning speech Intention tremors
A client who is 60 pounds more than the ideal body weight is admitted to the hospital with a diagnosis of type 1 diabetes. Which concept should the nurse include in teaching about diabetes when discussing strategies to lose weight?
Obesity leads to insulin resistance.
A nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the primary concern of the nurse when caring for this client?
Skin integrity
A nurse is caring for a client who just had a thyroidectomy. For which client response should the nurse assess the client when concerned about an accidental removal of the parathyroid glands during surgery?
Tetany
A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply.
Cool skin Constipation Periorbital edema Decreased appetite
The nurse provides discharge medication education to a client who has been switched from a prescription for heparin to a prescription for warfarin sodium (Coumadin). The nurse concludes that the teaching was effective when the client states, "I will:
take acetaminophen (Tylenol) for my occasional headaches."
Fludrocortisone (Florinef) is prescribed for a client with adrenal insufficiency. Which responses to the medication should the nurse teach the client to report? Select all that apply.
Edema Rapid weight gain
The nurse is caring for a client with diabetes mellitus that is scheduled to receive an intravenous (IV) administration of 25 units of insulin in 250 mL normal saline. The only type of insulin that is compatible with intravenous solutions is:
Novolin R insulin
A client is suspected of having rabies after being bitten by a raccoon. For which clinical indicators should the nurse assess the client? Select all that apply.
Nuchal rigidity Pharyngeal spasm,
A nurse is caring for a client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? Select all that apply.
Obese trunk Sleep disturbance Thin arms and legs
A nurse is caring for a client with a tentative diagnosis of pheochromocytoma who is receiving chlorpromazine (Thorazine). A 24-hour urine specimen to assess the presence of vanillylmandelic acid (VMA) is prescribed to assist in the confirmation of the diagnosis. What information should the nurse include in the client teaching regarding this test? Select all that apply.
- All urine excreted over the 24-hour period must be saved and refrigerated. - Avoid coffee, chocolate, and citrus fruit for three days before and during the test.
A client is admitted with thrombocytopenia. What specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply.
- Avoid intramuscular injections. - Examine the skin for ecchymotic areas.
The client is admitted with supraventricular tachycardia at a rate of 140 beats per minute. The client's blood pressure is 110/55 mm Hg, and he is asymptomatic except for a "fluttering feeling" in his chest. Which of the following treatments would be appropriate? Select all that apply:
- Intravenous adenosine (Adenocard) - Intravenous beta blockers - Intravenous calcium channel blockers - Intravenous amiodarone
The registered nurse determines that the new graduate understands the type(s) of hepatitis that generally develop into a chronic hepatitis infection if the graduate identifies which of the following? Select all that apply
3. Hepatitis C 4. Hepatitis D
A client weighing 125 kilograms (275 pounds), is considered to be in septic shock when the mean arterial pressure is less than 65 mm Hg or the systolic blood pressure is less than 90 mm Hg after receiving how many liters of intravenous crystalloids?
5 L
A client is scheduled for an adrenalectomy. Which nursing intervention should the nurse anticipate will be prescribed for this client?
Administer intravenous (IV) steroids.
A client with a recent history of sinusitis develops meningitis and demonstrates a positive Brudzinski sign. The priority nursing care is:
Administering prescribed antibiotics
A client with the diagnosis of Cushing syndrome has the following laboratory results: Na (sodium) 149 mEq/L; K (potassium) 3.2 mEq/L; Hb (hemoglobin) 17 g/dL; and glucose 90 mg/dL. What should the nurse teach the client? Select all that apply.
Avoid foods high in salt. Eat foods high in potassium
A client receiving chemotherapy takes a steroid daily. The client has a white blood cell count of 12,000/mm3 and a red blood cell count of 4.5 million/mm3. What is the priority instruction that the nurse should teach the client?
Avoid large crowds and persons with infections
A nurse is giving an educational program to paramedics who have volunteered to give the smallpox vaccine in a community vaccination drive. Which type of needle and method of administration should the nurse teach the volunteers to use when administering the smallpox vaccine?
