Med surg b
A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction? Decreased lipase Decreased erythrocyte sedimentation rate (ESR) Elevated creatinine Elevated troponin
Elevated troponin
A nurse is caring for a client who has dementia due to Alzheimer's disease. Which of the following actions should the nurse take to reduce the client's confusion? Restrict visitors to three at a time. Avoid touching the client during care. Encourage reminiscence of past experiences. Give the client multiple options for daily events.
Encourage reminiscence of past experiences. Rationale: The nurse should encourage reminiscence of past experiences to reduce the client's confusion.
A nurse is collecting data from a client who has 30% body surface area deep partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate? Granulation tissue is present. Urine output is 50 mL/hr. Lung sounds are clear. Oxygen saturation level is 95%.
Urine output is 50 mL/hr. Rationale: The nurse should closely monitor the client's urinary output as an indicator of effective fluid resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid resuscitation is adequate. NOTE: Granulation tissue: monitor the client's wounds because infection is a complication of burns. The presence of granulation tissue is an indicator used to monitor the effectiveness of wound therapy.
A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan? Measure rectal temperature every 4 hr. Remind the client to cough as needed. Use a turn sheet to reposition the client. Apply wrist restraints.
Use a turn sheet to reposition the client. Rationale: Change client's position slowly to prevent sudden (+) in ICP. Turn sheet gives the nurse better control of the client's movement and alignment.
A nurse is preparing a client for a cardiac catheterization. Which of the following actions should the nurse take rst? Verify the client has given informed consent. Administer preoperative medication. Mark the location of the pedal pulses. Have the client void.
Verify the client has given informed consent. Rationale: The greatest risk to the client in this situation is performing an unauthorized invasive procedure. Therefore, the first action the nurse should take is to verify that the client has given informed consent. If documentation of informed consent is not on the client's medical record, the nurse should withhold medications, which can alter the client's consciousness, until consent is obtained.
A nurse is reinforcing teaching with a client who has coronary artery disease. Which of the following instructions should the nurse include in the teaching? "Maintain a fat intake of 40 percent of your total daily calories." "Limit consumption of whole milk products to 8 ounces three times per week." "Exercise for 20 minutes twice per week." "Add oily fish to your diet twice weekly."
"Add oily fish to your diet twice weekly."
A nurse is reinforcing instructions with a client who has a new hearing aid. Which of the following instructions should the nurse include? "Change the batteries if you hear a whistling sound." "Adjust the volume to a level where you can hear others speak at a distance of 3 feet." "Keep the hearing aid in place while showering." "Clean the hearing aid with a bristle brush to remove excess cerumen."
"Adjust the volume to a level where you can hear others speak at a distance of 3 feet." Rationale: 3 feet is a comfortable level for hearing others speak.
A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for calcitonin. Which of the following statements should the nurse make to describe the effect of calcitonin in treating osteoporosis? "Calcitonin will slow the breakdown of bone in your body." "Calcitonin will increase the level of cortisol in your blood." "Calcitonin will decrease the amount of calcium you are losing in your urine." "Calcitonin will increase the blood ow to your skeletal muscles."
"Calcitonin will slow the breakdown of bone in your body."
A nurse is reinforcing teaching about hospice care with a client who has terminal cancer. Which of the following statements should the nurse make? "Hospice care will provide support for you and your loved ones during the dying process." "As part of hospice services, you will need to decide if you want resuscitative measures or not." "Hospice care must be provided in the hospital." "As part of hospice services, nursing care will be available Monday through Friday."
"Hospice care will provide support for you and your loved ones during the dying process." Rationale: The nurse should inform the client that hospice care supports clients and their loved ones with the goal of helping provide a peaceful and dignified death.
A nurse in a health clinic is reinforcing teaching with a client about tuberculosis (TB). Which of the following client statements indicates an understanding of the teaching? "I can develop TB by breathing in the infection." "After exposure, I could develop TB within 5 days." "A positive reaction to a TB test means I'm currently infected." "I need to wear a mask in my house if I become infected."
"I can develop TB by breathing in the infection." Rationale: TB is spread by airborne transmission. Therefore, the nurse should identify this statement as an understanding of the teaching.
A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? "I drink bottled water." "I eat at a salad bar for lunch." "I like to eat steak cooked medium." "I put plenty of pepper on my soft-boiled eggs."
"I drink bottled water." Rationale: To avoid exposure to bacteria, clients who have cancer and are receiving chemotherapy should be sure that drinking water is safe. Drinking fresh, bottled water limits exposure to bacteria.
A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine? "I am allergic to shrimp." "I am allergic to latex balloons." "I had a tuberculosis skin test 2 days ago." "I had a low fever this morning."
"I had a low fever this morning." Rationale: Clients who have a febrile illness should not receive the influenza vaccine.
A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response to the medication? "I have been sleeping less since I started the medication." "I have gained 3 pounds since my last appointment." "My bowel movements have become more frequent." "I urinate more often than before."
