HI 4
A client with a self-inflicted gunshot wound in his arm is brought to the inpatient psychiatric unit from the emergency department. With his arm bandaged and in a sling, he is escorted to the unit by emergency department staff. A staff member states to the nurse, "He only hurt his arm, so he probably did it for attention." Which response by the nurse to the staff member would be most appropriate? "He really must not have wanted to kill himself, but he certainly injured his arm." "All suicide attempts or acts of self-harm are very serious and indicate a cry for help." "You seem to have some strong feelings about suicide attempts, do you want to tell me about them?" "It was probably a way to escape a serious problem. The hospital is a safe and secure environment."
"All suicide attempts or acts of self-harm are very serious and indicate a cry for help."
A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms? "Eat cold, bland foods with a large amount of water." "Eat low-fiber blended foods only." "Eat larger amounts of bland, soft foods less frequently." "Eat small amounts of bland, soft foods frequently."
"Eat small amounts of bland, soft foods frequently."
An adolescent client comes to the community crisis clinic. The client has multiple superficial cuts on their bilateral wrists. The client is crying uncontrollably and states that a close friend has left recently and the client doesn't want to live without the friend. What would be the most therapeutic initial nursing response? "Many friends change their minds about relationships. This is really quite normal." "I can see that you are feeling anxious. I will stay with you until you feel better." "There are plenty of friends out there. Don't worry, at your age you will find another friend quickly." "Let's set some boundaries on your behavior, and let's find ways to deal with your stress."
"I can see that you are feeling anxious. I will stay with you until you feel better."
The client, who is a veteran and has posttraumatic stress disorder, tells the nurse about the horror and mass destruction of war. He states, "I killed all of those people for nothing." Which response by the nurse is appropriate? "Maybe you didn't kill as many people as you think." "War is a terrible thing." "You did what you had to do at that time." "How many people did you kill?"
"You did what you had to do at that time."
The nurse is assessing a client's respiratory status. Which assessment data indicate a problem? 18 breaths/min and inhaled through the mouth 16 breaths/min and deep in character 20 breaths/min and shallow in character 28 breaths/min and audible
28 breaths/min and audible
A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the health care provider immediately because the client probably is experiencing which problem? A hemolytic allergic reaction caused by an antigen reaction A hemolytic reaction caused by bacterial contamination of donor blood A hemolytic reaction to mismatched blood A hemolytic reaction to Rh-incompatible blood
A hemolytic allergic reaction caused by an antigen reaction
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify? Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels Low levels of urine constituents normally excreted in the urine Electrolyte imbalance that could affect the blood's ability to coagulate properly Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client? Acute respiratory distress syndrome (ARDS) Chronic obstructive pulmonary disease (COPD) Anaphylaxis Mitral valve prolapse
Acute respiratory distress syndrome (ARDS)
pH: 7.39 CO2: 56 HCO3: 33
Answer: fully compensated respiratory acidosis via metabolic alkalosis
pH: 7.54 CO2: 22 HCO3: 18
Answer: partially compensated respiratory alkalosis via metabolic acidosis
pH: 7.29 CO2: 40 HCO3: 19
Answer: uncompensated metabolic acidosis
A client with pneumonia has developed dyspnea, has a respiratory rate of 32 breaths/min, and is having difficulty expelling secretions. The nurse auscultates the lung fields and hears bronchial sounds in the lower left lobe. Which action should the nurse take first? Encourage bed rest Assess nutritional intake Administer antibiotics Apply oxygen
Apply oxygen
A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden onset of shortness of breath and chest pain that increases with a deep breath. What should the nurse do first? Assess the oxygen saturation. Perform range of motion exercises in the involved leg. Administer morphine sulfate 2 mg IV. Call the health care provider (HCP).
Assess the oxygen saturation.