Bifurcated needle for 15 injections within 5 mm
The nurse is assessing a client 12 hours after the client sustained a deep partial-thickness burn on the forearm. What characteristics should the nurse expect to identify when assessing the injured tissue?
Blistered and wet
A nurse is reviewing the diagnostic blood tests of a client with a diagnosis of type 1 diabetes. Which laboratory results support the nurse's suspicion that the client is experiencing ketoacidosis?
Blood glucose of 300 mg/100 mL, blood pH of 7.20
Two days after a severely burned client is admitted to the hospital, the client begins to exhibit restlessness. The nurse determines that this most likely indicates that the client is developing:
Cerebral hypoxia,
What should the nurse include in a teaching plan for a client taking calcium channel blockers such as Nifedipine (Procardia)? Select all that apply.
Change positions slowly. Report peripheral edema. Avoid drinking grapefruit juice.
The nurse is monitoring a client who is having a third transfusion of packed red blood cells. Which of these may be evident if the client is experiencing a febrile transfusion reaction? Select all that apply.
Chills, Hypotension Tachycardia
A client presents to the emergency department with a fever, headache, loss of appetite, and malaise. The nurse identifies raised red bumps on the client's arms and legs. A diagnosis of chickenpox is made. The client should be placed in a private room with what kind of precautions? Select all that apply.
Contact precautions Airborne precautions
A client sustains severe burns over 40% of the surface area of the body. The nurse is assigned to care for the client during the first 48 hours after the injury. What clinical finding does the nurse anticipate if the client develops water intoxication?
Disorientation with twitching
A nurse is assessing a client with diabetic ketoacidosis. Which clinical manifestations should the nurse expect? Select all that apply.
Dry skin Abdominal pain Kussmaul respirations
A nurse is assessing a client with a diagnosis of hypothyroidism. Which clinical manifestations should the nurse expect when assessing this client? Select all that apply.
Dry skin Brittle hair
The nurse is planning discharge instructions for a client who had a thyroidectomy. For which signs of surgically induced hypothyroidism should the nurse alert the client? Select all that apply
Fatigue Dry skin
A client is diagnosed with hyperthyroidism and is treated with 131I. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms should be included in the teaching? Select all that apply.
Fatigue Dry skin Progressive weight gain
Before a client's discharge after a thyroidectomy, the nurse teaches the client to observe for signs of surgically induced hypothyroidism. What clinical indicators identified by the client provide evidence that the nurse's instructions are understood? Select all that apply.
Fatigue Dry skin
A nurse is caring for a newly admitted client with a diagnosis of Cushing syndrome. Why should the nurse monitor this client for clinical indicators of diabetes mellitus?
Glucocorticoids accelerate the process of gluco-neogenesis.
A client is prescribed epoetin (Epogen) injections. To ensure the client's safety, which lab value should the nurse assess before administration?
Hematocrit
A pregnant woman develops chest pain and is found to be in atrial fibrillation. Which medication would be appropriate to prescribe for this client?
Heparin
A client with Addisonian crisis exhibits severe manifestations of glucocorticoid and mineralocorticoid deficiencies. Which responses should the nurse expect the client to exhibit? Select all that apply.
Hyperkalemia Hyponatremia Postural hypotension
During the first 48 hours after a client has sustained a thermal injury, the nurse should assess for:
Hyperkalemia and hyponatremia
The nurse is performing an assessment and notes that the client has exophthalmos and complains of double vision. These assessment findings are found with which condition?
Hyperthyroidism
A nurse is caring for a client who had an adrenalectomy. For what clinical response should the nurse monitor while steroid therapy is being regulated?
Hypotension
Valsartan (Diovan), an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? Select all that apply.
Irregular pulse rate Orthostatic hypotension
When the exposure method of treatment is used for burns, the nurse explains to the client that:
Isolation precautions will be required while hospitalized
A nurse is caring for a client with a diagnosis of type 1 diabetes who has developed diabetic coma. Which element excessively accumulates in the blood to precipitate the signs and symptoms associated with this condition?
