Final NUR II
Which action will the nurse take to prevent vascular occlusion in the client with sickle cell disease?
Maintaining an oral fluid intake of at least 4500 mL/day
Which actions will the nurse perform when caring for a client with acute pancreatitis before surgical management? SATA
Maintaining the client on NPO status Administering IV fluids as prescribed Advising the client to maintain semi-Fowler position Giving adequate medications to control the client's pain
Which risk factor(s) places a client at risk for leukemia? SATA A. Chemical exposure B. Genetically modified foods C. Vaccinations D. Viral infección
Chemical exposure Ionizing radiation exposure Viral infección
A nurse assesses a client who has cholecystitis. Which sign or symptoms indicates that this condition is chronic rather than acute?
Clay-colored stool
Ch 49 A nurse participates in a community screening event for oral cancer. What client is the highest priority for referral to a primary health care provider?
Client who smokes and drink daily
Which diagnostic test will the nurse prepare a client for to confirm the Dx of CRC?
Colonoscopy with biopsy
Which precaution is most important for the nurse to teach a client at continued risk for hypernatremia?
Read labels on canned or packaged foods to determine sodium content
Ch 33 A nurse is assessing a client with peripheral artery disease (PAD). The client states that walking five blocks is possible without pain. What question asked next by the nurse will give the best information?
Could you walk further than that a few months ago ?
What is the nurse's next action 5 minutes after administering a sublingual (SL) nitroglycerin tablet to a client with chest pain?
Recheck pain intensity and vital signs
The nurse is caring for a client with provable colorectal cancer (CRC). What assessment findings would the nurse expect? SATA
Rectal bleeding Anemia Change in stool shape Abdominal discomfort
Which are the most common symptoms of colorectal cancer the clients are likely to report to nurses?
Rectal bleeding and.change in stool consistency
Ch 67 The nurse is teaching a client with BPH. What statement indicates the client needs further information ?
There should be no problem with drinking wine with dinner each night
The nurse is assessing a client with chronic leukemia. Which laboratory test result (s) is (are) expected for this client? SATA
Decreased hematocrit Abnormal WBC count Low platelet count Decreased hemoglobin
How soon does the nurse expect anginal pain to begin subsiding after administering sublingual nitroglycerin to a client with chronic stable angina?
1-2 mins
Which statement by a client with leukemia indicates a need for further teaching by the nurse?
I will take a daily laxative to prevent constipation
What priority action will the nurse take when providing care for a client with chest pain being treated with IV nitroglycerin?
Monitor blood pressure continuously
After administering SL nitroglycerin to a client whose baseline BP is 130/80 mm Hg, for which finding would the nurse immediately notify the HCP?
systolic pressure is 90 mm Hg
A client has a DVT. What comfort measure does the nurse delegate to the assistive personnel (AP)?
Apply a warm moist pack Rationale: warm moist packs will help with the pain of a DVT
Which action will the nurse take first when an 80 y.o client with acute pancreatitis has no breath sounds in the left lower lung lobe?
Apply oxygen
Which type of immunity will the nurse initiate by administering an influenza vaccination to a client?
Artificial active immunity
A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best?
Assess client further for fall risk
A client with a known AAA reports dizziness and severe abdominal pain. The nurse assesses the client's BP at 82/40 mm Hg. Where actions by the nurse are most important. SATA
Assess distal pulses every 10 minutes Notify the Rapid Response Team Take vital signs every 10 minutes
A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care? SATA
Assess the client for bleeding Monitor the daily aPTT results Weight the client daily on the same scale
A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time?
Assess the client for hypoglycemia and hypoxia.
The family of a neutropenic client reports that the client "is not acting right.." What action by the nurse is priority?
Assess the client for infection
The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? A. Administer high-ceiling (loop) diuretics B. Assess the client's lung sounds every 2 hours C. Place a pressure-relieving overlay on the mattress D. Weigh the client daily at the same time on the same scale
Assess the client's lung sounds every 2 hours.
A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first ?
