Med-Surg Exam 1

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition would the nurse include in this client's teaching? (Select all that apply.)

"Avoid drinking fluids just before and during meals." "Rest before meals if you have dyspnea." "have about six small meals a day"

An older client asks the nurse why "people my age" have weaker immune systems than younger people. What responses by the nurse are best? (Select all that apply.)

"Bone marrow produces fewer blood cells as you age." "You have lower levels of plasma proteins in the blood."

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best?

"Breathing so quickly can be dehydrating."

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching?

"Call your primary health care provider for diarrhea."

A nurse is caring for a client who had a myocardial infarction. The nurse is confused because the client states that nothing is wrong and yet listens attentively while the nurse provides education on lifestyle changes and healthy menu choices. What response by the charge nurse is best?

"Continue to educate the client on possible healthy changes."

A nurse is assessing a client with peripheral artery disease (PAD). The client states that walking five blocks is possible without pain. What question asked next by the nurse will give the best information?

"Could you walk further than that a few months ago?"

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first?

"Do you experience shortness of breath with basic activities?"

An emergency department nurse obtains the health history of a client. Which statement by the client would alert the nurse to the occurrence of heart failure?

"I get short of breath when I climb stairs."

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements would the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.)

"I held the client's morning bronchodilator medication." "I advised the client not to smoke for 6 hours prior to the test." "The client is alert and can follow your commands."

After providing discharge teaching, a nurse assesses the client's understanding regarding increased risk for metabolic alkalosis. Which statement indicates that the client needs additional teaching?

"I take sodium bicarbonate after every meal to prevent heartburn."

A client has thrombocytopenia. What statement indicates that the client understands self-management of this condition?

"I usually put ice on bumps or bruises."

A clinic nurse is reviewing care measures with a client who has asthma, Step 3. What statement by the client indicates the need to review the information?

"I will always use the spacer with my dry powder inhaler."

After teaching a client who was malnourished and is being discharged, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood teaching to decrease risk for the development of metabolic acidosis?

"I will eat three well-balanced meals and a snack daily."

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.)

"I will keep my feet dry, especially between the toes." "Lotion is important to keep my feet smooth and soft." "Washing my feet in room-temperature water is best."

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates that the client comprehends the teaching?

"I will take this medication every morning to help prevent an acute attack."

A nurse has educated a client on isoniazid. What statement by the client indicates that teaching has been effective?

"I will take this medication on an empty stomach."

After teaching a client who is prescribed salmeterol, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?

"I will use the drug when I have an asthma attack."

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching?

"I will weigh myself each morning before I eat or drink."

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that going out with friends is no longer enjoyable. How would the nurse respond?

"I'd like to hear about thoughts and feelings causing you to limit social activities."

The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement by the client indicates understanding about those changes?

"I'll increase animal proteins like fish and meat."

A nurse is planning care for a client who is lethargic and confused. The client's arterial blood gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L (19 mmol/L). Which questions would the nurse ask the client and spouse when developing the plan of care? (Select all that apply.)

"Is your spouse's current behavior typical?" "Do you drink any alcoholic beverages?" "Have you been participating in strenuous activity?"

The primary health care provider requests the nurse start an infusion of milrinone on a client. How does the nurse explain the action of this drug to the client and spouse?

"It increases the force of the heart's contractions."

A client asks what "essential hypertension" is. What response by the registered nurse is best?

"It is hypertension with no specific cause."

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement would the nurse include in this patient's teaching?

"Make sure you clean the humidifier to prevent infection."

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?

"Most people with hypertension do not have symptoms."

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care?

"My hands shake when I try to do things requiring coordination."

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client would alert the nurse to the presence of edema?

"My shoes fit tighter by the end of the day."

A nurse teaches a client who has epistaxis and recently had his nasal packing removed. Which statements indicate that the client correctly understood the teaching? (Select all that apply.)

"Nasal saline sprays will help to prevent rebleeding." "I will wait at least 1 month before resuming weight lifting." "I will apply a small amount of petroleum jelly to my nares."

A client is taking warfarin and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best?

"No, it may interfere with the warfarin."

A nurse is teaching a female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best?

"No, women should only have one beer a day as a general rule."

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The primary health care provider orders a chest x-ray. The family member questions why this is needed since the symptoms seem so vague. What response by the nurse is best?