Ketones as a result of rapid fat breakdown, causing acidosis
The nurse is caring for a client diagnosed with Cushing syndrome. The nurse expects that the client will exhibit:
Lability of mood
A nurse is caring for a client who has had type 1 diabetes for 25 years. The client states, "I have been really bad for the last 15 years. I have not paid attention to my diet and have done little to control my diabetes." What signs of common complications of diabetes might the nurse expect to identify when assessing this client? Select all that apply.
Leg ulcers Loss of visual acuity Thick, yellow toenails Decreased sensation in the feet
A client is admitted to the hospital with a diagnosis of Cushing syndrome. When performing an assessment, the nurse should take into consideration that the client will most likely exhibit signs of
Muscle weakness and frequent urination
A client is receiving ABVD (doxorubicin [Adriamycin], bleomycin [Blenoxane], vinblastine [Velban], and dacarbazine [DTIC]) therapy for Hodgkin disease. About halfway through the first six-month course of treatment, the client complains of burning and tingling of the feet. The nurse determines that these symptoms are a result of:
Neurotoxicity caused by vinblastine
A client with peripheral arterial insufficiency is scheduled for surgery. On admission, the client complains of discomfort and aches in the legs and feet. To safely position this client the nurse takes into consideration that the feet and legs should be:
Placed dependent to the torso
A nurse is caring for a client who is receiving total parenteral nutrition. Which responses indicate that the client is experiencing hyperglycemia? Select all that apply.
Polyuria Polydipsia,
A client is receiving penicillin G and probenecid for syphilis. What rationale should the nurse give for the need to take these two drugs?
Probenecid delays excretion of penicillin, thus maintaining blood levels for longer periods.
A nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify?
Retention of sodium and water
Five days after a client has abdominal surgery a nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence?
Serosanguineous drainage
When teaching about the dietary control of gout, the nurse evaluates that the dietary teaching is understood when the client states; "I will avoid eating:
Shellfish."
The nurse is interpreting the client's rhythm strip and finds that the P and QRS waves are consistent, with a P wave preceding every QRS complex. The PR interval is 0.26 seconds long. The rate is 64 beats per minute. The nurse interprets this rhythm as:
Sinus rhythm with first degree AV block
An obese client must self-administer insulin using an insulin syringe. The technique that the nurse teaches the client to use is to:
Spread the tissue and inject at a 90-degree angle
A client is admitted to the hospital with severe burns. What client response should the nurse anticipate when caring for the client during the acute phase of burn recovery?
Stable vital signs
A nurse is assessing the legs of a client with a history of chronic venous insufficiency. What physiologic changes should the nurse conclude are the result of this disease process? Select all that apply.
Stasis ulcer Brown discoloration
A client develops a maculopapular rash on the upper extremities and audible wheezing during the administration of intravenous vancomycin (Vancocin). To ensure the client's safety, which action would the nurse carry out first?
Stop infusion
Ampicillin 250 mg by mouth every six hours is prescribed for a client who is to be discharged. Which statement indicates to the nurse that the client understands the teaching about ampicillin?
The medicine should be taken one hour before or two hours after meals."
The nurse provides education related to manifestations of hyperglycemia to a client with type 1 diabetes. Which signs and symptoms identified by the client indicate that the teaching was effective? Select all that apply.
Thirst Fruity breath odor Excessive urination
A client with psoriasis asks the nurse what can help this condition. Which should the nurse include in a teaching plan for this client?
Topical application of steroids
A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client?
Use standard precautions.
A nurse is caring for a client with an underactive thyroid gland. Which responses should the nurse expect the client to exhibit as a result of decreased levels of triiodothyronine (T3) and thyroxine (T4)? Select all that apply.
Weight gain Cold intolerance
A client who was diagnosed recently with type 1 diabetes states, "I feel bad. I don't think I even want to go home. My spouse doesn't care about my diabetes." What is the most appropriate nursing response?
You are unhappy. Have you tried to talk with your spouse?
A person sustains severe burns of the arms and is waiting for emergency services to arrive. A nurse bystander responds to the scene. Another bystander is getting ready to apply butter to the burns, stating that it will provide soothing relief. An appropriate response by the nurse is, "I wouldn't advise putting the butter on. Our focus should be on:
covering up the victim with one of those tablecloths.
