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The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in client interactions? (Select all that apply)
- Avoid eating grapefruit or drinking grapefruit juice -Report changes in the use of daily supplements -Notify you heal care provider if your skin looks yellow
The nurse is preparing to discharge an older adult female client who is at risk for hypcalcemia....nurse include with this clients discharge teaching? Select all that apply A. Report any muscle twitching or seziures B. Take vitamin D with calcium daily C. Avoid seafood, particularly shellfish D. Low fat yogurt is a good source of calcium E. Keep a diet record to monitor calcium intake
A. Report any muscle twitching or seziures B. Take vitamin D with calcium daily D. Low fat yogurt is a good source of calcium E. Keep a diet record to monitor calcium intake
A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement?
Infuse sodium chloride 0.9% (normal saline)
A toddler presents to the clinic with a barking cough, strider, refractions with respiration, the child's skin is pink with capillary refill of 2 seconds. Which intervention should the nurse implement?
Administered Nebulized Epinephrine
After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?
Ask the client about gastrointestinal pain.
The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three day. The clients plan to live with a family member. Which action should the nurse implement? Select all that apply
Assess the client for self-care ability ● Provide pain medication instructions ● Teach care of ostomy to care provider
After checking the fingerstick glucose at 1630, what action should the nurse implement? A. Notify the healthcare provider B. Administer 8 units of insulin aspart SubQ C. Give an IV bolus of Dextrose 50% 50 ml D. Perform quality control on the glucometer
B. Administer 8 units of insulin aspart SubQ
A client with hypertension receives a prescription for enalapril, and ACE inhibitor. Which instruction should the nurse include in the medication teaching plan? A. Increase intake of potassium rich foods B. Report increased bruising or bleeding C. Stop medication if a cough develops D. Limit intake of leafy green vegetables
B. Report increased bruising or bleeding
The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress?
Contractions of the sternocleidomastoid muscle
The nurse is administering a 750 ml cleansing enema to an adult client. After approximately150 ml of enema has informed, the client states, 'stop I can't hold anymore." What action should the nurse take?
Clamp the tubing and instruct the client to breathe deeply before continuing.
Progressive kyphoscolisis leading to respiratory distress is evident in a client with muscular weakness. which finding warrants immediate intervention by the nurse? A. Extremity muscle weakness B. Bilateral eyelid drooping C. Inability to swallow pills D. Evidence of hypoventilation
D. Evidence of hypoventilation
An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?
Destruction of joint cartilage.
A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement?
Digitally check the client for a fecal impaction
In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management?
Enable clients to become active participants in controlling the disease process
The nurse caring for a client with dysphagia is attempting to insert an NG tube, but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus?
Flex the client's head with chin to the chest and insert.
A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which Implements decisions about future hospices services within the next 3 months. Marinating pain level below 4 when implementing outpatient pain clinic strategies. Request home health care if independence become compromised for 5 days. Arranges for short term counseling stressors impact work schedule for 2 weeks.
Marinating pain level below 4 when implementing outpatient pain clinic strategies.
While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with the needle. After washing the puncture site with soap & water, which action should the nurse take?
Notify the employee health nurse.
The family of a client who just died arrives on the nursing unit after receiving telephone notification of the death. Several family members state they would like to view the body. How should the nurse respond?
Offer to go with the family members to view the body.
The nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video. Which nurse takes next
Open the roller clamp on the tubing.
In assessing a pressure ulcer on a client's hip, which action should the nurse include? Determine the degree of elasticity surrounding the lesion Photograph the lesion with a ruler placed next to the lesion Stage the depth of the ulcer using the Braden numeric scale Use a gloved finger to palpate for tunneling around the lesion
Photograph the lesion with a ruler placed next to the lesion
The nurse is caring for a client immediately after inserting a PICC line. Suddenly, the client becomes anxious and tachycardiac, and loud churning is heard over the pericardium upon auscultation. What action should the nurse take first?
Place client in Trendelenburg position on the left side.