"Older people often have vague symptoms, so an x-ray is essential."

A nurse prepares a client for coronary artery bypass graft surgery. The client states, "I am afraid I might die." What is the nurse's best response?

"Tell me more about your concerns about the surgery."

A nurse prepares a client for cardiac catheterization. The client states, "I am afraid I might die." What is the nurse's best response?

"Tell me more about your concerns about the test."

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best?

"The best source is fish, but pills have benefits too."

A client asks about the process of graft-versus-host disease. What explanation by the nurse is correct?

"The donor's cells are actually attacking the patient's cells."

A client received tissue plasminogen activator (tPA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best?

"The heparin keeps that artery from getting blocked again."

The nurse is caring for a client who has cystic fibrosis (CF). The client asks for information about gene therapy. What response by the nurse is best?

"There is a good treatment for the most common genetic defect in CF."

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond?

"This is normal after surgery. What types of food do you like to eat?"

An assistive personnel is caring for a client with leukemia and asks why the client is still at risk for infection when the white blood cell count (WBC) is high. What response by the nurse is correct?

"Those WBCs are abnormal and don't provide protection."

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful?

"Try warm, moist heat packs on your face."

A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble breathing while I'm sleeping at night." What is the nurse's best response?

"Use pillows to elevate your head and chest while you are sleeping."

A nurse is teaching a client how to perform pursed-lip breathing. Which instructions would the nurse include in this teaching? (Select all that apply.)

"Use your abdominal muscles to squeeze air out of your lungs." "Breath out slowly without puffing your cheeks." "Exhale at least twice the amount of time it took to breathe in."

A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." What is the nurse's best response?

"What do you understand about what happened to you?"

While obtaining a client's health history, the client states, "I am allergic to avocados, molds, and grass." Which responses by the nurse are best? (Select all that apply.)

"What happens when you are exposed to those things? "How do you treat these allergies?" "I will document this in your record so all so everyone knows." "Have you ever been in the hospital after an allergic response?"

A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important?

"What is your occupation?"

A nurse is planning care for a client who is hyperventilating. The client's arterial blood gas values are pH 7.52, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L (26 mmol/L). Which question would the nurse ask when developing this client's plan of care?

"You appear anxious. What is causing your distress?"

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition would the nurse include in this client's teaching?

"You should balance weight loss with consuming necessary nutrients."

A nurse teaches a client who is being discharged after a jaw wiring for a mandibular fracture. Which statements would the nurse include in this patient's teaching? (Select all that apply.)

"You will need to cut the wires if you start vomiting." "Eat six soft or liquid meals each day while recovering." "Use a Waterpik for dental hygiene until you can brush again. "Sleep in a semi-Fowler position after the surgery."

A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, "What does this mean?" How would the nurse respond?

"Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke."

rior to discharge, a client who had an acute myocardial infarction and coronary artery bypass graft asks the nurse about sexual activity. What information does the nurse provide? (Select all that apply.)

"Your usual sexual activity is not likely to damage your heart." "Start having sex when you are most rested, like in the morning." "Use a comfortable position that doesn't stress your incision."

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best?

0.45% normal saline

A client presents to the emergency department with an acute myocardial infarction (MI) at 15:00 (3:00 p.m.). The facility has 24-hour catheterization laboratory abilities. To improve client outcomes, by what time would the client have a percutaneous coronary intervention performed?

16:30 (4:30 p.m.)

A nurse caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?

21%

A nurse assesses several clients who have a history of respiratory disorders. Which client would the nurse assess first?

A 27-year-old client with a heart rate of 120 beats/min

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia?

A 34 year old who is NPO and receiving rapid intravenous D5W infusions.

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client would the nurse assess first?

A 52 year old in a tripod position using accessory muscles to breathe

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?

A 55-year-old woman who is 50 lb (23 kg) overweight.

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for airway loss related to aspirated oral and nasopharyngeal secretions? (Select all that apply.) A 24 year old with a traumatic brain injury

A 58 year old getting radiation therapy A 66 year old who is a quadriplegic An 80-year-old who is aphasic A 24 year old with a traumatic brain injury

A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as having the greatest risk for cardiovascular disease?

A 65-year-old woman with diabetes mellitus.

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration?

A 76 year old who is cognitively impaired.

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.)