"I have gained 3 pounds since my last appointment." Rationale: Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight gain as an indication that the methimazole therapy has been effective.
A nurse is reinforcing teaching with a client prior to the removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching? "I will scrub the skin to remove the old skin flakes." "I can expect my leg to be swollen after the cast is removed." "I can go back to my usual activities as soon as the cast is off." "I will feel vibrations on my leg from the cast cutter."
"I will feel vibrations on my leg from the cast cutter."
A nurse is reinforcing teaching with a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching? "I will eat a banana every day." "I will walk for 20 minutes 3 days per week." "I will limit my coffee intake." "I will take vitamin E at bedtime."
"I will limit my coffee intake." Rationale: limit their intake of caffeinated products, such as coffee and soda. Coffee can cause excretion of calcium through diuretic effects.
A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching? "I will add a banana to my morning cereal." "I will decrease my intake of carbohydrates." "I will limit my daily intake of protein." "I will season my foods with a salt substitute.
"I will limit my daily intake of protein." Rationale: (-) their intake of protein to slow the progression of kidney failure. Therefore, the nurse should identify this statement as an understanding of the teaching.
A nurse is reinforcing discharge teaching with a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching? "I will notify my dentist about this procedure." "I will take an enteric-coated aspirin daily." "I will use a firm-bristled toothbrush." "I will weigh myself once a week."
"I will notify my dentist about this procedure."
A nurse is reinforcing discharge teaching with a client who has Crohn's disease. Which of the following statements should the nurse include in the teaching? "Increase your intake of dietary fat." "Maintain a low-residue diet." "Avoid taking antidiarrheal medications." "Plan to weigh yourself weekly."
"Maintain a low-residue diet." Rationale: Maintain a low-fiber, low-residue diet, which helps control pain and inflammation in the small intestine and reduces episodes of diarrhea.
A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as an expected change associated with aging? "I sweat more than I used to." "Sometimes, I can't remember my kids' names." "I seem to have more loose stools than I used to." "My food tastes bland even after I add seasoning."
"My food tastes bland even after I add seasoning." Rationale: There is a (-) in the # of taste buds on the tongue due to tongue atrophy.
A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching? "Perform testicular self-examination after taking a warm shower." "Examine both testicles at the same time." "Use the palm of your hand to palpate for abnormalities." "Perform testicular self-examination every 6 months."
"Perform testicular self-examination after taking a warm shower."
A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify that which of the following client statements indicates an understanding of the teaching? "I should perform pursed-lip breathing exercises before going to bed." "When I'm fatigued, I should inhale slowly through pursed lips." "Pursed-lip breathing works best for activities like walking up stairs." "I will exhale through my nose after breathing in through pursed lips."
"Pursed-lip breathing works best for activities like walking up stairs." Rationale: The nurse should acknowledge that performing pursed-lip breathing during times of activity, such as walking up stairs, helps increase airway pressure and reduce the amount of trapped air in the lungs. This breathing technique helps eliminate excess carbon dioxide that clients who have COPD might retain. (Pursed (pucker) lip breathing is one of the simplest ways to control shortness of breath)
A nurse is reinforcing teaching with a client who has osteoporosis. Which of the following instructions should the nurse include in the teaching? "Place throw rugs on wooden floors at home." "Supplement your diet with vitamin E." "Swim laps for 20 minutes twice per week." "Take calcium supplements with meals."
"Take calcium supplements with meals."
A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching? "I will need to take the medication until my thyroid function returns to normal." "The medication should be taken before I eat breakfast every morning." "The medication might lower my blood sugar." "I will take the medication with an antacid if it gives me heartburn."
"The medication should be taken before I eat breakfast every morning." Rationale: preferably 1 hr before breakfast. NOTE: levothyroxine must be taken for the rest of their life & will not affect glucose levels. Client to not take levothyroxine within 4 hr of taking antacids, iron, or calcium supplements because they will decrease the medication's absorption.
A nurse is caring for a client who has prostate cancer. The client asks the nurse why they are having difficulty with urination. Which of the following responses should the nurse make? "The kidneys' ability to filter urine is decreased." "The tumor causes obstruction of urine from the urethra." "The cancer results in hormonal changes, which aect urination." "The protein-specific antigen in your blood is decreased."
"The tumor causes obstruction of urine from the urethra." Rationale: As a prostate tumor grows, it compresses the urethra, resulting in obstructed urine flow.
A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include? "Use barrier methods for sexual contact when lesions are present." "Look for lesions that have a wart-like appearance." "The virus can be transmitted without lesions being present." "The lesions resolve in 2 weeks and usually do not recur."
"The virus can be transmitted without lesions being present." Rationale: Inform the client that viral shedding and spreading of the infection can occur when lesions are not present.
A home health nurse is caring for a client who has COPD. The client reports shortness of breath while eating, despite the use of home oxygen. Which of the following recommendations should the nurse make? "Limit the intake of protein in your diet." "Use a bronchodilator 30 minutes before your meal." "Drink beverages throughout your meal." "Lie down for 1 hour after finishing a meal."