In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test? - Serum Creatinine - Glucose - Urine output - Serum BUN
Serum creatinine
A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client's teaching plan
Take on an empty stomach with a full glass of water.
Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medication should be held until a later time?
The mucosal barrier, sucralfate (Carafate), for a client diagnosed with peptic ulcer disease. Rationale: Carafate coats the mucosal lining prior to eating a meal
A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?
Total calcium 5.0 mg/dl
A client admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor, which important finding places the client at greatest risk?
Unresponsive to painful stimuli
The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard. Which intervention should the nurse implement next?
Wait 1 minute and palpate the systolic pressure before auscultating again.
A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first? ● Administer epinephrine IV ● Give an IV bolus of amiodarone ● Provide immediate defibrillation ● Prepare for synchronized cardioversion
● Provide immediate defibrillation
A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution? ● 0.9% sodium chloride solution (normal saline) ● 0.45% sodium chloride solution (half normal saline) ● 10% Dextrose in 0.45% sodium chloride ● 5% dextrose in 0.2% sodium chloride
● 0.9% sodium chloride solution (normal saline)
The nurse is conducting health assessments. Which assessment finding increases a 56- year-old woman's risk for developing osteoporosis? ● Body mass index of (BMI) of 31 ● 20 pack-year history of cigarette smoking ● Birth control pill usage until age 45 ● Diabetes mellitus in family history
● 20 pack-year history of cigarette smoking
When assessing a male client, the nurse notes that he has unequal lung expansion. What conclusion regarding this finding is most likely to be accurate? The client has ● A history of COPD ● A chronic lung infection ● A collapsed lung ● Normally functioning lungs
● A collapsed lung
A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? ● Altered consciousness within the first 24 hours after injury. ● Cushing reflex and cerebral edema after 24 hours ● Fever, nuchal rigidity and opisthotonos within hours ● Headache and pupillary changes 48 hours after a head injury
● Altered consciousness within the first 24 hours after injury.
The nurse requests a meals tray for a client follows Mormon beliefs and who is on clear liquid diet following abdominal surgery. Which meal item should the nurse request for this client? (Select all that apply) ● Apple juice ● Hot chocolate ● Orange juice ● Black coffee ● Chicken broth.
● Apple juice ● Chicken broth.
The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide? ● Stroke the inner thigh below the perineum to initiate urinary flow ● Contract, hold, and then relax the pubococcygeal muscle ● Pour warm water over the external sphincter at the distal glans ● Apply downward manual pressure at the suprapubic regions.
● Apply downward manual pressure at the suprapubic regions.
The healthcare provider prescribes oxycodone/ aspirin 1 tab PO every 4h as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the prescription should the nurse question? ● Dose ● Aspirin content. ● Route ● Risk for addiction
● Aspirin content.
A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement? ● Auscultate all quadrant of the abdomen. ● Perform a digital rectal exam ● Palpate the liver and spleen ● Obtain a hemoccult of the client's stool
● Auscultate all quadrant of the abdomen.
A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? ● Review the heart rhythm on cardiac monitors ● Check urinary catheter for obstruction ● Auscultated bilateral breath sounds ● Give PRN dose of lorazepam (Ativan)
● Auscultated bilateral breath sounds
A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client's plan of care? ● Adhere to a bland diet whenever planning to eat out ● Decrease fluid intake at meal times ● Avoid foods that caused gas before the colostomy ● Eliminate foods high in cellulose
● Avoid foods that caused gas before the colostomy
The home care nurse provide self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply ● Avoid prolonged standing or sitting ● Use recliner for long period of sitting ● continue wearing elastic stocking ● Maintain the bed flat while sleeping ● Cross legs at knee but not at ankle
● Avoid prolonged standing or sitting ● Use recliner for long period of sitting ● continue wearing elastic stocking
A client admitted to the emergency center had inspiratory and expiratory wheezing,nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering? ● Beta blockers ● Bronchodilators ● Corticosteroids ● Beta-adrenergics
● Bronchodilators
Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)? ● A high ventilation-to-perfusion ratio is characteristic of affected lung fields in ARDS ● Functional residual capacity and lung compliance increase as the disease progresses ● Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema ● Interstitial edema that occurs due to capillary fluid shifts is usually more serious than alveolar edema
● Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema
A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse? ● Low-grade fever, headache, and malaise for the past 72 hours ● Unable to bear weight on the left foot, with the swelling and bruising ● Chest discomfort one hour after consuming a large, spicy meal ● One-inch bleeding laceration on the chain of the crying five-year-old
● Chest discomfort one hour after consuming a large, spicy meal Rationale: Emergency triage involves quick assessment to prioritize the need for further evaluation and care. Those with trauma, chest pain, respiratory distress, or acute neurological changes are priority. In this example, while clients with other conditions require attention, the client with chest discomfort is at greatest risk and is a priority.