Absorptive atelectasis Combustion Dried mucous membranes Toxicity

A nurse studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.)

Accompanied by shortness of breath Feelings of fear or anxiety No relief from taking nitroglycerin Pain occurs without known cause

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions by the nurse are best? (Select all that apply.)

Administer oxygen and place client on an oximeter. Administer prescribed albuterol inhaler. Assess the client's lung sounds after administering the inhaler.

A nurse admits a client from the emergency department. Client data are listed below: History Physical Assessment Laboratory Values What action by the nurse is the priority?

Administer oxygen at 4 L per nasal cannula.

A client presents to the emergency department in sickle cell disease crisis. What intervention by the nurse takes priority?

Administer oxygen.

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take?

Administer pain medication and encourage the client to take deep breaths.

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition?

Administers bisphosphonates as prescribed.

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience would the nurse provide this service?

African-American churches

A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first?

Airway patency

A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need to be reported to the primary health care provider immediately?

Alanine aminotransferase (ALT): 180 U/L

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as the priority prior to this procedure?

Allergies to iodine-based agents

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?

Allow continued bathroom privileges.

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action would the nurse perform first for comfort?

Allow family members to remain at the bedside.

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which client condition does the nurse correlate with these results?

Anxiety-induced hyperventilation

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss?

Anxious client who has tachypnea.

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the assistive personnel (AP)?

Apply a warm moist pack.

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the assistive personnel (AP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)

Apply compression stockings. Assist with ambulation. Offer fluids frequently.

A nurse cares for a client with arthritis who reports frequent asthma attacks. What action would the nurse take first?

Ask about medications the client is currently taking.

A nurse is working with a client who takes clopidogrel. The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?

Ask if the client eats grapefruit.

A nurse is caring for a client with a nonhealing arterial ulcer. The primary health care provider has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.)

Ask the client to describe his or her current emotions. Assess the client for support systems and family. Offer to stay with the client if he or she desires

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this client's plan of care? (Select all that apply.)

Ask the client to drink 2 L of fluids daily. Add humidity to the prescribed oxygen. Use a vibrating chest physiotherapy device. Administer the ordered mucolytic agent.

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? (Select all that apply.)

Assess for allergies to iodine. Administer intravenous fluids. Assess blood urea nitrogen (BUN) and creatinine results.

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate?

Assess for any hemodynamic effects of the rhythm.

A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which intervention does the nurse implement first?

Assess the airway.

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes that the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?

Assess the client for bleeding.

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care? (Select all that apply.)

Assess the client for bleeding. Monitor the daily activated partial thromboplastin time (aPTT) results. Use an IV pump for the infusion.

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin. The client is adamant about refusing the drug because "it's dangerous." What action by the nurse is best?

Assess the reason behind the client's fear.

A nurse is preparing to administer a packed red blood cell transfusion to an older adult. Understanding age-related changes, what alteration(s) in the usual protocol is (are) necessary for the nurse to implement? (Select all that apply.)

Assess vital signs at least every 15 minutes. Avoid giving other IV fluids. Assess the client for fluid overload.

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best?

Assist in finding one change the client can control.

A client is 1-day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.)

Assist the client into a position of comfort in bed. Provide complementary therapies such as music. Remind the client to splint the incision when coughing.

A nurse cares for a client who is scheduled for a total laryngectomy. What action would the nurse take prior to surgery?

Assist the client to choose a communication method.

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention would the nurse include in this client's plan of care?

Assistance with activities of daily living

A client has been diagnosed with an empyema. What interventions would the nurse anticipate providing to this client? (Select all that apply.)

Assisting with chest tube insertion Facilitating pleural fluid sampling Performing frequent respiratory assessment Providing antipyretics as needed

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates that the client is managing this condition well with diet?

Baked chicken breast, broccoli, tomatoes

A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition?

Bence-Jones protein in urine

A nurse is caring for an older adult receiving multiple packed red blood cell transfusions. Which assessment finding(s) indicate(s) possible transfusion circulatory overload? (Select all that apply.)

Bounding pulse Hypertension Acute confusion Dyspnea

A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which clinical situation does the nurse correlate with these values?

Bronchial obstruction related to aspiration of a hot dog

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.)