"Use a bronchodilator 30 minutes before your meal." Rationale: bronchodilator 30 min before meals to prevent shortness of breath while eating.
A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching? "You should thaw frozen meat at room temperature." "You should use paprika as a seasoning for your food." "You should place your toothbrush in hydrogen peroxide." "You should use a glycerin-based soap while bathing."
"You should place your toothbrush in hydrogen peroxide." Rationale: Hydrogen peroxide or bleach solution rids the toothbrush of bacteria and prevents infection.
A nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM) machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching? (Select all that apply.) "Your knee is flexed and extended as prescribed by your provider." "The machine is padded with sheep skin." "You might have the head of the bed elevated to 45 degrees while using this machine." "To use the machine, you must pedal as if you are riding a bike." "We will store the CPM machine on the oor under the bed when not in use."
"Your knee is flexed and extended as prescribed by your provider." Rationale: The provider will give specific instructions concerning the CPM machine's flexion and extension motion each day. "The machine is padded with sheep skin." Rationale: Padding the CPM machine with sheep skin prevents injury to pressure points on the extremity. NOTE: incorrect. The client should exert force on the CPM machine but allow the machine to perform passive range-of-motion exercises. incorrect. The nurse should avoid placing the CPM machine on the floor to protect it from contamination.
A nurse is preparing to assist with the insertion of a double-lumen gastric sump tube for a client who has peptic ulcer disease and has developed gastrointestinal bleeding. Which of the following images depicts the tube that the nurse should select?
(first picture, clear tube ending with blue tube) When using a double-lumen gastric sump tube, the clear portion of the tube allows for aspiration of stomach contents. The blue portion of the tube, or the "pigtail", vents the tube to the atmosphere, which prevents the tube from becoming lodged against the wall of the stomach and protects the stomach from damage.
A nurse is reinforcing dietary teaching with a client about increasing the intake of foods containing vitamin C to enhance absorption of oral iron supplements. Which of the following food choices should the nurse include in the teaching? 1 cup of cooked brown rice 1 cup of boiled broccoli 1 cup of cottage cheese 1 cup of scrambled eggs
1 cup of boiled broccoli Rationale: 1c of broccoli contains 115 mg of vitamin C per serving
A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should recommend which of the following foods as the best source of fiber? 1/2 cup cooked kidney beans 1/2 cup raw cauliflower 1 cup cucumber with peel 1 cup parboiled brown rice
1/2 cup cooked kidney beans
A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
864
A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify that the client's injury occurred in which of the following lobes of the brain? (You will nd hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A Frontal Lobe is correct. Rationale: Injury to the frontal lobe can result in alterations to motor function or voluntary movement. This involves the ability to speak and the ability to move purposefully.
A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A client who had a colectomy 2 days ago and has a nasogastric tube attached to low suction A client who is dehydrated, has mental confusion, and has tried to get out of bed several times during the night A client who had a right lower lobectomy 4 days ago and has 50 mL/hr of serous drainage from a chest tube A client who has pneumonia, has an elevated oral temperature, and is requesting medication for a cough
A client who is dehydrated, has mental confusion, and has tried to get out of bed several times during the night
A nurse is reviewing the medication administration record of a client who has osteoarthritis. Which of the following analgesic prescriptions should the nurse expect to administer when the client reports pain? Methotrexate Acetaminophen Gabapentin Etanercept
Acetaminophen Rationale: Acetaminophen is a nonopioid analgesics that is a good choice for a client who has osteoarthritis because its adverse effects are less toxic than many other analgesics.
A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. Which of the following actions should the nurse take? Prepare for intubation of the client. Administer opioid medication. Administer oxygen via nasal cannula. Place the client in low-Fowler's position.
Administer oxygen via nasal cannula.
A nurse is delegating the task of repositioning a client who is in skeletal traction to an assistive personnel (AP). Which of the following instructions should the nurse give the AP? Allow the weights to hang freely. Release the tension of the ropes. Remove the weights when rewrapping bandages. Manually lift the weights when moving the client up in bed
Allow the weights to hang freely. Rationale: The nurse should instruct the AP to allow the weights to hang freely and to refrain from bumping the weights. Skeletal traction maintains alignment of fractured bones through the use of counterweights. If these weights rest on the floor or another object, they do not maintain the counterbalance necessary to maintain the alignment of the fracture, which can result in client injury or pain.
A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan? Massage both lower extremities to promote comfort. Begin the client on a regular diet when the gag reflex returns. Encourage the client to use the incentive spirometer every 4 hr while awake. Assist the client to change positions at least every 2 hr.
Assist the client to change positions at least every 2 hr. Rationale: To promote return of respiratory function following anesthesia and prevent atelectasis (partial or complete collapse of the lung) and pneumonia.