Nurse is educating a patient with chronic venous insufficiency about prevention of complications related to the disorder. What should the nurse include? Avoid constricting garments Elevate the legs about the heart level for 30 minutes every 2 hours Sit as much as possible to rest the valves in the legs Sleep with the foot of the bed elevated about 6 inches Sit on the side of the bed and dangle feet
Avoid constricting garments YES Elevate the legs about the heart level for 30 minutes every 2 hours YES Sleep with the foot of the bed elevated about 6 inches YES
A client reports feeling tired, cold, and short of breath at times. Assessment reveals tachycardia and reduced energy. What would the nurse expect the physician to order? ECG antibiotic chest radiograph CBC
CBC
During a home visit, the nurse assesses a client who is taking hydrochlorothiazide and lisinopril for the treatment of hypertension. Which finding would indicate the nurse should inform the health care provider of a possible need to change medication therapy? Blood pressure is 132/80 mm Hg. Client is experiencing nocturia. Potassium level is 4.1 mEq/L. Client has a persistent cough.
Client has a persistent cough.
A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client? Risk for falls related to complaints of dizziness Fatigue related to decreased hemoglobin and hematocrit Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients
Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit
Which is a characteristic of right-sided heart failure? Cough Pulmonary crackles Jugular vein distention Dyspnea
Jugular vein distention
Which enzyme aids in the digestion of fats? Lipase Trypsin Secretin Amylase
Lipase
Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole? Preload Afterload Ejection fraction Stroke volume
Preload
A client at the clinic has just been diagnosed with iron deficiency anemia. What would you recommend the client consume to promote the absorption of iron? Rich sources of vitamin C Sources of vitamin B12 Meat, egg yolks, oysters, and shellfish Vitamin E
Rich sources of vitamin C
The nurse assesses a school-age client who excessively cleans and categorizes. Her parents report that she has always been orderly, but since her brother died of cancer 6 months ago, her cleaning and categorizing have escalated. In school, she reads instead of playing with other children. These behaviors are now interfering with homework and leisure activities. To bolster her self-esteem, the nurse should encourage the child to engage in which activity? Lead a group project with four peers. Serve as a library helper. Be captain of the kickball team. Volunteer to organize a party for the class.
Serve as a library helper.
Which adolescent would the nurse determine needs further evaluation? a young adolescent girl who reads "dark" novels and questions why God allows innocent people to be harmed a young adolescent boy who coughs for 5 minutes after trying his first marijuana cigarette and declares he does not want to do it again a young adolescent boy who restricts his food and fluid intake to be able to box in a lower weight class a young adolescent girl whose mood changes when upset with her parents, though she has never been in trouble in school or the community
a young adolescent boy who restricts his food and fluid intake to be able to box in a lower weight class
The nurse is caring for 9-year-old boy undergoing chemotherapy whose complete blood count (CBC) with differential reports 7% banded and 13% segmented neutrophils with a white blood cell count of 2,540. He has an oral temperature of 38.6°C (101.5°F). Which intervention would be the priority? monitoring his vital signs every 4 hours restricting visitors with symptoms of infection assessing for signs of infection every 8 hours administering prescribed broad-spectrum IV antibiotics
administering prescribed broad-spectrum IV antibiotics
The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight circumoral cyanosis is developing. Which laboratory test best measures the adequacy of tissue oxygenation? red blood cell count pulmonary function test hemoglobin level arterial blood gases
arterial blood gases
Which nursing intervention is most important in preventing postoperative complications? early ambulation bowel and elimination monitoring progressive diet planning pain management
early ambulation
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? "My pants don't fit around my waist." "I sleep on three pillows each night." "My feet are bigger than normal." "I don't have the same appetite I used to."
"I sleep on three pillows each night."
Which statement indicates that a client understands discharge instructions about propranolol? "I will take this medication in the morning." "I will assess my heart rate before I take my medication." "I will not take this medication if I see yellow halos around lights." "I will take this medication whenever I feel anxious."
"I will assess my heart rate before I take my medication."
The daughter of a client with metastatic cancer is confused as to why the client is receiving radiation therapy and asks the nurse, "Why are we still treating the cancer? The plan was only for comfort care." What is the nurse's best response? "In this case, the radiation is being used to help alleviate the bone pain your family member is experiencing." "This type of radiation has no serious adverse effects so we often apply it in palliative cases as there is no harm." "Radiotherapy is slowing tumor growth so you can have more time with your family member, but it is not curative." "You will need to discuss the plan of care with your family member as I am not at libe
"In this case, the radiation is being used to help alleviate the bone pain your family member is experiencing."