Calculate pulse pressure with each blood pressure reading. Assess for pitting edema in dependent body areas. Monitor trends in the client's daily weights. Assist the client to change positions frequently. Teach client and family how to read food labels for sodium.

A client has a platelet count of 9000/mm3 (9 109/L). The nurse finds the client confused and mumbling. What nursing action takes priority at this time?

Call the Rapid Response Team.

A client is receiving an infusion of tissue plasminogen activator (tPA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best?

Call the primary health care provider immediately.

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.2, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L (19 GRADESLAB.COM mmol/L). Which assessment would the nurse perform first?

Cardiac rate and rhythm

What is the nurse's priority when caring for a client who just completed a bone marrow aspiration and biopsy?

Check the pressure dressing frequently for signs of excessive or active bleeding.

Which risk factor(s) places a client at risk for leukemia? (Select all that apply.)

Chemical exposure Ionizing radiation exposure Viral infections

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic action?

Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system.

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?

Client has reduced breath sounds—nurse calls primary health care provider immediately.

A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What assessment finding by the nurse indicates that an important outcome for this client has been met?

Client is able to decrease blood pressure medications.

A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met?

Client is able to swallow own secretions without drooling.

An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?

Client who describes intense squeezing pressure across the chest.

A nurse is caring for four clients. Which one would the nurse see first?

Client who had a first dose of captopril and needs to use the bathroom.

A nurse is caring for four clients with leukemia. After hand-off report, which client would the nurse assess first?

Client who had two bloody diarrhea stools this morning.

A nurse is caring for four client s. Which client would the nurse assess first?

Client who is 1 hour post-angioplasty, and has tongue swelling and anxiety

A nurse is in charge of the coronary intensive care unit. Which client would the nurse see first?

Client who is 1-day post coronary artery bypass graft, with blood pressure 88/64 mm Hg

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client would the nurse assess first?

Client who reports shortness of breath

A nurse is caring for four clients. After reviewing today's laboratory results, which client would the nurse assess first?

Client with a prothrombin time (PT) of 28 seconds

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.)

Client with well-controlled diabetes Healthy 72-year-old client A 22-year-old client with asthma Client who is taking medication for hypertension

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.)

Cognition Dexterity Range of motion Vision Upper arm range of motion

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next?

Collect the nasal drainage on a piece of filter paper.

A nurse assesses a client who is recovering from a myocardial infarction. The client's blood pressure is 140/88 mm Hg. What action would the nurse take first?

Compare the results with previous blood pressure readings.

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first?

Connect the client to a cardiac monitor.

A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best?

Consult with the PHCP about the medication.

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best?

Consult with the wound care nurse.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. What action would the nurse take first?

Contact the primary health care provider and prepare for intubation.

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the chest tube is dislodged. Which action by the nurse is best?

Cover the insertion site with sterile gauze.

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.)

Create a communication system. Try loose-fitting shirts with collars. Wear fashionable scarves.

A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory test results. Which finding would the nurse report to the primary health care provider?

Creatinine: 2.9 mg/dL (256 mcmol/L)

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital?

Dangle the client on the bedside before ambulating.

The nurse is assessing a client with chronic leukemia. Which laboratory test result(s) is (are) expected for this client? (Select all that apply.)

Decreased hematocrit Abnormal white blood cell count Low platelet count Decreased hemoglobin

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?

Decreased orthostatic changes when standing

The nurse is assessing a client experiencing anemia. Which laboratory findings will the nurse expect for this client? (Select all that apply.)

Decreased red blood cell count Decreased serum iron Decreased hemoglobin

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first?

Depth of respirations

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?

Determine if the client can switch to a nasal cannula during the meal.

While taking a client history, which factor(s) that place the client at risk for a hematologic health problem will the nurse document? (Select all that apply.)

Diet high in Vitamin K Excessive alcohol consumption Family history of bleeding problems

A client presents to the emergency department with a thoracic aortic aneurysm. Which findings are most consistent with this condition? (Select all that apply.)

Difficulty swallowing Hoarseness

A client has progressed to Killip class III heart failure after a myocardial infarction. What does the nurse anticipate the client's care to include?

Dobutamine

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first?

Document the findings.

The nurse is caring for a patient with leukemia who has severe fatigue. What action by the client best indicates that an important outcome to manage this problem has been met?

Doing activities of daily living (ADLs) using rest periods

Which statement(s) about blood transfusion compatibilities is (are) correct? (Select all that apply.)