Assess the client's respiratory rate, rhythm, and depth
For which client complication of diabetes will the nurse expect to administer glucagon intramuscularly ?
B. Severe hypoglycemia
What is the nurse's best response when a client asks which diagnostic test will determine if an oral tumor is cancerous?
Biopsy is the definitive method for diagnosing oral cancer
Which s/s will the nurse assess when a client is dx with oral cancer? SATA
Bleeding from the mouth Difficulty chewing or swallowing Thick or absent saliva Thickening or lump in check
Based on the known risk factors for stroke, which health promotion practices would the nurse teach a client to promote heart health and prevent strokes? (Select all that apply.) a. Blood pressure control b. Aspirin use c. Smoking cessation d. Low carbohydrate diet e. Cholesterol management f. Increased red wine consumption
Blood pressure control Aspirin use Smoking cessation Cholesterol management
Ch 50 Which s/s does the nurse expect to assess when a client experiences an upper GI? SATA
Decreased BP Dizziness or light-headedness Melena (tarry or dark sticky ) stools Weak peripheral pulses
The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client?
Decreased level of consciousness
A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?
Decreased orthostatic changes when standing
A nurse assesses a pt who is experiencing DKA. For which assessment findings would the nurse monitor the client. SATA
Deep and fast respiration Tachycardia Orthostatic hypotension
What does the nurse suspect when assessing a client on bed rest and finding that he or she has a left calf that is swollen, warm to touch, reddened, and moderately painful?
Deep vein thrombosis (DVT)
What is the nurse's interpretation of a client's Urine specific gravity of 1.039 ?
Dehydration
A nurse working with clients Dx with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factor (s) should clients be taught to avoid ? SATA A. Dehydration B. Exercise C. Extreme stress D. High altitudes E. Pregnancy
Dehydration Extreme stress High altitudes Pregnancy
Which symptom does the nurse most likely expect when admitting a client Dx with BPH?
Difficulty passing urine
A client presents to the emergency department with a thoracic aortic aneurysm (TAA). Which findings are most consistent with this condition? SATA A. Abdominal tenderness B. Difficulty swallowing C. Changes in bowel habits D. Shortness of breath E. Hoarseness
Difficulty swallowing Hoarseness
What is the most common symptoms the nurse expects client with esophageal cancer to report?
Difficulty with swallowing
Which action will the nurse take to help relieve the severe pain in a client with acute pancreatitis? SATA
Maintaining the.client on NPO status Providing opioids by patient-controlled analgesia (PCA) Assisting the client to a side-lying position with knees drawn up to the chest
Ch 37 What are the priority actions for the nurse to perform when caring for a client in sickle cell crises? SATA
Managing pain Ensuring hydration Assessing oxygen saturation Monitoring for indications of infection
Which nursing assessment has the highest priority for the nurse to perform on a client admitted in severe pain with acute pancreatitis?
Measuring heart rate, blood pressure, and oxygen saturation
Ch 13 For which indication of a fluid balance problem will the nurse assess in an older client at risk for fluid and electrolyte problems?
Mental status change
Ch 14 A nurse assesses a client who is prescribed furosemide for HTN. For which acid-base imbalance does the nurse assess to present complications of this therapy?
Metabolic alkalosis
Which precautions are most important for the nurse to teach a client with leukemia to prevent an infection by auto contamination? SATA
Perform mouth care three times daily Shower or wash your armpits and genital area daily
What would the nurse suspect when assessing a client's lower extremities and finding decreased pedal pulses, skin test is cool to touch, loss of hair, and thickened toenails?
Peripheral arterial disease (PAD)
Which food will the nurse recommend a client avoid when he or she reports fear of stomach cancer ?
Pickled or processed foods
The nurse is caring for a client dx with oral cancer. What is the nurse's priority for client care?
Place the client on Aspiration Precautions
A nurse assesses a client who presents with renal calculi. Which question would the nurse ask?
Do any of your family members have this problem?