A young female client has pale nailbeds. Her hemoglobin count is 10.2 gm/dL and her hematocrit count is 30%. She reports fatigue and states, "I'm tired all the time." The client also reports excessive menstrual flow. The nurse assesses further and determines the client's diet is balanced and provides adequate calories. The client is prescribed supplemental iron therapy. The highest nursing diagnosis is Fatigue related to diminished oxygen-carrying capacity of the blood Altered nutrition: less than body requirements, related to inadequate intake of nutrients Altered tissue perfusion related to diminished oxygen-carrying capacity of the blood Deficient knowledge related to new information with no previous experience
Altered tissue perfusion related to diminished oxygen-carrying capacity of the blood
A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring? Oxygen saturation 94% Respiratory rate of 20 breaths/minute Heart rate of 72 beats/minute Blood pressure 80/46 mm Hg
Blood pressure 80/46 mm Hg
The nursing instructor is teaching their clinical group how to assess a client for congestive heart failure. How would the instructor teach the students to assess a client with congestive heart failure for nocturnal dyspnea? By questioning how many pillows the client normally uses for sleep By collecting the client's urine output By observing the client's diet during the day By measuring the client's abdominal girth
By questioning how many pillows the client normally uses for sleep
The nurse instructs a client with coronary artery disease in the proper use of nitroglycerin. The client has had 2 previous episodes of coronary artery disease. At the onset of chest pain, what should the client do? Take one tablet and then immediately call 911. Go to the emergency department if two nitroglycerin tablets taken 5 minutes apart are not effective. Call 911 when five nitroglycerin tablets taken every 5 minutes are not effective. Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective.
Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective.
Place the pathophysiological processes in order for how sickle cell disease leads to fatigue.
Decreased hemoglobin in RBCInflamed vascular endotheliumIncreased inflammatory cytokinesDecreased muscle strength
A client with suspected biliary obstruction due to gallstones reports changes to the color of his stools. Which stool color does the nurse recognize as common to biliary obstruction? Gray Black Red Green
Gray
A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload? Prone with legs elevated on pillows Head of the bed elevated 45 degrees and lower arms supported by pillows Head of the bed elevated 30 degrees and legs elevated on pillows Supine with arms elevated on pillows above the level of the heart
Head of the bed elevated 45 degrees and lower arms supported by pillows
Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? Hot roast beef sandwich with gravy White rice Vanilla pudding Mashed potatoes
Hot roast beef sandwich with gravy
Which of the following describes a red blood cell (RBC) that has pale or lighter cellular contents? Normocytic Hyperchromic Microcytic Hypochromic
Hypochromic
While assessing a client, the nurse will recognize what as the most obvious sign of anemia? Flow murmurs Tachycardia Jaundice Pallor
Pallor
The client with cardiac failure is taught to report which symptom to the health care provider or clinic immediately? Increased appetite Persistent cough Ability to sleep through the night Weight loss
Persistent cough
EXAM 2 A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema? The client says he is short of breath when ambulating. The client says he has been hungry in the evening. The client says that he has been urinating less frequently at night. The client says his rings have become tight and are difficult to remove.
The client says his rings have become tight and are difficult to remove.
A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client? The development of left-sided heart failure The development of chronic obstructive pulmonary disease (COPD) The development of cor pulmonale The development of right-sided heart failure
The development of left-sided heart failure
A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)? decrease in renal perfusion vasodilation of skin increased blood volume ejected from ventricle dehydration
decrease in renal perfusion
A client is scheduled to undergo surgical creation of an ileal conduit. The primary nurse educates the client about surgery and the postoperative period. The nurse states that many members of the health care team (including a mental health practitioner) will see the client. A mental health practitioner should be involved in the client's care to: assess whether the client is a good candidate for surgery. help the client cope with the anxiety associated with changes in body image. evaluate the client's need for mental health intervention. assess suicidal risk postoperatively.
help the client cope with the anxiety associated with changes in body image.