Donor blood type O can donate to anyone. Donor blood type A can donate to recipient blood type AB.

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?

Double-check the client and blood product identification.

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority?

Educating the client on adherence to the treatment regimen

The nurse is reviewing risk factors in a client who has atherosclerosis. Which findings are most concerning? (Select all that apply.)

Elevated low-density lipopotein (LDL-C) Decreased levels of high-density lipoprotein cholesterol (HDL-C) History of smoking

A nurse assesses a client who is prescribed fluticasone and notes oral lesions. What action would the nurse take?

Encourage oral rinsing after fluticasone administration.

The nurse is assessing a client who has probable lymphoma. What is the most common early assessment finding for clients with this disorder?

Enlarged painless lymph node(s)

A nurse is preparing to administer a blood transfusion. What action is most important?

Ensure that informed consent is obtained.

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?

Ensure that informed consent is on the chart.

A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client?

Ensure that the balloon does not remain wedged.

A home health nurse evaluates a client who has chronic obstructive pulmonary disease. Which assessments would the nurse include in this client's evaluation? (Select all that apply.)

Examination of mucous membranes and nail beds Measurement of rate, depth, and rhythm of respirations Determine the client's need and use of oxygen Ability to perform activities of daily living

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.)

Expanding groin hematoma Rhythm changes on the cardiac monitor Serum potassium of 2.9 mEq/L (2.9 mmol/L)

A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme dry mouth. What action by the nurse is most appropriate?

Explain that xerostomia may be a permanent side effect.

A nurse working with clients diagnosed with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factor(s) should clients be taught to avoid? (Select all that apply.)

Extreme stress High altitudes Pregnancy Dehydration

A nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect?

Fatigue and shortness of breath

An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.)

Fatigue despite adequate rest Indigestion Shortness of breath

A client is being discharged on warfarin therapy. What discharge instruction is the nurse required to provide? (Select all that apply.)

Follow-up laboratory monitoring Possible drug-drug interactions Reason to take medication Dietary restrictions

The nurse is caring for four hypertensive clients. Which drug-laboratory value combination would the nurse report immediately to the health care provider?

Furosemide/potassium: 2.1 mEq/L

A client is to receive a dopamine infusion. What does the nurse do to prepare for this infusion?

Gather central line supplies.

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best for optimal client outcomes?

Give the client a nonenteric coated aspirin.

A nurse prepares a client for a pharmacologic stress echocardiogram. What actions would the nurse take when preparing this client for the procedure? (Select all that apply.)

Give the client nothing by mouth 3 to 6 hours before the procedure. Explain to the client that dobutamine will simulate exercise for this examination. Prepare for continuous blood pressure and pulse monitoring.

A client hospitalized with sickle cell disease crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe that the client is drug seeking. When the client requests pain medication, what action by the nurse is best?

Give the client pain medication if it is time for another dose.

A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect?

Heart rate of 120 beats/min

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.)

Hyperkalemia—salt substitutes Hyponatremia—heart failure Hypernatremia—hyperaldosteronism Hypocalcemia—diarrhea Hypokalemia—loop diuretics

A nurse learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.)

Hypertension Obesity Smoking Stress

A nurse is teaching a community group about the long-term effects of untreated sleep apnea. What information does the nurse include? (Select all that apply.)

Hypertension Stroke Weight gain Diabetes Cognitive deficits Pulmonary disease

A diabetic client becomes septic after a bowel resection and is having problems with respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50, PaCO2 30, HCO3 : 24, and PaO2 68. What does the nurse recognize as the primary factor causing this the acid-base imbalance?

Hyperventilation due to poor oxygenation

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)

Hypokalemia—muscle weakness with respiratory depression Hypermagnesemia—bradycardia and hypotension Hyponatremia—decreased level of consciousness Hypomagnesemia—hyperactive deep tendon reflexes Hypernatremia—weak peripheral pulses

The nurse assesses the client using the device pictured below to deliver 50% O2:

Immediately increase the flow rate.

A client is admitted with suspected pneumonia from the emergency department. The client went to the primary health care provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: The reddened area is firm. What action by the nurse is best?

Immediately place the client on Airborne Precautions.

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process would the nurse correlate with this client's history and clinical signs and symptoms?