A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? (Select all that apply.)
lack of hair thickened toenails pain at the ulcer site diminished pedal pulse
What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? (Select all that apply.)
1 Joint pain 2 Facial rash 3 Pericarditis
A client with type 1 diabetes self-administers NPH insulin (Novolin N) every morning at 8:00 AM. The nurse concludes that the client understands the action of this insulin when the client says, "I should be alert for signs of hypoglycemia between:
12 PM and 8 PM.
The client is admitted to the emergency department with burns on the anterior part of both arms, from the shoulders to the hands, and the anterior part of the head. The nurse uses the Rule of Nines to assess the percentage of total body surface area burned. What percent should the nurse document in the client's hospital record?
13.5%
An adult client sustains partial- and full-thickness burns of the left thigh, left arm, and head. Using the Lund-Browder chart, the nurse calculates that the percentage of total body surface area burned is:
23.5%
A client has been in a coma for two months and is maintained on bed rest. At what angle should the nurse adjust the head of the bed to prevent the effects of shearing force?
30 degrees
The nurse uses the rule of nines to estimate the percentage of the burn surface area on a client who has burns covering the entire surface of both arms, the posterior trunk, the genitals, and the left leg. The nurse estimates the surface area to be?
55
During the early postoperative period after a subtotal thyroidectomy, the nursing priority is to assess for:
Airway obstruction
A client who had a myocardial infarction requests assistance to have a bowel movement. The nurse should:
Assist the client to a bedside commode
The nurse is teaching first aid to a group of community members. A participant asks what first aid should be administered to a person who suffers extensive burns. An appropriate response by the nurse is to call 911 and:
Cover the burned areas with a bed sheet
A health care provider prescribes bed rest for a client after surgery. What nursing intervention is most beneficial in preventing skin breakdown?
Encourage movement in bed
A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply.
Hirsutism Buffalo hump
A nurse is assessing a client with Cushing syndrome. Which signs should the nurse expect the client to exhibit? Select all that apply.
Hirsutism Round face Buffalo hump
A nurse is caring for a client after a thyroidectomy. For which signs of thyroid storm should the client be monitored? Select all that apply.
Increased heart rate Increased temperature
A nurse is assessing a client experiencing a diabetic coma. What unique response associated with diabetic coma that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client?
Kussmaul respirations
Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is nothing by mouth (NPO) is complaining of severe thirst. The client's urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do?
Moisten the client's lips with a wet 4 × 4 gauze.
A nurse is caring for a client with severe burns during the immediate hypovolemic stage (emergent phase). What is the expected amount of urine produced by the client if the nurse concludes that the rate of intravenous fluid replacement is satisfactory?
One third the intake
A nurse must obtain a client's apical pulse. Click the site where the nurse should place the stethoscope.
Place your stethoscope at the fifth intercostal space over the left midclavicular line.
What dietary choices should the nurse instruct the client taking spironolactone (Aldactone) to avoid? Select all that apply.
Potatoes Cantaloupe
Which action should the nurse take when caring for a client with malaria?
Provide nutrition between paroxysms.
When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply.
- Dependent rubor - Ulcers on the toes - Delayed capillary refill
A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure that a nurse should instruct the person to apply before seeking health care?
Cool, moist towels
The nurse expects the diagnostic studies of a client with Cushing syndrome to indicate:
High levels of 17-ketosteroids in a 24-hour urine test
A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Place the nurse's responsibilities in the order in which they should be performed.
- Evaluate whether the client has inhaled smoke - Insert a venous access device in an unaffected arm - Remove the client's clothing - Determine the extent of the burns, using the rule of nines - Apply sterile saline dressings to the burned surfaces,
A client is diagnosed with psoriasis and the nurse is providing health teaching concerning skin care at home. What recommendation does the nurse include in the teaching?
Apply moisturizing lotion several times a day.
A client has a diagnosis of partial-thickness burns. The nurse recalls that the client's burn is different than full-thickness burns in that partial-thickness burns
Are often painful, reddened, and have blisters,
A client with hyperthyroidism is treated with radioactive iodine to ablate thyroid tissue. What should the nurse instruct the client to do after the procedure?