The home health nurse attends to a terminally ill client whose older adult spouse is the primary caregiver. The spouse states, "I am so ashamed to admit that sometimes I wish it would all just end. I am so tired." How should the nurse respond? "I hear you saying you are wishing it to end. Would you like to explore hospice settings?" "It is absolutely normal and understandable that you wish your spouse's suffering could be over." "This is a difficult time for you and your reaction is understandable. You should not be ashamed." "It sounds like you are overwhelmed. How can we better support you through this process?"
"It sounds like you are overwhelmed. How can we better support you through this process?" SUBMIT ANSWER
When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods? Fruits high in vitamin C, such as oranges and grapefruits Dairy products Berries and orange vegetables Beans, dried fruits, and leafy, green vegetables
Beans, dried fruits, and leafy, green vegetables
The nurse should advise a client with iron deficiency anemia to take which action in order to prevent staining of the teeth? Avoid taking iron simultaneously with an antacid. Use a straw or place a spoon at the back of the mouth to take the liquid supplement. Take iron with or immediately after meals. Do not combine iron with other prescribed or over-the-counter medications.
Use a straw or place a spoon at the back of the mouth to take the liquid supplement.
The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided and left-sided heart failure? warm extremities ascites weight loss resting bradycardia
ascites
A client comes to the emergency department reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). Which should the nurse do first when the client is admitted to the coronary care unit? Auscultate heart sounds. Obtain a health history. Begin telemetry monitoring. Evaluate the client's pain.
Begin telemetry monitoring.
A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. Blood loss Inadequate formed white blood cells Infection Destruction of normally formed red blood cells Abnormal erythrocyte production
Destruction of normally formed red blood cells Abnormal erythrocyte production Blood loss
The nurse and the client are discussing some strategies for ingesting iron to combat the client's iron-deficiency anemia. Which is among the nurse's strategies? Take iron with an antacid to avoid stomach upset. Taking iron pills with milk aids in absorption. Drink liquid iron preparations with a straw. Avoid vitamin C as it prevents absorption.
Drink liquid iron preparations with a straw.
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure? Dyspnea on exertion Decreased urinary output Hypotension Tachycardia
Dyspnea on exertion
The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption? Eating leafy green vegetables with a glass of water Eating apple slices with carrots Eating a steak with mushrooms Eating calf's liver with a glass of orange juice
Eating calf's liver with a glass of orange juice
Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Blood urea nitrogen (BUN) Echocardiogram Electrocardiogram (ECG) Serum electrolytes
Echocardiogram
Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat? Cheese and bananas Shrimp and tomatoes Lobster and squash Lamb and peaches
Lamb and peaches
A client with cancer is being evaluated for possible metastasis. What is one of the most common metastasis sites for cancer cells? Colon Reproductive tract Liver White blood cells (WBCs)
Liver
A client with a history of asthma is brought to the emergency department in respiratory distress. Which is the priority action by the nurse? Position in high Fowler's position, initiate oxygen, and administer bronchodilators as ordered. Place in supine position, initiate oxygen, and administer bronchodilators as ordered. Encourage ambulation and administer bronchodilators and steroids as ordered. Position in high Fowler's position and administer bronchodilators as ordered.
Position in high Fowler's position, initiate oxygen, and administer bronchodilators as ordered.
The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding? The woman is demonstrating the early signs of cardiogenic shock. The woman has left-sided heart failure. The woman is also likely to experience shortness of breath. The woman may be experiencing an exacerbation of right-sided HF.
The woman may be experiencing an exacerbation of right-sided HF.
A nurse on a hematology/oncology floor is caring for a client with aplastic anemia. Which would not be included in the client's discharge instructions? Encourage frequent handwashing. Avoid contact with family/friends who are sick. Plan for frequent periods of rest. Use a disposable razor when shaving.
Use a disposable razor when shaving.