Increased pulmonary pressure creating a higher workload on the right side of the heart

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.)

Increased pulse rate Distended neck veins Skeletal muscle weakness Visual disturbances

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client's compensatory mechanisms?

Increased rate and depth of respirations

A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best?

Inform the client that oral antibiotics will be needed for 60 days.

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD):Arterial Blood Gas Results Vital Signs What action would the nurse take first?

Initiate oxygenation therapy to increase saturation to 88% to 92%.

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery?

Initiation of an external pacemaker

The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best?

Inquire as to recent travel outside the United States.

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met?

Intact skin behind the ears

A client in the emergency department is taking rifampin for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.)

International normalized ratio (INR): 6.3 Prothrombin time: 35 seconds

A nurse is assessing a client's history of particular matter exposure. What questions are consistent with the I PREPARE tool? (Select all that apply.)

Investigate all history of known exposures. Determine if breathing problems are worse at work. Ask the client what type of heating is in the home. Gather details about the geographic location of the client's home. Have client list all previous jobs and work experiences. Assess what hobbies the client and family enjoy.

A nurse cares for a client who is prescribed an intravenous prostacyclin agent for pulmonary artery hypertension. What actions would the nurse take to ensure the client's safety while on this medication? (Select all that apply.)

Keep an intravenous line dedicated strictly to the infusion. Ensure that there is always a backup drug cassette available. Use strict aseptic technique when using the drug delivery system.

A nurse cares for a client who has a pleural chest tube. What action would the nurse take to ensure safe use of this equipment?

Keep padded clamps at the bedside for use if the drainage system is interrupted.

A nurse cares for a client who is infected with Burkholderia cepacia. What action would the nurse take first when admitting this client to a pulmonary care unit?

Keep the client separated from other clients with cystic fibrosis.

A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance would the nurse assess?

Kussmaul respirations

A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below would the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?

Location A

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client?

Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority?

Maintain airway patency.

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?

Measure and compare cuff pressures.

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit. What action by the nurse is best?

Measure for new compression stockings.

A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.)

Metabolic acidosis—older adult who is following a carbohydrate-free diet Respiratory alkalosis—client on mechanical ventilation at a rate of 28 breaths/min Metabolic alkalosis—older client prescribed antacids for gastroesophageal reflux disease

A nurse assesses a client who is prescribed furosemide for hypertension. For which acid-base imbalance does the nurse assess to prevent complications of this therapy?

Metabolic alkalosis

The nurse is assessing an older client for any potential hematologic health problem. Which assessment finding is the most significant and would be reported to the primary health care provider?

Multiple petechiae and large bruises

A nurse works in a gerontology clinic. What age-related change(s) related to the hematologic system will the nurse expect during health assessment? (Select all that apply.)

Nail beds may be thickened or discolored. Progressive loss or thinning of hair occurs.

A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.)

New-onset cough Tachypnea Pain with respirations

A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse is most important?

Notify the Rapid Response Team.

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. What action would the nurse take next?

Notify the Rapid Response Team.

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)

Notify the Rapid Response Team. Take vital signs every 10 minutes. Assess distal pulses every 10 minutes.

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take?

Notify the primary health care provider before scheduling the MRI.

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage stops suddenly. What action by the nurse is most important?

Notify the primary health care provider immediately.

A nurse assesses a client's respiratory status. Which information is most important for the nurse to obtain?

Occupation and hobbies.

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection would the nurse provide for this client?

Omelet, soft whole-wheat bread

The nurse is teaching a client with obstructive sleep apnea (OSA) about the prescribed CPAP. What information does the nurse include? (Select all that apply.)

Once the delivery mask is adjusted, do not loosen the straps. The CPAP provides pressure that holds your upper airways open. The humidification increases the risk of fungal infections. Be patient when first using the system, it can be frustrating at first.

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met?

Oxygen saturation of 98%

A hospitalized client has a platelet count of 58,000/mm3 (58 109/L). What action by the nurse is most appropriate?

Place the client on safety precautions.

A client has received a bone marrow transplant and is waiting for engraftment. What action(s) by the nurse are most appropriate? (Select all that apply.)

Placing the client in protective precautions Teaching visitors appropriate hand hygiene Telling visitors not to bring live flowers or plants

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?

Poor peripheral pulses and cool skin

A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an acid-base imbalance would the nurse assess? (Select all that apply.