Avoid holding an infant.
A client has a Mantoux test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. The nurse concludes that this response indicates that the client has:
Been exposed to the tubercle bacillus
A nurse is collecting a health history from a client with thromboangiitis obliterans (Buerger disease). What symptoms most likely are to be associated with this disorder?
Burning pain after exposure to cold.
A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include that will decrease the risk of complications? Select all that apply
Examining the feet daily Wearing well-fitting shoes Performing regular exercise
The parents of a young man suspected of having Cushing syndrome expresses anxiety about their son's condition. What should the nurse tell the parents to help them better understand the illness?
He may have mood swings or depression as a result of his illness.
A nurse is discussing dietary guidelines to help reduce a client's risk for heart disease. What should the nurse teach the client?
Increase complex carbohydrates.
A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis?
Increased blood urea nitrogen levels
The nurse cares for a client who develops pyrexia three days after surgery. The nurse should monitor the client for which signs and symptoms commonly associated with pyrexia? Select all that apply. Tachypnea
Increased pulse rate
A nurse is caring for a client who is human immunodeficiency virus (HIV) positive. For which complication associated with this diagnosis is it most important for the nurse to teach prevention strategies?
Infection,
A client is found unconscious and unresponsive. What should the nurse do first?
Initiate a code.
When a client develops ventricular fibrillation in a coronary care unit, what is the responsibility of the first person reaching the client?
Initiate defibrillation
A nurse is caring for several clients with type 1 diabetes, and they each have a prescription for a specific type of insulin. Which insulin does the nurse conclude has the fastest onset of action?
Insulin lispro (Humalog)
A client with small cell carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH). What signs should the nurse expect to observe? Select all that apply.
Oliguria Seizures Vomiting
A nurse identifies 12 mm of induration at the site of a Mantoux test when a client returns to the health office to have it read. The nurse explains to the client that the:
Result indicates a need for further tests and a chest x-ray
A client is receiving total parenteral nutrition via a central venous access catheter. When providing care to the site, the nurse should wear:
A mask and sterile gloves
The nurse is providing care for a client with small-cell carcinoma of the lung that develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What clinical findings correspond with the secretion of antidiuretic hormone (ADH)? Select all that apply.
Edema Hyponatremia
The nurse teaches a health class about communicable diseases and states that the virus that causes chickenpox also can cause:
Herpes zoster
After surgery, a client has a portable wound drainage system in place. What nursing intervention promotes drainage?
Maintaining compression of the drainage system.
A nurse is assessing a client with a diagnosis of hypoglycemia. What clinical manifestations support this diagnosis? Select all that apply.
Palpitations Diaphoresis Slurred speech
A nurse is teaching a community class about campfire safety. A class participant asks about what to do if a person catches on fire. How should the nurse respond?
Roll the person in the grass."
The nurse notes that the client's rhythm strips show more P waves than QRS complexes. When there are PR intervals, they are all consistent. The nurse realizes that the client is in:
Second degree AV block Mobitz II.
Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply.
Tachycardia Exophthalmos
A client's sputum smears for acid-fast bacilli (AFB) are positive, and transmission-based airborne precautions are prescribed. What should the nurse teach visitors to do?
Wear a particulate respirator mask.
After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which manifestations of excessive levels of ADH should the nurse assess the client? Select all that apply.
Weight gain Hyponatremia
A transfusion of packed red blood cells is prescribed for a client with anemia. List the following actions in the order in which they should be performed by the nurse. Ensure that the client signed a consent for the transfusion.
- Determine the client's vital signs - Compare the number on the blood - product and laboratory record. - Don a pair of clean gloves Run the transfusion slowly.
A nurse is preparing to obtain a blood specimen for culture and sensitivity from a client with an elevated temperature for the last two days. Place in order of priority the nursing actions that should be taken.