A nurse is monitoring a client who has a cast and reports intense itching underneath the cast. Which of the following actions should the nurse take? Blow cool air into the cast using a blow dryer on a cool setting. Obtain a prescription for pregabalin. Ask the provider to bivalve the cast. Provide the client with a tongue blade to rub the skin under the cast
Blow cool air into the cast using a blow dryer on a cool setting. Rationale: Using a blow dryer on a cool setting to blow cold air into the cast is an effective way to relieve the client's itching without damaging the skin.
A nurse is caring for a client who has an intestinal obstruction and reports a new onset of nausea. The client has an NG tube set at low intermittent suction and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take first? Check for kinks in the NG tube. Increase the IV uid rate. Provide ice chips. Administer an antiemetic
Check for kinks in the NG tube.
A nurse is caring for a client who is 2 hr postoperative following the amputation of a foot. Which of the following actions should the nurse take first? Obtain the client's temperature. Observe for phantom pain. Measure urinary output. Check the incisional dressing
Check the incisional dressing Rationale: The greatest risk to the client is hemorrhage following an amputation of the lower extremity. Therefore, the first action the nurse should take is to check the client's incisional dressing for excessive bleeding. NOTE: The nurse should obtain the client's temperature to monitor for hyperthermia, which can indicate an infection, or hypothermia following anesthesia administration. However, there is another action the nurse should take first.
A nurse is caring for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG? Position the client in Sims' position before electrode placement. Ensure that each electrode is dry before application. Cleanse the client's skin prior to electrode placement. Place the electrodes on the client's abdomen and back.
Cleanse the client's skin prior to electrode placement. Rationale: The nurse should cleanse the client's skin prior to electrode placement to improve electrode conduction.
A nurse is changing the dressing for a client who has an abdominal incision and a closed-suction drain. Which of the following actions should the nurse take? Secure the drainage tube to the client's bedding. Wear sterile gloves to empty the drainage system. Cut an absorbent gauze dressing to t around the drainage tube. Cleanse the drainage plug with alcohol swabs.
Cleanse the drainage plug with alcohol swabs. Rationale: to remove excess drainage and discourage pathogens from entering the drainage system. NOTE: (a) The nurse should secure the drainage tube to the client's gown to allow for ambulation. Pinning the gown to the client's bedding can result in dislodgement of the drain. (b) wear clean gloves not sterile. (c) use a precut or folded gauze dressing to fit around the drainage tube. If the nurse cuts the gauze dressing, small threads and fibers can embed in the incision and increase inflammation and infection.
A nurse is caring for a client who is postoperative following an above-the-knee amputation of the right leg and reports pain in the absent portion of the limb. The client received an opioid analgesic 1 hr prior. Which of the following actions should the nurse take? Recommend a referral for a mental health provider to begin lithium therapy. Remind the client that the portion of the limb where they feel pain is gone. Ask the provider to increase the frequency of the client's opioid medication. Collaborate with the physical therapist to initiate alternative pain therapies
Collaborate with the physical therapist to initiate alternative pain therapies
A nurse is caring for a client who is postoperative and has a portable wound bulb suction device. Which of the following actions should the nurse take? Fill the bulb reservoir with 0.9% sodium chloride. Prepare for the drain to be removed after 24 hr. Cut a slit in a gauze sponge and apply it around the tubing insertion site. Compress the bulb reservoir and then close the drainage valve
Compress the bulb reservoir and then close the drainage valve
A nurse is providing information regarding transmission-based precautions for a client who has Clostridium dicile to an assistive personnel (AP). Which of the following instructions should the nurse include? (Select all that apply.) "Provide the client with disposable utensils and dishes for meals." "Leave blood pressure equipment in the client's room." "Clean contaminated surfaces with a bleach solution." "Use an alcohol-based hand sanitizer after client care." "Wear a face mask when in the client's room."
Contact Precautions (remember) "Provide the client with disposable utensils and dishes for meals." Rationale: using disposables during meals to prevent exposure to contaminants by others. "Leave blood pressure equipment in the client's room." Rationale: Staff should dedicate equipment to single-client use to prevent transmission of pathogen. "Clean contaminated surfaces with a bleach solution." Rationale: Use bleach solution to clean equipment to prevent transmission of the pathogen.
A nurse is caring for a client who has been taking enalapril. The nurse should monitor the client for which of the following adverse effects? Bradycardia Tremors Cough Hyperglycemia
Cough Rationale: Enalapril is an ACE inhibitor, which can cause a dry, nonproductive cough. Therefore, the nurse should monitor the client for this adverse effect.
A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective? Adventitious lung sounds Decrease in exertional dyspnea Respiratory rate of 26/min while sitting in a chair Elevation of the head of the bed is required to sleep
Decrease in exertional dyspnea Rationale: A (-) in exertional dyspnea indicates the antibiotics are resolving the infection and the albuterol treatments are facilitating effective ventilation. Therefore, the nurse should evaluate the therapeutic regimen as effective for the client.
