final practice

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching? "Eating a high fiber diet will reduce my risk for developing skin cancer." "I should check my skin monthly for any changes." "I should avoid the use of tanning booths." "I should use sunscreen even on cloudy days."

"Eating a high fiber diet will reduce my risk for developing skin cancer."

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? "I will need to wipe my perineal area from back to front after urination." "I will need to empty my bladder regularly and completely." "I will need to drink apple cider vinegar each day." "I need to drink 8 cups of liquid each day."

"I will need to wipe my perineal area from back to front after urination."

A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16,000/mm³ with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results? An acute infectious process Neutropenia Allergic reaction A resolving inflammatory process

An acute infectious process

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? Assess the client's level of consciousness. Administer epinephrine. Auscultate for wheezing. Monitor for hypotension.

Auscultate for wheezing.

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? Pernicious anemia Dehydration Prostate enlargement Bladder infection

Bladder infection

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? Body weight Skin integrity Blood pressure Respiratory rate

Body weight

A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors? Pale yellow Greenish-brown Red Dark and foamy

Dark and foamy The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are filtering excess bilirubin from the blood.

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? Cleanse the perineum from back to front. Obtain a prescription for an indwelling urinary catheter. Encourage fluid intake at and between meals. Offer the client the bedpan every 2 hr.

Encourage fluid intake at and between meals. Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital-acquired) UTI is reduced, even for a client who has a spinal cord injury.

A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take? Apply cold compress to the client's flank area. Restrict protein intake to 2 servings per day. Discourage ambulation. Encourage intake of at least 3 L of fluids per day.

Encourage intake of at least 3 L of fluids per day. The nurse should encourage the client to consume at least 3,000 mL of fluids per day to dilute the urine, increase hydrostatic pressure behind the stone, and move the calculi down the urinary tract.

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain? Lower left quadrant Upper left quadrant Lower right quadrant Upper right quadrant

Lower left quadrant The nurse should expect the client to have abdominal pain in the lower left quadrant of the abdomen. The disease is usually found in the sigmoid colon, where high pressure to move fecal contents from the rectum causes pouch formation.

A nurse is caring for a client 4 hr postoperative following a kidney biopsy. Which of the following interventions should the nurse take? (Select all that apply). Monitor for hematuria. Check for flank pain. Monitor for extravasation of tissue surrounding the biopsy site. Encourage ambulation. Administer aspirin PRN for pain.

Monitor for hematuria. Check for flank pain.

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? Weigh the second client. Obtain vital signs for both clients. Administer pain medication to the first client. Change the dressings of both clients.

Obtain vital signs for both clients.

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer? Lactulose Sevelamer Sodium polystyrene Darbepoetin alfa

Sodium polystyrene It removes excess potassium by ion exchange through the bowel. The client's serum potassium level of 6.8 mEq/L is significantly above the reference range of 3.5 - 5.0 mEq/L..

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first? Urticaria Stridor Vomiting Hypotension

Stridor When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is stridor, which indicates narrowing of the airway. The nurse should position the head of the client's bed at 45° or more, if tolerable, and call for emergency assistance.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? check the catheter for twisting or kinks in the tubing Replace the catheter every 3 days. Irrigate the catheter once each shift. Clean the perineal area with an antiseptic solution daily.

check the catheter for twisting or kinks in the tubing

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.) "Your provider might prescribe anticholinergic medications." "You should limit fluids in the evening." "You should restrict your intake of caffeine." "You might require intermittent urinary catheterization." "You might require an anterior vaginal repair."

"Your provider might prescribe anticholinergic medications." "You should limit fluids in the evening." "You should restrict your intake of caffeine."

A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client? Prone Semi-Fowler's Supported Sims' Dorsal recumbent

Semi-Fowler's The nurse should expect a prescription to place the client in semi-Fowler's position following a traditional cholecystectomy to facilitate lung expansion as well as coughing and deep breathing. This position will place minimal stress on the abdomen and increase comfort.

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect? Ulcerative colitis Cholecystitis Paralytic ileus Wound dehiscence

Paralytic ileus

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted? Contract the pelvic muscles. Take a sip of water. Exhale slowly. Bear down.

Bear down.

A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make? "The laxative will prevent the absorption of magnesium." "The laxative helps eliminate the barium." "The laxative is the protocol at this facility." "The laxative makes the barium turn brown."

"The laxative helps eliminate the barium."

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.) Bounding pulse Pitting edema Swelling at the IV site Urine-specific gravity greater than 1.030 Crackles upon auscultation

Bounding pulse Pitting edema Crackles upon auscultation

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse? Clamps the NG tube during auscultation Performs auscultation between meals Auscultates bowel sounds for 3 to 5 min Palpates the abdomen prior to performing auscultation.

Palpates the abdomen prior to performing auscultation.