- Explain the procedure to the client - Collect the specimen according to protocol. - Send the specimen to the laboratory - Administer the first dose of antibiotics
An older adult, who alternately lives in a homeless shelter on the street, is brought to the emergency department by friends. The client has a fever, night sweats, and a blood-tinged productive cough. The health care provider suspects that the client has tuberculosis and orders purified protein derivate (PPD) test, chest x-ray, and sputum culture. Place these interventions in the order that they should be performed.
- Institute airborne precautions.. - Have a chest x-ray performed.. - Perform a PPD intradermal skin test. - Obtain a sputum specimen. - Notify the Department of Health
Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Select all that apply.
- Muffled heart sounds - Increased central venous pressure (CVP), - Jugular vein distention
A health care provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply.
- Obtaining the client's vital signs - Determining typing and crossmatching of blood - Using a Y-type infusion set to initiate 0.9% normal saline
The nurse provides care to the client with diabetes insipidus (DI) following head injury by Select all that apply.
- Providing adequate fluids within easy reach - Assessing for and reporting changes in neurological status - Monitoring for constipation, weight loss, hypotension, and tachycardia
A nurse is assessing four clients for risk factors for developing a pressure ulcer. List in order of priority the client with the greatest risk for developing a pressure ulcer to the client with the smallest risk.
70-year-old male, admitted with metastatic bone cancer, weighing 80 lbs, dehydrated, and bed bound 62-year-old female, admitted because of a brain attack (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift 25-year-old male, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory 78-year-old female, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory
A client is admitted with 50% of the body surface area burned after an industrial explosion and fire. The client's serum albumin is 1.5 g/dL, the hematocrit is 30%, the urine specific gravity is 1.025, and the serum globulin is 3 g/dL. When evaluating the client's response to fluid replacement, the nurse should prepare to administer a colloid when the:
Albumin is below 2 g/dL
During a first aid class, a student asks what should be done if a person's clothes catch on fire. The nurse explains that after the flames are extinguished it is most important to:
Assess the person's breathing
A urine specimen is needed to test for the presence of ketones in a client who is diabetic. What should the nurse do when collecting this specimen from a urinary retention catheter?
Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine
An older client exhibits typical clinical indicators of pulmonary edema. List the following clinical indicators of pulmonary edema in the order they typically appear.
Crackles Increased respirations Tachycardia Orthopnea Frothy, blood-tinged sputum
A nurse is caring for a client who has acute malaria. For which complication should the nurse monitor the client?
Electrolyte imbalances
A client has a fracture of the tibia and a cast is applied. When caring for the client, the nurse should:
Elevate the affected leg above the level of the heart
A client has surgery for the insertion of an implanted infusion port for chemotherapy. The client asks, "The doctor said after my chemotherapy is finished, the port will stay in, but it needs to be flushed routinely. How often does this have to be done?" What should the nurse tell the client about how often the port will most likely need to be flushed when not in use?
Every month
A nurse is assessing a client with a diagnosis of diabetes insipidus. For which signs indicative of diabetes insipidus should the nurse assess the client? Select all that apply.
Excessive thirst Dry mucous membranes Decreased urine specific gravity,
A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome?
Glucose level
A nurse is caring for a client who is scheduled to have a pigskin graft applied to a burned area. Which type of graft is going to be applied by the health care provider?
Heterograft
A nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client?
Highly contagious
A client with a tentative diagnosis of Cushing syndrome has an increased cortisol level. For what response should the nurse assess this client?
Hypernatremia
A nurse is caring for a client with a diagnosis of Cushing syndrome. What is the most common cause of Cushing syndrome that the nurse should consider before assessing this client for physiological responses?
Hyperplasia of the adrenal cortex
A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. What should the nurse conclude is causing these clinical findings?
Hypokalemia
A client with 35% of total body surface area burned in a fire is now 48 hours postburn. The nurse concludes that the client is moving from the emergent to the acute phase of burn management. Which response supports this conclusion?
Hypokalemia,
After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse expects that manifestations of excessive levels of antidiuretic hormone are:
Hyponatremia and decreased urine output
A client is scheduled to receive irradiation to the chest wall after a tumor was removed from the client's lung. When teaching skin care to the client, the nurse emphasizes:
Keeping the skin dry to protect it from excoriation
Which clinical indicators can the nurse expect when assessing a client with Cushing syndrome? Select all that apply.