Which actions will the nurse teach a client with GERD to use to prevent harm? SATA
Do not consume caffeinated or carbonated beverages Avoid peppermint, chocolate, and fried foods Eat slowly and chew food thoroughly Consume 4 to 6 small meals each day Do not eat for 3 hours before going to bed
A nurse teaches a client with DM about foot care. Which statements would the nurse incl in this client's teaching? SATA
Do not walk around barefoot Trim toenails straight across with a nail clipper
The nurse is caring for a pt with leukemia who has severe fatigue. What action by the client best indicates that an important outcome to manage this problem has been met?
Doing activities if daily living (ADLs) using rest periods
A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?
Double-checking the client and blood product identification
Which actions will the nurse teach a client with severe GERD that causes pain after each meal, lasts for at least 45 minutes, and worsens when he or she lies down? SATA
Drink fluids right away Take an antacid as prescribed by the health care provider Maintain an upright position for at least an hour after you eat
The client Dx with type 2 DM is admitted to the ICU with HHNS coma. Which assessment data should the nurse expect the client to exhibit?
Dry mucous membranes
Which are the most common symptoms of GERD reported to the nurse by a client? SATA
Dyspepsia Regurgitation
The nurse is caring for a client dx with probable GERD. What assessment finding (s) would the nurse expect? SATA *** all are correct A-F
Dyspepsia Regurgitation Belching Coughing Chest discomfort Dysphagia
The nurse is caring for a client who is Dx with UTI. WhT common urinary s/s does the nurse expect? SATA
Dysuria Frequency Burning Hematuria
The nurse assesses clients for the cardinal signed of inflammation. Which s/s does this include? SATA
Edema Redness Warmth Decreased function
A client is admitted with AKI and a urine output of 2000 mL/day., What is the major concern of the nurse regarding this patient's care?
Electrolyte and Fluid imbalance
Ch 51 The nurse is caring for a client who is Dx with a complete small bowel obstruction. For what priority problems is this client most likely at risk ?
Electrolyte imbalance
The nurse is caring for a cowhide is experiencing excess diarrhea. The client's ABG values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3- 16 mEq/L. Which primary health care provider order does the nurse expect to receive?
Sodium bicarbonate
The nurse reviews the lab results for a client who has possible appendicitis. Which lab test finding would the nurse expect ?
Elevated leukocyte count
Which behavioral modification interventions will the nurse teach a client with BPH? SATA
Limit alcohol Avoid caffeine containing beverages Do not consume large amounts of fluid in a short time Avoid taking antihistamine drugs
The nurse is caring for a client who has DM. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time would the nurse assess the client for potential hypoglycemia r/t the NPH insulin?
4pm (1600)
Which effect on respiratory effort does the nurse expect to find in a client with severe hypokalemia?
A. Shallow respirations and low oxygen saturation
Which client does the nurse assess as at highest risk for development of esophageal cancer?
55-y.o. who smokes and is w5 lb overweight
Which client does the nurse understand had the greatest risk of developing AKI?
73 y.o male who has HTN and PVD
A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia?
A 34 year old who is NPO and receiving rapid intravenous D5W infusions.
A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the highest risk factor for a stroke?
A 37-y.o. heavy - cocaine user
A nurse assesses clients at a community health center. Which client is at highest risk for developing colorectal cancer?
A 72-year-old who eats fast food frequently
Ch 13 A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration?
A 76 y.o who is cognitively impaired
What type of exercise will the nurse recommend for the client with diabetic retinopathy?
A. Non-weight bearing activities such as swimming
Which information would the nurse be sure to include when teaching a client with PAD about methods to promote vasodilation? SATA
Maintain a warm environment at home Wear socks or insulated shoes at all times Prevent cold exposure to the affected limb Completely abstain from smoking or chewing tobacco Avoid emotional stress and excessive caffeine
The client is admitted to the ICU Dx with DKA. Which intervención should the nurse implement? SATA * All are correct
Maintain adequate ventilation Assess fluid volume status Administer intravenous potassium Check for Urinary ketones Monitor I&O
A nurse evaluates the following ABGs in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3- 22 mEq/L. Which client condition does the nurse correlate with these results ?