A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? posting a "no smoking" sign over the client's bed collaborating with respiratory therapy to determine the flow rate assessing the client's respiratory status, orientation, and skin color measuring the client for the appropriate sized mask
assessing the client's respiratory status, orientation, and skin color
A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid: angel food cake. ready-to-eat cereals. dried peas. canned peas.
canned peas.
A nurse is preparing a teaching plan for a male client newly prescribed atenolol. Which information is important for the nurse to teach this client? prevention of constipation management of incontinence causes and treatments for erectile dysfunction control of excessive flatus
causes and treatments for erectile dysfunction
A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals coarse crackles in the lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing bilateral pneumonia. tuberculosis. decompensated heart failure with pulmonary edema. acute exacerbation of chronic obstructive pulmonary disease.
decompensated heart failure with pulmonary edema.
The nurse is discussing postoperative care with the parents and their 5-year-old child who is going to have a tonsillectomy and adenoidectomy. The nurse should emphasize which measures? need for frequent coughing use of aspirin for pain, as needed use of sips of clear liquids when awake and alert ability to have ice cream right after surgery
use of sips of clear liquids when awake and alert
A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity? dry mouth and urine retention. visual disturbances. taste and smell alterations. nocturia and sleep disturbances.
visual disturbances.
Which feature is the hallmark of systolic heart failure? Pulmonary congestion Limited activities of daily living (ADLs) Basilar crackles Low ejection fraction (EF)
Low ejection fraction (EF)
During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding? Enlarged mean corpuscular volume (MCV) Low ferritin level concentration Elevated hematocrit concentration Elevated red blood cell (RBC) count
Low ferritin level concentration
A nurse is teaching clients newly diagnosed with coronary heart disease (CHD) about the disease process and risk factors for heart failure. Which problem can cause left-sided heart failure (HF)? Cystic fibrosis Ineffective right ventricular contraction Pulmonary embolus Myocardial ischemia
Myocardial ischemia
A client is receiving furosemide as part of the treatment for heart failure. Which assessment finding indicates that the medication is attaining a therapeutic effect? crackles auscultated halfway up lungs, previously in bases PaO2 80 mm Hg trace peripheral edema, previously +2 blood pressure 140/80 mm Hg
trace peripheral edema, previously +2
A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor? Decreased total iron-binding capacity Increased mean corpuscular volume Decreased level of erythropoietin Increased reticulocyte count
Decreased level of erythropoietin
The nurse is providing preoperative instructions to a client who is deaf. Which strategy is most effective in assuring that the client understands the information? Provide instructions to the spouse, and have the spouse explain them to the client. Stand in front of the client, and slowly explain the instructions. Give the client written material to read, and follow up with time for questions. Show the client a DVD with instructions.
Give the client written material to read, and follow up with time for questions.
The nurse is caring for an infant with a congenital heart defect. What priority health teaching should the nurse offer to the parents of this infant? Keep feedings small, but frequent. There are no restrictions on play. Your child will need oxygen at home. It is dangerous to let your child cry.
Keep feedings small, but frequent.
The nurse is assessing a patient who is a strict vegetarian. What type of anemia is the nurse aware that this patient is at risk for? Sickle cell anemia Megaloblastic anemia Iron deficiency anemia Aplastic anemia
Megaloblastic anemia
A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination? Select all that apply. Monitor the client for signs of lethargy or confusion. Examine the client's neck for distended veins. Examine the client's eyes for excess tears. Examine the client's joints for crepitus.
Monitor the client for signs of lethargy or confusion. Examine the client's neck for distended veins.
An older adult client who is a vegetarian has a hemoglobin of 10.2 gm/dL, vitamin B12 of 68 pg/mL (normal: 200-900 pg/mL), and MCV of 110 cubic micrometers. After interpreting the data, what instruction should the nurse give to the client? Continue with the diet but include more sources of iron. Ingest a diet higher in vitamin B12 sources. Supplement the diet with vitamin B12. Change the vegetarian diet and begin to eat red meat.
Supplement the diet with vitamin B12.