Lability of mood Slow wound healing
A client is receiving combination chemotherapy for treatment of metastatic carcinoma. For which systemic side effect should the nurse monitor the client?
Leukopenia
The nurse should wear what personal protective equipment when providing central venous access device site care?
Mask and sterile gloves
A client with heart failure is receiving digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). The nurse will assess for which signs and symptoms of digoxin toxicity? Select all that apply.
Nausea Yellow vision Irregular pulse
A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? Select all that apply.
Nausea and vomiting Increased weight Decreased serum sodium Decreased level of consciousness,
A nurse stops at the scene of an accident and finds a man with a deep laceration on his hand, a fractured arm and leg, and abdominal pain. The nurse wraps the man's hand in a soiled cloth and drives him to the nearest hospital. The nurse is:
Negligent and can be sued for malpractice
A client has been diagnosed with hyperthyroidism. The nurse expects the client to exhibit which clinical manifestations? Select all that apply.
Nervousness Increased appetite
When changing the dressings on deep partial-thickness burns on a client's hand, the nurse should use what type of gauze and what technique?
Non-cotton-backed; placing a hand roll with gauze between each finger.
A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply.
Pallor Tachycardia Narrow pulse pressure
A nurse mixes a short-acting and an intermediate-acting insulin in the same syringe to administer to a client with diabetes. List the actions in the order the nurse should perform them.
Put air into the intermediate-acting insulin vial. Put air into the short-acting insulin vial. Withdraw the prescribed amount of short-acting insulin. Withdraw the prescribed amount of intermediate-acting insulin. Don a pair of clean gloves.
A state's Nurse Practice Act does not allow a registered nurse (RN) to suture wounds. The primary health care provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. The nurse should:
Refuse to suture wounds
A nurse is caring for a client with a chronic venous stasis ulcer. A negative-pressure wound treatment device has been prescribed to hasten wound healing. Which nursing action is most appropriate when caring for this client?
Replace the wound sponge every 48 hours
A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? Select all that apply.
Scaly lesions Pruritic lesions Reddened papules
A nurse notes that a client's urine has a sweet fruity odor. Which information is most important to evaluate when performing a further client assessment?
Serum glucose level
The client is returned to the surgical unit from the postanesthesia care unit (PACU) after a having a splenectomy. In the immediate postoperative period, the nurse specifically should monitor for which potential complications? Select all that apply.
Shock Abdominal distention Pulmonary complications
During a party, an individual reports intense chest pain and begins to perspire profusely. Which action should the nurse take first when the client is brought to the emergency department?
Start an intravenous infusion in the client's arm.
A health care provider in the emergency department identifies that a client is in mild hypovolemic shock. Which type of drug should the nurse anticipate will be prescribed?
Sympathomimetic
On the third postoperative day after a subtotal thyroidectomy for a tumor, a client complains of a "funny, jittery feeling." On the basis of this statement, the nurse's best action is to:
Test for Chvostek's and Trousseau's signs and notify the health care provider of the complaints
A nurse working in the health services center of a college is reviewing the vaccination records of a young adult who plans to enroll. Which immunizations are required to meet admission criteria according to the American Academy of Pediatrics?
Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine.
A client has been taking levothyroxine (Synthroid) for hypothyroidism for three weeks. The nurse suspects that a decrease in dosage is needed when the client exhibits which clinical manifestations? Select all that apply.
Tremors Heat intolerance
A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data?
Urinary output every hour
A nurse is caring for a client with full-thickness burns of the anterior trunk and thigh. During the first two to three days after the burn to monitor fluid balance, it is important for the nurse to assess the:
Urinary output every hour,
Which clinical indicator should the nurse identify as expected for a client with type 2 diabetes?
Urine negative for ketones and hyperglycemia.
A nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client says, "What should I do about my dry skin? It is so itchy." What is the best response by the nurse?
Use a moisturizer on the skin daily to help reduce itching."