Anxiety-induced hyperventilation
What would the nurse assess for when a client is suspected of having an AAA? SATA
Abdominal flank, or back pain Gnawing pain unaffected by movement Pulsation in the upper abdomen Palpitation of a mass in the upper abdomen
Ch 52 Which cardinal signs will the nurse expect to assess in a client Dx with peritonitis?
Abdominal pain with distention and tenderness
Ch 35 A nurse studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? SATA A. Accompanied by shortness of breath B. Feelings of fear or anxiety C. Lasts less than 15 minutes D. No relief from taking nitroglycerin E. Pain occurs without known cause F. Can be precipitated by exertion or stress
Accompanied by shortness of breath Feelings of fear or anxiety No relief from taking nitroglycerin Pain occurs without known cause
The client Dx with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first?
Administer 50% dextrose IVP
A nurse assesses a client who has DM and notes that the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of Orange juice, the client's s/s have not changed. What action would the nurse take next?
Administer another half-cup (120 mL) of orange juice
The nurse is caring for a client who has severe hypoglycemia and is experiencing a seizure. What actions will the nurse take at this time? SATA
Administer glucagon 1 mg SubQ Be sure the bed side rails are in the up position Notify the primary health care provider immediately Monitor the client's blood glucose level
A client presents to the emergency department in sickle cell disease crisis. What intervention by the nurse takes priority? A. Administer oxygen B. Initiate pulse oximetry C. Give pain meds D. Start an IV line
Administer oxygen
A nurse cares for a client experiencing DKA who presents with Kussmaul respirations. What action would the nurse take?
Administration of intravenous insulin
The nurse learns that which risk factors can affect immunity ? SATA
Age Environmental factors Drugs Nutritional status
Which are the major risk factors for development of colorectal cancer that the nurse will be sure to ask about when taking a client's hx? SATA
Age older than 50 years Personal or family hx of cancer Crohn's disease Ulcerative colitis
The nurse is teaching a client about risk factors for esophageal cancer. Which risk factors would the nurse include? SATA
Alcohol intake Obesity Smoking Lack of fresh fruits and vegetables Untreated GERD
What is the nurse's priority action when a client with AAA suddenly exhibits decreased level of consciousness, blood pressure 82/48 mm Hg, irregular apical pulse, and perfume diaphoresis?
Alert the Rapid Response Team
Which most accurate diagnostic test will the nurse expect to be ordered for a client to verify the dx of GERD?
Ambulatory esophageal pH monitoring
Which s/s will the nurse assess for in a client who is suspected of having cholecystitis ? SATA
Anorexia Jaundice Steatorrhea Erucration Rebound tenderness
What does the nurse suspect when a client comes into the ED with RLQ cramping pain, nausea, vomiting, and guarding with rigidity of the abdomen?
Appendicitis
A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client's support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client's obligations.
Assist in finding one change the client can control. All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the client's feelings of control
The nurse is teaching a client about the risk of uncontrolled or untreated GERD. What complication (s) May occur if the GERD is not successfully managed? SATA *all are correct A-E
Asthma Laryngitis Dental caries Cardiac disease Cancer
The nurse working in the emergency department knows that which factors are commonly r/t aneurysm formation? SATA A. Atherosclerosis B. Down syndrome C. Frequent heartburn D. History of hypertension E. History of smoking F. Hyperlipidemia
Atherosclerosis Hx of HTN Hx of smoking Hyperlipidemia
When providing discharge teaching, for which symptoms will the nurse teach a client with PUD to seek immediate medical attention? SATA
Bloody or black stool Bloody vomit or vomit that looks like coffee grounds Sharp, sudden, persistent, and severe epigastric or abdominal pain
A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan ? SATA
Calculate pulse pressure with each BP reading Assess for pitting edema in dependent body areas Monitor trends in the client's daily weights Assist the client to change positions frequently Teach client and family how to read food labels for sodium
A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What nursing action takes priority at this time?
Call the Rapid Response Team
A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching?