The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse? ● Finger stick blood glucose 120 mg/dL post exchange ● Arteriovenous (AV) graft surgical site pulsations. ● Anorexia and poor intake of adequate dietary protein ● Cloudy dialysate output and rebound abdominal pain
● Cloudy dialysate output and rebound abdominal pain
The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is....which action should the nurse take to ensure adequate filling of the drip chamber? ● Lower the IV bag to a flat surface ● Compress the drip chamber ● Open the roller clamp ● Squeeze the bag of IV solution
● Compress the drip chamber
The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs? ● Stares straight ahead without blinking ● Face does not convey any emotion ● Cries frequently during the interview ● Uses a monotone when speaking
● Cries frequently during the interview
A client is admitted with a wound on the right hand and associated cellulitis. In assessing the client's hand, which finding required most immediate follow-up by the nurse? ● Localized tenderness ● Cyanotic nailbedsb ● Diffuse erythema ● Skin hot to touch
● Cyanotic nailbeds
Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective? ● Decrease abdominal girth ● Increased blood pressure ● Clear breath sounds ● Decrease serum albumin.
● Decrease abdominal girth
The nurse is caring for four clients...postoperative hemoglobin of 8.7 mg/dl; client C,newly admitted with potassium...an appendectomy who has a white blood cell count of 15,000mm3. What intervention... ● Determine the availability of two units of packed cells in the blood bank for client B ● Increase the oxygen flow rate to 4 liters/minute per face mask for client A ● Remove any foods, such as banana or orange juice, for the breakfast tray for client C ● Inform client D that surgery is likely to be delayed until the infection responds to antibiotics
● Determine the availability of two units of packed cells in the blood bank for client B
A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first? ● Determine the client's responsiveness and respirations ● Bring the crash cart to the room to defibrillate the client. ● Immediately initiate chest compressions. ● Notify the emergency response team
● Determine the client's responsiveness and respirations
The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse? ● Diabetic ketoacidosis and titrated IV insulin infusion ● Emphysema extubated 3 hours ago receiving heated mist ● Subdural hematoma with an intracranial monitoring device ● Acute coronary syndrome treated with vasopressors
● Diabetic ketoacidosis and titrated IV insulin infusion
The nurse assesses a 78-year-old male client who has left sides heart failure. Which symptoms would the nurse expect this client to exhibit? ● Hepatomegaly and distended neck veins ● Pain over the pericardium and friction rub. ● Narrowing pulse pressure and distant heart sounds. ● Dyspnea, cough, and fatigue.
● Dyspnea, cough, and fatigue.
The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider? ● Decreased white blood cell count ● Pruritus and muscle aches ● Elevated liver function tests ● Vomiting and diarrhea
● Elevated liver function tests
The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide? ● Exercise at least three times weekly ● Monitor blood glucose levels daily ● Limit intake of foods high in saturated fat ● Learn to read all food product labels
● Exercise at least three times weekly
While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition? ● Tinea corporis ● Herpes zoster ● Psoriasis ● Drug reaction
● Psoriasis
Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication? ● Arterial ischemia ● Tissue necrosis ● Fat embolism ● Nerve damage
● Fat embolism
When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do? ● Check for any abrasions or bruises. ● Help the client to stand. ● Get a blood pressure cuff. ● Report the fall to the nurse-manager.