A nurse is caring for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure? Changes in the client's sputum Decreased blood pressure Changes in neurological status Increased urinary output
Decreased blood pressure Rationale: This finding indicates hypovolemia as a result of excess fluid withdrawal. Depending on the amount of fluid withdrawn, hypovolemia can lead to shock.
A nurse in a dermatology clinic is reviewing the medical records of a group of clients. Which of the following prescriptions for a client who has psoriasis should the nurse clarify with the provider? Topical corticosteroids Coal tar ointment Moderate UV radiation Dermabrasion
Dermabrasion Rationale: Dermabrasion is a treatment for acne that could trigger further irritation in a client who has psoriasis. Therefore, the nurse should clarify this prescription with the provider. NOTE: (a) topical steroid cream is a treatment for psoriasis. Therefore, the nurse does not need to clarify this prescription with the provider. (b) coal tar preparations is a treatment for psoriasis. Therefore, the nurse does not need to clarify this prescription with the provider. (c) UV radiation is a treatment for psoriasis. Therefore, the nurse does not need to clarify this prescription with the provider.
A nurse is caring for four clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease? Rheumatoid arthritis Diabetes mellitus Myasthenia gravis Crohn's disease
Diabetes mellitus Rationale: Clients who have diabetes mellitus are at (+) risk for developing cardiovascular and peripheral vascular disease because of the changes in the microvasculature resulting from elevated levels of glucose.
A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following findings should the nurse report to the provider? Absent gag reflex Blood-tinged mucus Diminished breath sounds Oxygen saturation 95%
Diminished breath sounds Rationale: Diminished breath sounds might indicate a pneumothorax or laryngeal edema. The nurse should report this finding to the provider for further evaluation of the client. NOTE: (a) The nurse should expect a temporarily absent gag reflex following a bronchoscopy because the nasal and oral pharynx receive a local anesthetic immediately prior to the procedure. (b) The nurse should expect possible blood-tinged mucus from bleeding secondary to tissue trauma during the procedure. (c) This oxygen saturation is within the expected reference range. The nurse should continue to monitor for hypoxia following bronchoscopy.
A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome? Reduced cough Diminished headache Relaxed muscles Decreased peripheral edema
Diminished headache
A nurse is caring for a client who has age-related macular degeneration. Which of the following findings should the nurse expect? Seeing halos around artificial lights Distorted central vision of the eyes Colored spots before the visual fields Spontaneous tearing of the eyes
Distorted central vision of the eyes Rationale: Macular degeneration results in a distortion and blurring of central vision. The client might completely lose central vision and view a dark spot in the center. NOTE: (a)Seeing halos around lights is a finding of narrow-angle glaucoma, not macular degeneration. (b)Colored spots before the visual fields are a finding of retinal detachment, not macular degeneration. (c) Spontaneous tearing of the eyes is a finding of uveitis, not macular degeneration.
A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate? Elevated serum amylase level Hypertension Bradycardia Decreased leukocyte count
Elevated serum amylase level Rationale: elevation in the client's serum amylase level due to injury of the pancreatic cells. NOTE: (a) acute pancreatitis to have hypotension as a result of third spacing and fluids shifts. (b) client who has acute pancreatitis to have tachycardia as a result of the inflammatory response and pain associated with the illness. (c) client who has acute pancreatitis to have an elevated white blood cell count due to the inflammation and necrosis of the pancreas.
A nurse is caring for a client who has restricted movement of the chest due to a burn injury. The nurse should anticipate preparing the client for which of the following procedures? Fasciotomy Escharotomy Skin grafting Hyperbaric oxygen therapy
Escharotomy Rationale: The nurse should anticipate a prescription for an escharotomy to relieve constriction of the client's chest due to a burn injury. Following removal of the eschar, chest wall movement will be possible, and the client's oxygenation should improve. NOTE: Skin grafting is used to promote wound healing for clients who have large wounds, like burn injuries.
A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the following information should the nurse recommend including in the pamphlet? The number of sexual partners does not affect the risk for STIs. Oral contraceptive use decreases the risk for STIs. Males seek treatment for STIs later than females. Females have a higher risk for contracting STIs than males.
Females have a higher risk for contracting STIs than males.
A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication? Frequent colds Vitamin deficiency Increased urination Orthostatic hypotensio
Frequent colds Rationale: corticosteroids can (+) susceptibility to infection by suppressing the immune response. The nurse should instruct the client about infection prevention measures to implement while taking a corticosteroid.
A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity? Potassium chloride Famotidine Levothyroxine Furosemide
Furosemide Rationale: The nurse should identify that loop diuretics, such as furosemide, increase the urinary excretion of potassium, which can lead to hypokalemia. Hypokalemia increases the risk for the development of digoxin toxicity. NOTE: (a) The nurse should recognize that hypokalemia can result in digoxin toxicity. Therefore, taking potassium chloride might decrease the risk for toxicity. (b) Famotidine The nurse should recognize that famotidine does not affect digoxin levels. (c) The nurse should recognize that levothyroxine can decrease the absorption of digoxin and lower the digoxin level. Therefore, it does not increase the risk for digoxin toxicity.