Call your primary health care provider for diarrhea
A nurse is caring for an older client who is admitted with moderate dehydration. Which intervención will the nurse implement to prevent injury while in the hospital?
Dangle the client on the bedside before ambulating
The nurse is caring for a client with a long hx of PUD. What assessment findings would the nurse anticipate if the client experienced upper GI bleeding? SATA
Decreased BP Dizziness Hematemesis Decreased urinary output
The nurse is caring for a newly admitted client who is Dx with HHS. What is the nurse's priority action at this time?
Establish intravenous access to provide fluid
Which s/s will the nurse expect on assessment of a client newly Dx with acute leukemia before initiating of treatment? SATA
Excessive bruising Bone pain Dyspnea in exertion Fatigue
Which s/s does the nurse expect to find in clients with any type of anemia? SATA
Exercise intolerance Fatigue Tachycardia Tachypnea
Which new assessment finding in a client with sickle cell disease who currently is in crises does the nurse report immediately to the primary health care provider to prevent harm?
Facial drooping on the right foot
Clients with which problems will the nurse assess most frequently for dehydration? SARA
Fever of 103 ^F (39.4*C) Extensive burns Thyroid crisis Continuous fistula drainage Diabetes insipidus
Which are the most common s/s of UTI that the nurse will recognize when assessing a client? SATA
Frequency Urgency Dysuria
Which nonsurgical management techniques would the nurse expect when caring for a client with DVT? Select all that apply. A. Gradual increase in ambulation as tolerated by the client B. Elevation of legs when in bed or sitting in a chair C. Knee-or thigh-high compression stockings D. Massage to ease the client's calf pain E. Anticoagulant drugs as prescribed F. Complete bedrest for up to 4 weeks
Gradual increase in ambulation as tolerated by the client Elevation of legs when in bed or sitting in a chair Knee- or thigh -high compression stockings Anticoagulant drugs as prescribed
The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL, a urine output of 185 mL in the past 8 hours, and a BUN of 44 mg/dL. What diabetic complication does the nurse suspect?
HHS
The nurse is preparing to administer a blood transfusion. Which action (s) by the nurse is (are) most appropriate? SATA
Hang the blood product using normal saline and a filtered tubing set Take a full set of vital signs prior to starting the blood transfusion Use gloves to start the client's IV if needed to handle the blood product
Which questions are most relevant for the nurse to ask when exploring the risk factors for the client newly Dx with acute leukemia? SATA
Have you ever been exposed to radioactive materials ? Has anyone in your family ever had leukemia? What type of work do you do for a living?
Which questions will the nurse ask a client to determine the presence of a/s of BPH ?
Have you noticed a sensation of incomplete bladder emptying? Have you noticed dribbling or leaking after you finish urination ? How many times do you have to get up during the night to urinate Have you noticed blood at the start or at the end of urination?
What priority question would the nurse ask before administering SL nitroglycerin to a middle-aged male client with chest pain?
Have you taken a medication for erectile dysfunction within the past 24 to 48 hours ?
Which s/s will the nurse teach a client to take action to prevent harm as indicators of mild hypoglycemia? SATA A. Headache B. Weakness C. Cold, clammy skin D. Irritability E. Pallor F. Tachycardia
Headache Weakness Irritability
A nurse assesses a client who has UC and severe diarrhea. Which assessment would the nurse complete first ?
Heart rate and rhythm
The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a stroke for which the nurse would assess for this client? **all answers are correct A-F
Heavy alcohol intake Diabetes mellitus Elevated cholesterol Obesity Smoking HTN
A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse us best?
Help the client find things to hope for each day of recovery
Which findings would the nurse expect to assess when a client presents with a thoracic aortic aneurysm? SATA
Hoarseness Shortness of breath Difficulty swallowing Visible mass above the suprasternal notch
A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which question (s) would the nurse ask? SATA
How much water do you drink every day ? Do you take estrogen replacement therapy? Are you on steroids or other immune/suppressing drugs?