A nurse is teaching a class at a community center to a group of young adult, adult, and older adult clients regarding regular screening recommendations for cancer prevention. Which of the following information should the nurse include? Women should start yearly mammograms at age 30. Clients should have a colonoscopy at age 40 and every 10 years thereafter. Clients should have a yearly test for fecal occult blood. Women should have a yearly clinical breast examination starting at age 45.

Clients should have a yearly test for fecal occult blood.

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? Urinary retention Low back pain Incontinence Confusion

Confusion

A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse's priority intervention? Insert an IV line. Count the respiratory rate. Administer oxygen. Prepare equipment for intubation.

Count the respiratory rate.

A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority? Bowel sounds Surgical dressing Temperature Oxygen saturation

Oxygen saturation

A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching? Determine the pH of the gastric secretions. Supply nutrients via tube feedings. Decompress the stomach. Administer medications.

Decompress the stomach. A pyloric obstruction, also called gastric outlet obstruction, is caused by edema, scarring, or spasm, often the result of gastritis or peptic ulcer disease. The nurse should inform the client that because the stomach is dilated and may contain undigested food, it must be decompressed, necessitating the placement of an NG tube.

A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi? Protein in the urine Dehydration Iron deficiency Obesity

Dehydration Dehydration can cause hypercalcemia which increases the risk for renal stone formation. Inadequate fluid intake can result in urinary stasis and promote the formation of calculi.

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? Collect a urine specimen for culture and sensitivity. Continue routine care because the results are within the expected reference range. Decrease the IV fluid infusion rate and limit oral fluid intake. Evaluate urine for amount and for specific gravity.

Evaluate urine for amount and for specific gravity. These results indicate that the client is dehydrated. Specific gravity and urine output measurements can support the laboratory findings. The higher the specific gravity, the more dehydrated the client.

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.) Excessive laxative use Ignoring the urge to defecate Inadequate fluid intake Increased fiber in the diet Increased activity

Excessive laxative use Ignoring the urge to defecate Inadequate fluid intake

A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's Jackson-Pratt (JP) drain? Measure the drainage every hour for the first 8 hr postoperative. Secure the drain to the client's bed sheet. Expel the air from the JP bulb after emptying to re-establish suction. Remove the JP drain when the drainage has ceased, covering the opening with sterile gauze.

Expel the air from the JP bulb after emptying to re-establish suction.

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect? Fatty stools Straw-colored urine Tenderness in the left upper abdomen Ecchymosis of the extremities

Fatty stools Chronic cholecystitis occurs after several bouts of acute cholecystitis. Repeated episodes of inflammation result in fibrotic and contracted gallbladder. Bc of inflammation in gallbladder, bile needed to absorb fat and fat-soluble vitamins is unable to enter bowel, resulting in steatorrhea.Urine would be dark colored, pain would be in the right upper quadrant of the abdomen that can radiate to the back or the right scapular area. Bile is absorbed by blood-skin and mucous membranes develop jaundice.

A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect? Hypothermia Protruding eyeballs Elevated blood pressure Furrows in the tongue

Furrows in the tongue

A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test (RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result? Immunoglobulin G (IgG) Immunoglobulin A (IgA) Immunoglobulin E (IgE) Immunoglobulin M (IgM)

Immunoglobulin E (IgE)

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings? Decreased urine specific gravity Decreased Hgb Increased BUN Increased urine ketones

Increased BUN

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of following indications should the nurse include? (Select all that apply). Relief of urinary retention Convenience for the nursing staff or the client's family Measurement of residual urine after urination Routine acquisition of a urine specimen An open perineal wound

Relief of urinary retention Measurement of residual urine after urination An open perineal wound

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding? Warm the feeding solution to body temperature. Place the client in low Fowler's position. Discard any residual gastric contents. Test the pH of gastric aspirate.

Test the pH of gastric aspirate. Before administering enteral feedings, the nurse should verify the placement of the NG tube. The only reliable method is x-ray confirmation, which is impractical prior to every feeding. Testing the pH of gastric aspirate is an acceptable method between x-ray confirmations.

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? The client who has been NPO since midnight for endoscopy. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. The client who has end-stage renal failure and is scheduled for dialysis today. The client who has gastroenteritis and is febrile.

The client who has gastroenteritis and is febrile. This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit.

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? The nurse initiates the feeding after aspirating 50 mL of gastric residual. The nurse irrigates the NG tube with tap water after feeding. The nurse administers the feeding through a syringe barrel by gravity. The nurse allows the client to rest in a supine position during feeding.

The nurse allows the client to rest in a supine position during feeding.

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? Sodium 165 mEq/L Potassium 5.2 mEq/L Urine specific gravity 1.020 Hct 62%

Urine specific gravity 1.020

A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding.

Verify the placement Check the residual feeding contents Administer the feeding Evaluate tolerance to the feeding