● Get a blood pressure cuff.
A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply.) ● Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors. ● T3 and T4 hormone levels are increased ● Large protruding eyeballs are a sign of hyperthyroid function ● Weight gain is a common complaint in hyperthyroidism ● Early treatment includes levothyroxine (Synthroid).
● Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors. ● T3 and T4 hormone levels are increased ● Large protruding eyeballs are a sign of hyperthyroid function
An adult man reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging in the neighborhood. He expresses concern because both of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintain his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply
● History of hypertension. ● Family heath history.
The nurse plans to administer a schedule dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take? ● Administer the Tropol immediately and monitor the client until the heart rate increases. ● Provide the dose of Tropol as scheduled and assign a UAP to monitor the client's BP q30 minutes. ● Give the Tropol as scheduled if the client's systolic blood pressure reading is greater than 180. ● Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern.
● Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern. Beta blockers such as metoprolol (Tropol SR) are contraindicated in clients with second or third degree heart block because they decrease the heart rate. Therefore, the nurse should hold the medication.
A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? ● Excessive thirst ● Elevated heart rate ● Hypernatremia ● Poor skin turgor
● Hypernatremia
A male client arrives at the clinic with a severe sunburn and explains that he did not use sun screen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse? ● Hypotension. ● Fever and chills ● Dizziness ● Headache
● Hypotension.
The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate? ● Initiation of the impulses from a location outside the SA node ● Inability of the SA node to initiate an impulse at the normal rate ● Increased conduction time from the SA node to the AV junction ● Interference with the conduction through one or both ventricles.
● Inability of the SA node to initiate an impulse at the normal rate
After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? ● Initiate intravenous fluid as prescribed ● Notify the HCP of the need to reposition the catheter ● Remove the catheter and apply direct pressure for 5 minute ● Secure the catheter using aseptic technique
● Initiate intravenous fluid as prescribed Rationale: Venous blood return to the heart and drains from the subclavian vein into the superior vena cava. The X-ray findings indicate proper placement of the CVC, so prescribed intravenous fluid can be started. A and B are not indicated at this time. The catheter should be secure immediate following insertion (C)
An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-side weakness. He has tried to get out of bed several times, but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement? ● Ask a family member to sit with the client ● Apply bilateral soft wrist restraints ● Assign staff to check client q15 minutes ● Install a bed exit safety monitoring device
● Install a bed exit safety monitoring device
Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? ● Intravenous administration of thyroid hormones ● Oral administration of hypnotic agents ● Intravenous bolus of hydrocortisone ● Subcutaneous administration of vitamin k
● Intravenous administration of thyroid hormones
The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor to the osteoarthritis? ● Lactose intolerant since childhood ● Photosensitive to a drug currently taking ● Recently treated for deep vein thrombosis ● Long distance runner since high school.
● Long distance runner since high school.
A 59-year-old male client comes to the clinic and reports his concern over a lump that, "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is not overlyingtissue inflammation. What do these findings suggest? ● Malignancy ● Bacterial infection ● Viral infection ● Lymphangitis
● Malignancy
The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan? ● Monitor for an elevated temperature ● Measure the abdominal girth daily ● Report the onset of sclera jaundice ● Keep a record of daily urinary output
● Monitor for an elevated temperature
A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply) ● Monitor heart, lung, and kidney function. ● Review client's abdominal ultrasound findings. ● Position client on abdomen to provide organ stability ● Encourage an increased intake of clear oral fluids ● Notify healthcare provider of serum amylase and lipase levels.
● Monitor heart, lung, and kidney function. ● Notify healthcare provider of serum amylase and lipase levels. ● Review client's abdominal ultrasound findings.
Which intervention should the nurse include in the plan of care for a client with leukocytosis? ● Avoid intramuscular injections ● Monitor temperature regularly ● Assess skin for petechiae or bruising ● Implement protective isolation measures
● Monitor temperature regularly
A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care? ● Assess for back muscle aches ● Record drainage from drain ● Monitor urine output hourly. ● Obtain body weight daily
● Monitor urine output hourly.