Ch 59 A nurse teaches a client who is Dx with DM. Which statement would the nurse include in this client's plan of care to delay the onset of micro vascular and macrovascular complications?
Maintain tight glycemic control and prevent hyperglycemia
Which electrolyte imbalance does the nurse expect when a client is in the early phase of CKD?
Hyponatremia
Which symptoms would indicate to the nurse that a client's aneurysm had ruptured? SATA
Hypotension Diaphoresis Decreased level of consciousness Loss of pulse dilated to rupture Scant urine output
A client has PAD. What statement by the client indicates misunderstanding about self-management activities?
I can use a heating pad on my legs if it's set on low Rationale: client with PAD should never use heating pads
After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching?
I must weigh myself each morning before I eat or drink
After teaching a client who has DM with retinopathy, nephropathy, and peripheral neuropathy, the nurse assess the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?
I should look into swimming or water aerobics to get my exercise
A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition? a. "I brush and use dental floss every day." b. "I chew hard candy for my dry mouth." c. "I usually put ice on bumps or bruises." d. "Nonslip socks are best when I walk."
I usually put ice on bumps or bruises
Which statements by the client indicate good understanding of foot care in peripheral vascular disease PVD ? SATA
I will keep my feet dry, especially between the toes Lotion is important to keep my feet smooth and soft Washing my feet in room-temperature water is best
What priority teaching would the nurse provide for a client who will be discharged with a prescription for atorvastatin?
Immediately report any muscle cramping to your primary health care provider
Which findings indicate to the nurse that a client may have hypervolemia (fluid overload) ? SATA
Increased , bounding pulse Jugular vein distention Presence of crackles Elevated BP
Which assessment finding does the nurse expect in a client who has polycythemia Vera (PV)?
Increased blood pressure
A nurse assesses a client who is admitted for treatment of fluid overload. Which s/s does the nurse expect to find. SATA
Increased pulse rate Distended neck veins Skeletal muscle weakness Visual disturbances
The nurse assesses a client with DKA. Which assessment finding would the nurse correlate with this condition?
Increases rate and depth of respiration
What is the priority action for the nurse and other members of the interprofessional health care team when caring for an older client admitted with HHS?
Increasing circulating blood volume
Which symptoms causes most clients to seek medical attention for PAD?
Intermittent claudication
Which essential points would the nurse include when teaching a client with angina about nitroglycerin tablets? SATA
Keep your nitroglycerin pills with you at all times You can tell the tablets are active when you feel a tingling after placing one under your tongue Keep the tablets in a glass, light-resistant container
A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance would the nurse assess?
Kussmaul respirations Rationale: the pancreas is a major site of bicarbonate production. Pancreatitis can cause metabolic acidosis through underproduction of bicarbonate ions
Which s/s would the nurse expect to find in a client with severe metabolic acidosis? SATA
Kussmaul respirations Warm , flushed skin Decreased bicarbonate
A nurse teaches a client with DM about sick-day management. Which statement would the nurse include in this client's teaching?
Monitor your blood glucose levels at least every 4 hours while sick
A client has been Dx with HTN but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is the best?
Most people with hypertension do not have symptoms
An older client with PVD is explaining the daily foot care regimen to the best family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care?
My hands shake when I try to do things requiring coordination
Ch 54 Which statement indicates to the nurse that a client who is experiencing frequent episodes of "indigestion" and flatulence may have cholecystitis ?
My right arm and shoulder always seem to hurt after I eat fried foods
Ch 16 The nurse understands that which type of immunity is the longest acting?
Natural active
The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect ? SATA
Nausea and vomiting Abdominal pain Bradycardia Decreased Urinary output Fever
The nurse is caring for a client who has DM type 1 and is experiencing hypoglycemia. Which assessment findings will the nurse expect? SATA A. Warm, dry skin B. Nervousness C. Rapid deep respiration D. Dehydration E. Ketoacidosis F. Blurred vision
Nervousness Blurred vision
A client is placed on fluid restriction because of CKD. Which assessment finding would alert the nurse that the client's fluid balance is stable at this time?