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching? The expected therapeutic reference range for HbA1c for a client who has diabetes mellitus is 9.5% to 10%. An HbA1c level below the expected reference range indicates ineffective glucose control HbA1c results measure glucose control for the prior 3 months. HbA1c testing is used to provide a diagnosis of diabetes mellitus
HbA1c results measure glucose control for the prior 3 months. Rationale: HbA1c testing reflects ave overall glucose control over a 3 month period. It's for long-term glucose control.
A nurse is collecting data from a client who is being treated for hypovolemia due to nausea and vomiting. Which of the following findings should the nurse report to the provider? Hemoglobin 15 g/dL Blood pressure 110/55 mm Hg Heart rate 120/min Potassium 3.6 mEq/L
Heart rate 120/min Rationale: heart rate of 120/min is above the expected reference range and indicates that the client's hypovolemia has not resolved. Therefore, the nurse should report this finding to the provider to obtain additional prescriptions for fluid replacement. NOTE: (a) hemoglobin level is within the expected reference range. (men, 13.5-17.5 g/dL; women 12.0-15.5) (d) potassium level is within the expected reference range. (3.6-5.2 mEq/L)
A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching? Weekly sputum cultures will be needed. Household family members should be tested for TB. TB is no longer contagious after 2 to 3 days of medication therapy. Family members should wear N95 masks when in contact with the client
Household family members should be tested for TB.
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. Which of the following provider prescriptions should the nurse expect? Clamp the urethral catheter for 30 min. Place the urethral catheter drainage bag at the client's heart level. Slow the bladder irrigation ow rate. Irrigate the urethral catheter with 0.9% sodium chloride.
Irrigate the urethral catheter with 0.9% sodium chloride. Rationale: The nurse should expect a prescription to irrigate the urethral catheter because this will clear the tubing of any blood clots or tissue pieces and allow for a better flow. NOTE: (a) Applying a clamp to the urethral catheter will prevent drainage from the bladder and increase the risk for bladder trauma. (b) Placing the urethral catheter drainage bag at the client's heart level will slow bladder output and increase the risk for infection. (c) Slowing the bladder irrigation flow rate will increase the risk for clotting in the tubing and disrupt the irrigation output.
A nurse is reviewing the plan of care for a client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care? Check neurovascular status on the extremity every 8 hr. Have the client perform incentive spirometry every 4 hr. Keep an abduction pillow between the client's legs. Maintain the client on bed rest until the third postoperative day
Keep an abduction pillow between the client's legs. Rationale: keep an abduction pillow or a splint between the client's legs to prevent hip dislocation after surgery. NOTE: Nurse should check neurovascular status every 2-4 hrs, incentive spirometry every 2 hrs, and should encourge and assist the client to ambulate soon after surgery.
A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. Which of the following interventions should the nurse include in the plan of care? Keep bed linens o of the affected areas. Position a heat lamp over the lower extremities. Apply warm, moist compresses to the affected areas. Initiate droplet isolation precautions.
Keep bed linens o of the affected areas. Rationale: Nurse should keep bed linens off of the affected areas by using a bed cradle, which will relieve pain caused by the linens rubbing against the lesions.
A nurse is caring for a client who has neutropenia. Which of the following nursing interventions should the nurse implement? Offer the client fresh fruits and vegetables. Monitor the client's platelet count daily. Limit visitors to healthy adults. Apply firm pressure to injection sites.
Limit visitors to healthy adults. Rationale: to minimize the client's risk for exposure to infection.
A nurse is caring for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Lower the client to the floor. Loosen the clothing around the client's neck. Place a pad beneath the client's head. Time the length of the client's seizure. Reorient and reassure the client.
Lower the client to the floor. Place a pad beneath the client's head. Loosen the clothing around the client's neck. Time the length of the client's seizure. Reorient and reassure the client.
A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? Avoid weight-bearing until healing of the hip incision is complete. Cross legs intermittently several times a day. Lean forward to change positions when sitting in a chair. Maintain hip exion at 90° or less when sitting.
Maintain hip exion at 90° or less when sitting.
A nurse is caring for a client who is undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect? Muscle spasticity Tremors at rest Ptosis Ascending paralysis
Muscle spasticity Rationale: Muscle spasticity is a manifestation of multiple sclerosis. NOTE: Tremors at rest is a manifestation of Parkinson's disease. Ptosis is a manifestation of myasthenia gravis. Ascending paralysis is a manifestation of Guillain-Barré syndrome.
A nurse is caring for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury? Anorexia Hoarseness Muscle twitching Blurred vision
Muscle twitching Rationale: A common complication of a thyroidectomy is parathyroid gland injury, leading to hypocalcemia. Clients experiencing hypocalcemia can have twitching, numbness, and tingling of fingers, toes, and around the mouth. NOTE: hoarseness following a thyroidectomy, which can result from intubation during surgery. Persistent hoarseness can also indicate damage to the vocal cords. However, hoarseness is not an indication of parathyroid gland injury.