When evaluating a patient's symptoms that are consistent with a diagnosis of leukemia, the nurse is aware that all leukemias have which common feature? Increased blood viscosity, resulting from an overproduction of white cells Unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements Reduced plasma volume in response to a reduced production of cellular elements Compensatory polycythemia stimulated by thrombocytopenia
Unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements
A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? Platelet count Potassium White blood cell (WBC) count Calcium
Potassium
A client undergoing chemotherapy has a critically low platelet count. To stimulate platelet cell production, the nurse expects to administer: oprelvekin, which is a thrombopoietin interferons, which support the proliferation of stem cells. filgrastim, which is a granulocyte colony-stimulating factor. Epoetin alfa, which is an erythropoietin
oprelvekin, which is a thrombopoietin
The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure? pitting edema decreased O2 saturation levels S4 ventricular gallop sign oliguria
pitting edema
A nurse is teaching a client stress management. Which techniques would be considered adaptive coping skills? Select all that apply. practice relaxation techniques try to eliminate total anxiety set realistic goals for each day maintain control of my life balance sleep, rest, and exercise
practice relaxation techniques set realistic goals for each day balance sleep, rest, and exercise
Prior to surgery, the client is to take nothing by mouth after 0400. Which statement indicates the client did not follow the preoperative directions? The client: smoked a cigarette at 0600. held a cold washcloth against the lips. ate a gelatin dessert at 0330. brushed the teeth at 0400 but did not swallow.
smoked a cigarette at 0600.
What position should the nurse use for the client with venous insufficiency to enhance blood supply? prone with head turned to one side Fowler with lower extremities in neutral position dorsal recumbent with legs separated supine with lower extremities elevated
supine with lower extremities elevated SUBMIT ANSWER
The nurse is assessing a client with chronic heart failure who is demonstrating neurohormonal compensatory mechanisms. Which are expected findings on assessment? Select all that apply. fluid overload decreased pulmonary perfusion increased heart rate decreased cardiac output vasoconstriction in skin, GI tract, and kidneys
decreased cardiac output increased heart rate vasoconstriction in skin, GI tract, and kidneys fluid overload
A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge? "I will be careful not to cross my legs." "I will need an elevated toilet seat." "I can't wait to take a tub bath when I get home." "I will implement the exercise program as soon as I get home."
"I can't wait to take a tub bath when I get home."
The nurse is caring for a client admitted for a quadruple coronary artery bypass graft. Which statements by the client indicate that preoperative teaching has not been effective? Select all that apply. "I will be on a heart monitor and a respirator to help me breathe." "I understand that I need to change my eating habits and activity levels to keep my heart healthy." "I had stopped smoking a month before the surgery; however, I will be able to start again once I have recovered." "I will be relieved to have this surgery over with; I have a very busy schedule at work right now." "I know that I will have to perform deep breathing and coughing exercises to prevent complications."
"I had stopped smoking a month before the surgery; however, I will be able to start again once I have recovered." "I will be relieved to have this surgery over with; I have a very busy schedule at work right now."
The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)? Nocturia Ascites Dizziness Tachycardia
Dizziness
You are caring for a 13-year-old diagnosed with sickle cell anemia. The client asks you what they can do to help prevent sickle cell crisis. What would be an appropriate answer to this client? Avoid any activity that makes you short of breath. Drink at least 8 glasses of water every day. Avoid any sports that tire you out. Stay on oxygen therapy 24/7.
Drink at least 8 glasses of water every day.