No adventitious sounds in the lungs
What is the nurse's best first action when a client with a gastric ulcer is found lying in the knee-chest (fetal) position with a rigid, tender, and painful abdomen?
Notify the primary health care provider
A nurse reviews the lab findings of a client with a UTI (bacterial cystitis) . The lab report notes a "shift to the left" in the client's WBC count. What action would the nurse take ?
Notify the primary health care provider and start an IV line for parenteral antibiotics
A client is taking furosemide 40 mg/day for management of early CKD. To assess the therapeutic effect of the medication, what action of the nurse is best ?
Obtain daily weights of the client
A nurse is caring for a client with a DVT. Where nursing assessment indicates that an important outcome has been met? A. Ambulated with assistance B. Oxygen saturation of 98% C. Pain of 2/10 after medication D. Verbalizing risk factors
Oxygen saturation of 98%
Ch 37 The nurse is assessing a client in sickle cell disease (SCD) crisis. What priority client problem will the nurse expect?
Pain
Which assessment findings indicate to the nurse that a client has stage 3 PAD? SATA
Pain is described as numbness, burning, toothache type pain Pain is relieved by placing the extremity in a dependent position Pain usually occurs in the distal part of the extremity (toes, arch, forefoot, or heel) Pain while resting commonly awakens the client at night
Which of these client assessment findings is typically associated with oral cancer.?
Painless red or raised lesion
A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse requires the nurse's mentor to interview?
Palpate the abdomen in four quadrants Rationale: Abdominal aneurysm should never be palpated as this increases the risk of rupture
Which complications does the nurse suspect when a client with PUF suddenly develops sharp epigastric pain that spreads over the entire abdomen?
Perforation
A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse? a. Place the client on a cardiac monitor immediately. b. Teach the client to limit high-potassium foods. c. Continue to monitor the client's intake and output. d. Ask to have the laboratory redraw the blood specimen.
Place the client on a cardiac monitor immediately. The priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.
What is the nurse's first action when a client with CKD develops restlessness, anxiousness, SOB, a rapid heart rate, frothy sputum., and. crackles in the bases of the lungs?
Place the client's HOB in the high-Fowler position
Which serum electrolyte level is most important for the nurse to monitor closely to prevent harm in a client who has hyperglycemia?
Potassium
A nurse cares for a client who has a serum potassium of 6.5 mEw/L and is exhibiting cardiovascular changes. Which intervention will the nurse implement first ?
Prepare to administer dextrose 20% and 10 units of regular insulin IV push
A nurse assesses a client with DM. Which assessment finding would alert the nurse to decreased kidney function in this client?
Presence of protein in the urine
Which collaborative problem will the nurse consider to have the highest priority when caring for a client with acute leukemia?
Protecting the client from infection
Which nursing care action will the nurse assign to the AP when caring for a client with a bowel obstruction?
Providing mouth care every 2 hours as needed
A nurse is preparing to administer a blood transfusion. Which action is most important? A. Document the transfusion B. Place the client on NPO status C. Place the client in isolation D. Put on a pair of gloves
Put on a pair of gloves
In which position will the nurse place a client with peritonitis to promote comfort and prevent harm from potential complications?
Semi-Fowler
The nurse is caring for a client with a large bowel obstruction due to fecal impaction. What position would be appropriate for the client while in bed?
Semi-Fowler
A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report?
Severe boring abdominal pain
The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect?
Severe, steady right lower quadrant pain
After administering potassium chloride, a nurse evaluated the client's response. Which s/s indicate that treatment is improving the client's hypokalemia? SATA
Strong productive cough Active bowel sounds
For prevention of DVT, which drug would the nurse expect the health care provider to prescribe?
Subcutaneous low-molecular weight heparin (LMWH)
The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? SATA
Take diabetic medication even if unable to eat the client's normal caloric intake If unable to eat, drink liquids equal to the client's normal caloric intake Call the HCP if glucose levels are higher than 180 mg/dL
The nurse is discussing ways to prevent DKA with the client Dx with type 2 diabetes. Which instruction is the most important to discuss with the client?