An older female who ambulate with a quad-cane prefer to use a wheel chair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply) ● Move personal items within client's reach ● Lower bed to the lower possible position ● Give directions to call for assistance ● Assist client to the bathroom in 2 hours. ● Encourage the use of the wheelchair ● Raise all bed rails when the client is resting
● Move personal items within client's reach ● Lower bed to the lower possible position ● Give directions to call for assistance ● Assist client to the bathroom in 2 hours.
A client with superficial burns to the face, neck, and hands resulting from a house fire... which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...? ● Expiratory stridor and nasal flaring ● Mucous membranes cherry red color ● Carbonaceous particles in sputum ● Pulse oximetry reading of 80 percent
● Mucous membranes cherry red color
A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider? ● Insomnia ● Muscle cramping ● Increase appetite ● Anxiety.
● Muscle cramping
The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic? ● Low bioavailability ● Rapid onset of action ● Short half life ● Narrow therapeutic index.
● Narrow therapeutic index.
A client is admitted to isolation with the diagnosis of active tuberculosis (TB). Which infection control measures should the nurse implement? ● Contact precautions ● Negative pressure environment ● Droplet precautions ● Protective environment
● Negative pressure environment
The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating ● A paced rhythm with 100% capture after pacemaker replacement ● Normal sinus rhythm and complaining of chest pain ● Atrial fibrillation with congestive heart failure and complaining of fatigue ● Sinus tachycardia 3 days after a myocardial infarction
● Normal sinus rhythm and complaining of chest pain
In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? ● Evaluate the client's ability to use an incentive spirometer ● Monitor the amount of drainage from the client's incision ● Observe both lower extremities for redness and swelling ● Palpate all peripheral pulse points for volume and strength
● Observe both lower extremities for redness and swelling
In determine the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition? ● High urinary PH ● Abdominal Ascites ● Orthopnea ● Fever.
● Orthopnea Rationale: If the client is orthopneic, the nurse needs to adapt the insertion position thatdoes not place the client in a supine position (the head of the bed should be elevated as much as possible).
To obtain an estimate of a client's systolic B/P. What action should the nurse take first? ● Pump up the blood pressure cuff ● Position the stethoscope diaphragm ● Palpate the client's brachial pulse ● Release the blood pressure cuff valve
● Palpate the client's brachial pulse
The nurse has received funding to design a health promotion project for African- American women who are at risk for developing breast cancer. Which resource is most important in designing this program? ● A listing of African-American women so live in the community ● Participation of community leaders in planning the program ● Morbidity data for breast cancer in women of all races ● Technical assistance to produce a video on breast self-examination.
● Participation of community leaders in planning the program
The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take? ● Document that an accurate oxygen saturation reading cannot be obtained ● Elevate to client's hands for five minutes prior to obtaining a reading from the finger ● Increase the oxygen based on the clients breathing patterns and lung sounds ● Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading
● Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading Rationale: Pulse oximeter clips can be attached to the earlobe to obtain an accurate measurement of oxygen saturation. Other options will not provide the needed assessment.