A client comes to the emergency department with pressure in the chest and shortness of breath. The client is admitted for observation after receiving a tentative diagnosis of a myocardial infarction. Which clinical indicator supports this diagnosis?
Vomiting
A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply.
Vomiting Muscle weakness Irregular heart rate
A client has a new diagnosis of hyperthyroidism. Which skin conditions should the nurse expect when performing a physical assessment? Select all that apply
Warm Moist Smooth
The nurse is providing education about care of the residual limb to a client that had a below-the-elbow amputation. The teaching should include:
Washing and drying the residual limb at least once a day
A client is admitted with a diagnosis of Cushing syndrome. For which clinical manifestations should the nurse observe when assessing this client? Select all that apply.
Weakness Hypertension Truncal obesity
A client is diagnosed with herpes genitalis. What should the nurse do to prevent cross-contamination?
Wear a gown and gloves when giving direct care.
Which is the best advice the nurse can give regarding foot care to a client diagnosed with diabetes?
Wear synthetic fiber socks when exercising
A healthcare provider prescribes doxorubicin for a client with acute myelogenous leukemia. Which specific interventions should the nurse implement? Select all that apply.
monitor for jaundice increase fluids by mouth provide frequent oral care assess Vital Signs frequently
A client who has been in a coma for two months is being maintained on bed rest. The nurse concludes that to prevent the effects of shearing force, the head of the bed should be maintained at an angle of:
30 degrees
The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful according to the client and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, the nurse should administer the medication:
60 minutes before the dressing change.
A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? Select all that apply.
Absence of hair on the toes Reports of pain associated with exercising
Which nursing action is most important to promote the nutritional status of a client during the acute phase of treatment following extensive burns?
Administer the prescribed intravenous fluid with the added vitamin C.
A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? Select all that apply.
Anorexia Hemiplegia History of diabetes Urinary incontinence
Within four to six hours after a client has a myocardial infarction, the nurse expects which blood level to increase?
Creatine kinase-MB band (CK-MB)-
The nurse is providing postoperative care for a client who has received a prescription for nalbuphine (Nubain) for pain. For which side effects or adverse reactions should the nurse assess this client after administering this medication? Select all that apply.
B. Dry mouth C. Palpitations D. Constipation F. Orthostatic
An older adult is brought to the emergency department after being found in the street without a coat during a snowstorm. What actions should the nurse implement? Select all that apply.
B. Obtain rectal temp C. Assess fingers for areas of frostbite D. Determine client's LOC E. Ask for client identification
A nurse is teaching a client who is taking a loop diuretic (e.g., furosemide [Lasix]) about foods that are high in potassium. Which foods should the nurse emphasize? Select all that apply.
Bananas Beef stew Baked potatoes
A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.
Bradycardia Hypotension Bladder dysfunction
A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply.
Butterfly facial rash Inflammation of the joints
A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. The nurse determines that the client understands the dietary instructions when the client identifies the following foods. Select all that apply.
Chicken broth Enriched whole milk Red meats, such as beef Liver and other glandular organ meats
A client is admitted to the hospital for the medical management of burns over 18% of the body's surface. What should the nurse teach the client to help manage pain during dressing changes?
Deep breathing exercises
A nurse is assessing a middle-aged female client for the presence of risk factors associated with coronary heart disease. Which risk factor carries a greater risk for women than for men?
Diabetes mellitus
While assessing a client during a routine examination, a nurse in the clinic identifies signs and symptoms of hyperthyroidism. Which signs are characteristic of hyperthyroidism? Select all that apply.
Diaphoresis Weight loss Protruding eyes
An 83-year-old client is diagnosed with left-sided congestive heart failure. Which assessment findings should the nurse expect to find on this client? Select all that apply.
Dyspnea Crackles Cool extremities
A client is scheduled to have a thyroidectomy. Which medication does the nurse anticipate the health care provider will prescribe to decrease the size and vascularity of the thyroid gland before surgery?
Potassium iodide (SSKI
What potentially adverse effect of an intravenous titrated drip of lidocaine (Xylocaine) should the nurse immediately report to the healthcare provider?
Tremors