A nurse is reviewing the medical record for a client who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take? Encourage the client to ambulate. Administer an antipyretic medication. Notify the charge nurse of the client's BUN level. Keep the temperature in the client's room warm
Notify the charge nurse of the client's BUN level. Rationale: BUN level is above the expected reference range of 10 to 20 mg/dL, which can indicate impaired renal function. The nurse should anticipate interventions to restore the client's fluid volume. NOTE: (b) no indication that an antipyretic medication is needed because the client's temperature is within the expected reference range. The nurse should administer an antiemetic medication as needed to the client to control the nausea and vomiting.
A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first? Place the client in Fowler's position. Obtain the client's blood pressure. Dangle the client's legs at the bedside. Apply nonskid slippers
Obtain the client's blood pressure. Rationale: The greatest risk to the client is postural hypotension due to decreased blood volume following surgery. Therefore, the first action the nurse should take is to obtain the client's baseline blood pressure to determine whether it is safe to have the client get out of bed.
A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? Encourage stimulating activities after dinner. Encourage a late afternoon nap. Offer a small snack at bedtime. Offer hot chocolate at bedtime
Offer a small snack at bedtime. Rationale: Nurse should offer the client a small snack of carbohydrates or a glass of milk as part of the bedtime routine, which can help the client relax and prepare for sleep.
A nurse is assisting with an educational program for clients who have been newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin? Store unopened insulin vials in the freezer for up to 1 month. Opened insulin can be stored on a cool countertop away from light. Roll discolored insulin gently to mix it before use. Use refrigerated insulin immediately after removing it from the refrigerator.
Opened insulin can be stored on a cool countertop away from light
A nurse is caring for a client who is 24 hr postoperative following an abdominal surgery. Which of the following findings requires immediate attention from the nurse? Reported pain level of 6 on a scale of 0 to 10 Urinary output of 110 mL in the past 4 hr Temperature of 38º C (100.4º F) Oxygen saturation of 88%
Oxygen saturation of 88% Rationale: airway, breathing, circulation approach to client care, the nurse should determine that the finding that requires immediate attention is an oxygen saturation of 88%. This finding is below the expected reference range of 95% to 100% and requires intervention to restore oxygenation to the client's tissues. NOTE: (a) YES pain However, there is another finding that requires more immediate attention. (b) YES you should monitor the client's urinary output to detect hypovolemia or kidney impairment. However, there is another finding that requires more immediate attention. (c) Yes monitor the client's temperature for indications of infection or hypothermia. However, there is another finding that requires more immediate attention.
A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include? Place a "no visitors" sign on the client's door. Have the client wear an N95 respiratory mask during transport. Initiate droplet precautions for the client. Place the client in a negative-pressure airflow room.
Place the client in a negative-pressure airflow room. Rationale: The nurse should place the client in a negative-pressure airflow room to filter the air and prevent the transmission of micro-organisms. NOTE: (a) Can have visitors. However, visitors should follow transmission precautions. (b) The nurse should place a surgical mask on the client when transporting them outside of the room to prevent the transmission of micro-organisms. (c) The nurse should implement droplet precautions for a client who has rubella or pertussis.
A nurse is caring for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome? Place the client in the supine position after meals. Administer pancreatic enzymes before meals. Encourage the client to drink 240 mL (8 oz) of uids with meals. Offer the client three meals daily
Place the client in the supine position after meals. Rationale: The nurse should encourage the client to lie in the supine position for a short time following meals to decrease rapid gastric emptying.
A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking their medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis? Metoprolol Methimazole Furosemide Prednisone
Prednisone Rationale: Prednisone is administered to replace glucocorticoids, which are deficient in adrenocortical insufficiency. Abrupt withdrawal of the medication can lead to adrenal crisis.
A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client? Rephrase client instructions when not understood. Cup hands around the mouth and direct speech toward the client. Accentuate vowel sounds by using a higher pitch when speaking. Sit to the side of the client and speak instructions into their best ear.
Rephrase client instructions when not understood.
A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased pain at the site of the fracture. Which of the following actions should the nurse take? Massage the area. Remove the weights. Loosen the ropes. Reposition the client
Reposition the client Rationale: When the client's body is out of alignment with the traction, muscle spasms develop, causing increased pain. Therefore, the nurse should reposition the client, ensuring there is a straight line from the client's hip to the traction rope and pulley, evaluate the client's response, and provide other interventions as needed.