A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important? ● Review record of recent analgesia ● Provide frequent pulmonary toilet ● Prepare the client for intubation ● Obtain STAT arterial blood gases
● Prepare the client for intubation
The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider? ● Rebound tenderness in the upper quadrants ● Hypoactive bowel sounds in the lower quadrants ● Tympany with percussion of the abdomen ● Light colored gastric aspirate via the nasogastric tube
● Rebound tenderness in the upper quadrants
Which interventions should the nurse include in a long-term plan of care for a client with COPD? ● Limit fluid intake to reduce secretions ● Use diaphragmatic breathing to achieve better exhalation ● Administer high flow oxygen during sleep ● Reduce risk factors for infection
● Reduce risk factors for infection
Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client? ● Maintain adequate cardiac output ● Promote adequate tissue perfusion ● Promote rest and sleep ● Reduce the risk for injury
● Reduce the risk for injury
The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take? ● Remind the client to hold his breath after inhaling the medication ● Confirm that the client has correctly shaken the inhaler ● Affirm that the client has correctly positioned the inhaler ● Ask the client if he has a spacer to use for this medication
● Remind the client to hold his breath after inhaling the medication
...An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor? ● Serum potassium ● Urine ketones ● Urine albumin ● Serum protein
● Serum potassium
A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition? ● Stroke ● Renal failure ● Left ventricular hypertrophy ● Pulmonary hypertension
● Stroke
A client with polycystic kidney disease (PKD) receiving antibiotics for an infected cyst is experiencing severe pain. What action should the nurse implement? ● Hold the next dose of antibiotic until contacting the healthcare provider ● Teach the client how to use a dry heating pad over the painful area ● Encourage the client to practice pelvic floor exercises every hour ● Assist the client to splint the site by applying an abdominal binder
● Teach the client how to use a dry heating pad over the painful area
A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? ● The client has asymmetrical chest wall expansion ● The clients complain of pain at the insertion site ● The client chest's x-ray indicates decreased pleural effusion ● The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26
● The client has asymmetrical chest wall expansion A potential complication of thoracentesis is a pneumothorax. The symptoms of a pneumothorax are uneven, unequal movement of the chest wall. A is an expected finding after the local anesthetic effects "wear off" B is a desired result of thoracentesis and C is within normal limits.
A 35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery? ● Supplemental hormonal therapy will probably be unnecessary ● The thyroid will regenerate to a normal size within a few years. ● The client will be restricted from eating seafood ● The remainder of the thyroid will be removed at a later date.
● The client will be restricted from eating seafood
A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain? ● Presence of bruising, weakness, or fatigue ● Therapeutic exercise included in daily routine. ● Average amount of protein eaten daily ● Existence of gastrointestinal discomfort
● Therapeutic exercise included in daily routine.
The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? ● High salt can damage the lining of the blood vessels ● Too much salt can cause the kidneys to retain fluid ● Excessive salt can cause blood vessels to constrict ● Salt can cause information inside the blood vessels
● Too much salt can cause the kidneys to retain fluid
A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions? ● Clam chowder ● Macaroni and cheese ● Bacon, lettuce, and tomato sandwich ● Turkey salad sandwich.
● Turkey salad sandwich.
After removing a left femoral arterial sheath, which assessment finding warrant immediately interventions by the nurse? (Select all that applied.) ● Unrelieved back and flank pain. ● Quarter-size red drainage at site ● Cool and pale left leg and foot. ● Tenderness over insertion site ● Left groin egg-size hematoma.
● Unrelieved back and flank pain. ● Cool and pale left leg and foot. ● Left groin egg-size hematoma.
A client in septic shock has a double lumen central venous catheter with one liter of 0.9% Normal Saline Solution infusing at 1 ml/hour through one lumen and TPN infusing at 50 ml/hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement? ● Use a secondary port of the Normal Saline solution to administer the antibiotic. ● Add the antibiotic to the TPN solution, and continue the normal saline solution. ● Stop the TPN infusion for the time needed to administer the prescribed antibiotic. ● Add the antibiotic to the Normal Saline solution and continue both infusions.
● Use a secondary port of the Normal Saline solution to administer the antibiotic.
A client who is schedule for an elective inguinal hernia repair today in day surgery is seem eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications? ● Review the surgical consent with the client ● Explain that vomiting can occur during surgery ● Remove the food from the client ● Withhold the preoperative medication
● Withhold the preoperative medication ● Explain that vomiting can occur during surgery
When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat? ● Processed cheese. ● Nuts ● Fresh turkey ● Yogurt. ● Fresh chicken
● Yogurt. ● Processed cheese.
In conducting a health assessment, the nurse determines that both parents of a child with asthma smoke cigarettes. What recommendation is best to the nurse to recommend to the parents? ● avoid smoking in the house ● stop smoking immediately ● decrease the number of cigarettes smoke daily ● obtain nicotine patches to assist in smoking sensation
● avoid smoking in the house