Positive Chvostek sign Tetany

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.)

Potassium: 5.4 mEq/L (mmol/L): Dehydration Osmolarity: 250 mOsm/L: Overhydration Hematocrit: 68%: Dehydration Magnesium: 0.8 mg/dL: Dehydration

A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate?

Prepare to administer a fluid bolus.

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first?

Prepare to administer dextrose 20% and 10 units of regular insulin IV push.

A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk, what activity would the nurse delegate to the assistive personnel (AP)?

Provide oral care every 4 hours.

A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find?

Pulse decreased from 100 to 80 beats/min.

A nurse is preparing to administer a blood transfusion. Which action is most important?

Put on a pair of gloves.

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.)

Raising the side rails on the bed Recording baseline vital signs

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L (18 mmol/L). For which clinical signs and symptoms would the nurse assess? (Select all that apply.)

Reduced deep tendon reflexes Drowsiness Increased respiratory rate

A nurse is planning interventions that regulate acid-base balance to ensure that the pH of a client's blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid-base imbalance? (Select all that apply.)

Reduction in the function of hormones Fluid and electrolyte imbalances Excitable cardiac muscle membranes Changes in GI tract excitability

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.)

Reports of palpitations Skeletal muscle weakness Tall, peaked T waves on ECG

A nurse is studying hemodynamic monitoring. Which measurements are correctly matched with the physiologic cause? (Select all that apply.)

Right atrial pressure 12 mm Hg: right ventricular failure Pulmonary artery pressure 20/10 mm Hg: normal finding Pulmonary artery occlusion pressure 20 mm Hg: mitral regurgitation Pulmonary artery occlusion pressure 2 mm Hg: afterload reduction

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.)

Serum potassium level of 5.4 mEq/L (5.4 mmol/L) Blood osmolality of 250 mOsm/kg (250 mmol/kg)

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure?

Sets the IV pump to deliver 30 mEq of potassium an hour.

The nurse is caring for a client being treated for Hodgkin lymphoma. For which side effect(s) of treatment will the nurse assess? (Select all that apply.)

Severe nausea and vomiting Low platelet count Skin irritation at radiation site Low red blood cell count

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?

Slurred speech and confusion

A nurse is caring for a client who is experiencing excessive diarrhea. The client's arterial blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L (16 mmol/L). Which primary health care provider order does the nurse expect to receive?

Sodium bicarbonate

A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority?

Sperm banking

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate?

Stay with the client and have someone else call the primary health care provider immediately.

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)

Stridor Ecchymosis behind the ear

The emergency department nurse is participating in a bioterrorism drill in which several "clients" are suspected to have inhalation anthrax. Which "clients" would the nurse see as the priorities? (Select all that apply.)

Stridor Oxygen saturation of 91% Diaphoresis

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.)

Strong productive cough Active bowel sounds

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.)

Sudden onset of shortness of breath Drainage greater than 70 mL/hr Disconnection at Y site Tracheal deviation

The nurse assesses a client's oral cavity as seen in the photo below:

Teach the client about cobalamin therapy.

A client is having a radioisotopic imaging scan. What action by the nurse is most important?

Teach the client about the procedure.

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. What action would the nurse take?

Teach the client fall prevention measures.

A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes that the client also has a severe headache and muscle aches. What action by the nurse is best?

Teach the client to sneeze in the upper sleeve.

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best?

Tell the client that anxiety is common and that you can help.

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)

The client does not allow smoking in the house. Electrical cords are in good working order. Flammable liquids are stored in the garage.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the client's decrease in self-esteem are being met?

The client has joined a book club that meets at the library.

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands the teaching?

The client places his or her hands on the abdomen.

A client, who has become increasingly dyspneic over a year, has been diagnosed with pulmonary fibrosis. What information would the nurse plan to include in teaching this client? (Select all that apply.)

The need to avoid large crowds and people who are ill Safety measures to take if home oxygen is needed Information about appropriate use of the drug nintedanib Measures to avoid fatigue during the day

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?

The trachea is shifted toward the opposite side of the neck.

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure would the nurse assess? (Select all that apply.)

Thrombophlebitis Pulmonary embolism Cardiac tamponade

A nurse reviews a client's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.)