Take the prescribed insulin even when unable to eat because of illness
A client has returned from a TURP with a continuous bladder irrigation. Five hours after the operation, the nurse noted the drainage is bright red with clots. What action should the nurse take first ?
Take vital signs and begin immediate irrigation with sterile water
A client with DM type 2 has been well controlled with metformin. The client is scheduled for MRI scan with contrast. What priority would the nurse take at this time?
Tell the client to withhold metformin for 24 hours before the MRI
Which situations or conditions will the nurse teach a client with diabetes are common causes of hypoglycemia? SATA
Too much insulin taken compared with food intake Insulin injected at the wrong time relative to food intake and physical activity Decreased insulin clearance from progressive kidney failure Decreased liver glucose production after alcohol ingestion
Ch 41 The nurse is preparing a client for discharge from the emergency department after experiencing a TIA. Before discharge, which factors would the nurse identify as placing the client at high risk for a stroke?
Unilateral weakness during a TIA
The nurse is caring for a client who has been Dx with PUD. For which complication would the nurse monitor?
Upper GI bleeding
What is the nurse's best interpretation when a client is admitted with flank pain, and the urine report indicates turbidity, foul odor , rust color , presence of white and red blood cells as well as bacteria, and microscopic crystals?
Urolithiasis and infección
A nurse teaches a client with DM who is experiencing numbness and reduced sensation. Which statement would the nurse include in this client's teaching to prevent injury?
Use a bath thermometer to test the water temperature
Which precautions are most important for the nurse to teach the client with polycythemia Vera (PV) to prevent harm?
Use soft-bristled toothbrush Elevate your feet whenever you are seated Wear gloves and socks outdoors in cool weather Exercise slowly and only on the advice of your primary health care provider
Which nutritional supplements does the nurse expect the HCP will prescribe for a client with CKD? SATA
Water-soluble vitamins Calcium Iron Vitamin D
A nurse is caring for four clients with leukemia. After hand-off report, which client would the nurse assess first ?
a. Client who had two bloody diarrhea stools this morning
After treating several young women for urinary tract infections (UTIs), the college nurse plans an educational offering on reducing the risk of getting a UTI. What information does the nurse include? (Select all that apply.) a. Void before and after each act of intercourse. b. Consider changing to spermicide from birth control pills. c. Do not douche or use scented feminine products. d. Wear loose-fitting nylon panties. e. Wipe or clean the perineum from front to back.
a. Void before and after each act of intercourse. e. Wipe or clean the perineum from front to back.
A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first? a. Client with a blood pressure of 180/98 mm Hg b. Client who reports shortness of breath c. Client who reports calf tenderness and swelling d. Client with a swollen and painful left great toe
b. Client who reports shortness of breath
A client returned from a transurethral resection of the prostate 8 hours ago with a continuous bladder irrigation. The client reports headache and dizziness. What action by the nurse is most appropriate? a. Consider starting a blood transfusion. b. Slow the bladder irrigation down. c. Report the findings to the surgeon immediately. d. Take the vital signs every 15 minutes.
c. Report the findings to the surgeon immediately.
A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset
d. Time of symptom onset
For which client problem will the nurse question a prescription for a diuretic?
end-stage renal disease
Which activity would the nurse advise during the recovery period for a client returning home after AAA repair?
gradually increased walking
Which acid-base imbalance does the nurse expect when a client experiences a bowel obstruction high in the small intestine?
metabolic alkalosis
Which assessment finding in a client with long-standing diabetes will the nurse interpret as an early sign of diabetic nephropathy?
microalbuminuria
Which assessment finding will the nurse expect in a client with diabetes who has peripheral neuropathy of the motor neurons?
muscle weakness
A nurse assesses a client who has DM. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this client?
pH 7.28, HCO3- 18mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg
Which ABGs results should the nurse expect in the client Dx with DKA?
pH 7.30 , PaO2 90, PaCO2 30, HCO3 18