A nurse is repositioning a client who has low back pain. Which of the following positions is should the nurse place the client in? Semi-Fowler's with knees flexed Orthopneic Dorsal recumbent Prone with legs straight
Semi-Fowler's with knees flexed Rationale: Sitting in semi-Fowler's position with the head of bed elevated 15° to 45° and flexing the knees will help relax the lumbar area of the client's back and relieve pressure on the nerves. NOTE: (a) orthopneic position sit forward and lean on an overbed table, which does not relax the lumbar area or relieve pressure on the nerves. Therefore, this is not an appropriate position for a client who has low back pain. (b) dorsal recumbent position lie flat in bed with pillows for support, which does not relax the lumbar area or relieve pressure on the nerves. Therefore, this is not an appropriate position for a client who has low back pain. (c) prone position lie flat on the abdomen, which does not relax the lumbar area or relieve pressure on the nerves. Therefore, this is not an appropriate position for a client who has low back pain.
A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort? Sleep on a firm mattress. Try jogging in place when joints feel stiff. Use a soft chair or recliner for sitting. Apply ice packs to painful joints
Sleep on a firm mattress. Rationale: A firm mattress or a bed board helps the client maintain joint alignment while sleeping.
A nurse is contributing to the plan of care for a client who had a stroke. For which of the following interprofessional team members should the nurse recommend a referral prior to initiating oral intake for the client? Occupational therapist Speech-language pathologist Physical therapist Case manager
Speech-language pathologist
A nurse in a telemetry unit is collecting data from a client who has a newly-inserted permanent pacemaker. Which of the following findings should the nurse report to the provider? The client experiences hiccups when sitting. The client's pulse rate is 5/min faster than the preset pacemaker rate. There is the presence of a pacing spike before the P-wave on the ECG rhythm strip. The dressing over the insertion site is dry and intact.
The client experiences hiccups when sitting. Rationale: The nurse should monitor clients who have a newly-inserted permanent pacemaker for hiccups because this finding can indicate that the pacemaker wires are displaced or that the pacemaker is not firing properly. Therefore, the nurse should report this finding to the provider. NOTE: (a) pulse rate of a client who has a newly-inserted permanent pacemaker should not fall below 5/min slower than the preset rate because this could indicate that the pacemaker is not functioning properly. A pulse rate of 5/min faster than the preset pacemaker rate does not need to be (b) presence of a pacing spike before the P-wave on the ECG rhythm strip is an indication that the pacemaker is firing correctly and that the atria is contracting as intended.
A nurse is caring for a client who has Cushing's syndrome and expresses concern regarding physical changes associated with the syndrome. Which of the following should the nurse recognize as a physical change caused by this disorder? Bronze skin Truncal obesity Lordosis Exophthalmos
Truncal obesity Rationale: Truncal obesity is a manifestation of Cushing's syndrome that occurs due to a redistribution of fat. The client also usually has fatty tissue edema between the scapula, also known as "buffalo hump". The nurse should use therapeutic communication techniques to investigate the client's body image concerns. NOTE: (b) lordosis is an increase in the curvature of the lumbar spine, which is common for clients who have poor posture. Muscle wasting and thinning of the extremities are expected findings of Cushing's syndrome. (c)Grave's disease to experience exophthalmos. Facial edema, also known as "moon face", and flushing of the cheeks are expected findings of Cushing's syndrome
A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease pain? Semi-Fowler's Supine with lower extremities elevated Upright, leaning forward Side-lying with knees bent
Upright, leaning forward Rationale: upright position, leaning forward, to facilitate breathing and decrease pain. NOTE: (a) semi-Fowler's position to facilitate breathing as part of management of peritonitis. (b) client who is in shock in the supine position with lower extremities elevated, or modified Trendelenburg position, to increase the venous return to the heart. (c) side-lying position with knees bent to assist in decreasing the pain related to a unilateral or sensory motor deficit on one side of the body.
A nurse is reviewing the medical record of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery? Serous drainage from the incision WBC count of 15,000/mm3 Temperature of 37.2° C (99° F) Urine output of 400 mL over the past 8 hr
WBC count of 15,000/mm3 Rationale: This WBC count is above the expected reference range and indicates the presence of infection. (normal 5,000 -10,000/mm3 for 2-adults)
A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse should document the sound as which of the following? (Click on the audio button to listen to the clip.) Pleural friction rub Wheezes Vesicular Crackles
Wheezes Rationale: The nurse should identify the breath sound auscultated as wheezes. These are high-pitched, musical sounds that occur as air passes through narrowed airways, such as when a client is experiencing an asthma attack.
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include? Withdraw both types of insulin and then add 0.2 mL of air to the syringe Gently shake the NPH insulin prior to withdrawing the dose. Withdraw the regular insulin before withdrawing the NPH insulin. Inject air into the NPH vial after withdrawing regular insulin.
Withdraw the regular insulin before withdrawing the NPH insulin. Rationale: The nurse should instruct the client to withdraw the regular insulin before withdrawing the NPH insulin. This will protect the regular insulin from contamination with the NPH insulin.
A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take? Give the dose as prescribed. Use a different route to administer the medication. Administer half of the prescribed dose. Withhold the dose.
Withhold the dose.