Because an adolescent has revealed a history of childhood cancer, the nurse should include in the plan of care an assessment for which late-therapy sequelae? Select all that apply. Diabetes Asthma Impaired growth Hormonal dysfunction Neurologic dysfunction
Impaired growth Hormonal dysfunction Neurologic dysfunction
The nurse has performed a thorough nursing assessment of the care of a client with chronic leg ulcers. The nurse's assessment should include which of the following components? Select all that apply Location and type of pain Apical heart rate Bilateral comparison of peripheral pulses Comparison of temp in the clients legs Identification of mobility limitations
Location and type of pain YES Bilateral comparison of peripheral pulses YES Comparison of temp in the clients legs YES Identification of mobility limitations YES
A 68-year-old black man who has smoked for at least 50 years reports that lately he feels as though food is getting stuck in his throat. At first this was a problem just with dry food, but now his morning oatmeal is getting "stuck." On questioning, he reports drinking at least 3 alcoholic beverages nearly every day. Which is most likely his problem? Squamous cell carcinoma of the esophagus Gastrointestinal reflux disease Achalasia Dysphagia secondary to scleroderma
Squamous cell carcinoma of the esophagus
A client is 2 hours postoperative after an appendectomy. The nurse recognizes a priority is to teach the client potential pulmonary postoperative complications. What action by the client demonstrates understanding of the teaching? incisional splinting to assist with pain management continued bed rest for 24-48 hours postoperatively to protect the incision site diaphragmatic breathing and use of incentive spirometry 4-8 times an hour while awake passive range of motion exercises with the physiotherapist
diaphragmatic breathing and use of incentive spirometry 4-8 times an hour while awake
A client was brought to the hospital in an agitated state and admitted to a psychiatric unit for observation and treatment. On admission, the client was found to be talking rapidly and folding and unfolding garments several times while putting personal belongings away. The client is unable to settle down. Which assessment of the client would have highest priority at this time? feelings of anxiety barriers to effective communication experiences of powerlessness ability to care for self
feelings of anxiety
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? "My pants don't fit around my waist." "I don't have the same appetite I used to." "I sleep on three pillows each night." "My feet are bigger than normal."
"I sleep on three pillows each night."
Upon hearing a blood pressure reading of 146/96 mm Hg, a 58-year-old client asks whether medication will be necessary. Which would be the best response by the nurse? "You will need to have your blood pressure reassessed before a diagnosis can be made." "It's fortunate that you came into the clinic today and this was caught this during your routine examination." "We will need to reevaluate the blood pressure because your age places you at a high risk for hypertension." "You have no need to worry. Your blood pressure is probably elevated becaus
"You will need to have your blood pressure reassessed before a diagnosis can be made."
After a lobectomy for lung cancer, the nurse instructs the client to perform deep breathing exercises. What is the expected outcome of these exercises? Elevate the diaphragm to enlarge the thorax so that the lung surface area available for gas exchange is increased. Control the rate of air flow to the remaining lobe to decrease the risk of hyperinflation. Expand the alveoli and increase lung surface available for ventilation. Decrease blood flow to the lungs for rest and increased surface alveoli ventilation.
Expand the alveoli and increase lung surface available for ventilation.
Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply. lung sounds clear bilaterally with non-labored respirations noted disoriented; oxygen saturation levels at 85%; coughing large amount thick, white sputum; dyspnea on exertion anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min respirations at 26 breaths/min, circumoral cyanosis present, orthopneic edema of the extremities, labored respirations, color normal
anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min lung sounds clear bilaterally with non-labored respirations noted
A client is treated for anemia. What is the nurse's best understanding about the correlation between anemia and the client's iron stores? There is an inverse relationship between iron stores and hemoglobin levels. There is a weak correlation between iron stores and hemoglobin levels. There is a strong correlation between iron stores and hemoglobin characteristics. There is a strong correlation between iron stores and hemoglobin levels.
There is a strong correlation between iron stores and hemoglobin levels.
When the nurse is preparing a teaching plan for an adult client about general anesthesia induction, which explanation by the nurse would be most appropriate? "Your premedication will put you to sleep." "You will receive intravenous medication to make you sleepy." "You will breathe in an inhalant anesthetic mixed with oxygen through a facial mask and receive intravenous medication to make you sleepy." "You will breathe in medication through a facial mask to make you sleepy."
"You will breathe in an inhalant anesthetic mixed with oxygen through a facial mask and receive intravenous medication to make you sleepy."
A patient with End Stage Kidney Disease is taking recombinant erythropoietin for the treatment of anemia. What laboratory study does the nurse understand will have to be assessed at least monthly related to this medication? Hemoglobin level Folate levels Creatinine level Potassium level
Hemoglobin level