Total cholesterol: 280 mg/dL (7.3 mmol/L) Triglycerides: 200 mg/dL (2.3 mmol/L) Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L)

A nurse is providing tracheostomy care. What action by the nurse requires intervention by the charge nurse?

Tying a square knot at the back of the neck

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure?

Validate that informed consent has been given by the client.

A hospital nurse is participating in a drill during which many "clients" with inhalation anthrax are being admitted. What drugs would the nurse anticipate administering? (Select all that apply.)

Vancomycin Ciprofloxacin Doxycycline

A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.)

Verify that the informed consent was obtained. Document the client's allergies. Review laboratory results. Monitor the client for at least 24 hours afterwards.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate?

Visiting nurses for directly observed therapy

A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or symptoms would the nurse identify as adverse effects of this medication? (Select all that apply.)

Visual hallucinations Manic behavior

A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client?

Zoledronic acid

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the client in response to this finding?

"Do you have any chronic breathing problems?"

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best?

"Do you have any concerns about sexuality?"

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions would the nurse ask to determine the client's activity tolerance? (Select all that apply.)

"Do you have any difficulty sleeping?" "How long does it take to perform your morning routine?" "Have you lost any weight lately?" "How does your activity compare to this time last year?"

A nurse is teaching a client who has cystic fibrosis (CF). Which statement would the nurse include in this client's teaching?

"Eat a well-balanced, nutritious diet."

A nurse teaches a client who is interested in smoking cessation. Which statements would the nurse include in this client's teaching? (Select all that apply.)

"Find an activity that you enjoy and will keep your hands busy." "Drink at least eight glasses of water each day." "Make a list of reasons you want to stop smoking." "Set a quit date and stick to it."

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities?

"I can use a heating pad on my legs if it's set on low."

Which statement by a client with leukemia indicates a need for further teaching by the nurse?

"I will take a daily laxative to prevent constipation."

A nurse cares for a client who has a family history of cystic fibrosis. The client asks, "Will my children have cystic fibrosis?" How would the nurse respond?

"Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested."

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the nurse include in this client's teaching?

"Smoking while taking this medication will increase your risk of a stroke."

A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection?

Appropriate hand hygiene before giving care

A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best?

Ask the spouse to explain the fear of visiting in further detail.

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The client's arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L (22 mmol/L). What action would the nurse take first?

Apply oxygen by mask or nasal cannula.

A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to assistive personnel (AP)?

Apply water-soluble ointment to nares and lips.

What nonpharmacologic comfort measures would the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.)

Applying elastic compression stockings Elevating the legs when sitting or lying Reminding the client to do leg exercises

A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What action by the student demonstrates that more teaching is needed?

Applying suction while inserting the catheter

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to assistive personnel (AP)? (Select all that apply.)

Applying water-soluble lip balm to the client's lips Reminding the client to cough and deep breathe often

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best?

Assess client further for fall risk.

A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values were pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L (16 mmol/L). The most recent blood gasses show a drop in the pH. What action does the nurse take next?

Assess client's rate, rhythm, and depth of respiration.

A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse is most important?

Assess distal pulses and skin color.

The family of a neutropenic client reports that the client "is not acting right." What action by the nurse is the priority?

Assess the client for infection

A nurse cares for a client who has hypertension that has not responded well to several medications. The client states compliance is not an issue. What action would the nurse take next?

Assess the client for obstructive sleep apnea.

A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first?

Assess the client's airway.

The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below: What action by the nurse is best?

Assess the client's ankle-brachial index.

A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below: What action by the nurse is most important?

Assess the client's blood pressure and level of consciousness.

A client is having a bone marrow aspiration and biopsy and is extremely anxious. What action by the nurse is the most appropriate?

Assess the client's fears and coping mechanisms.

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next?

Assess the client's gag reflex before giving any food or water.

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril and warfarin. The client reports new-onset cough. What action by the nurse is most appropriate?

Assess the client's lung sounds and oxygenation.

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?

Assess the client's lung sounds every 2 hours.

An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best?

Assess the client's lung sounds.

A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. What action would the nurse take first?

Assess the client's medications.

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the client's face is puffy and the eyelids are swollen. What action by the nurse takes best?

Assess the client's oxygen saturation.

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?

Assess the client's respiratory rate, rhythm, and depth.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take next?

Assess the color and temperature of the left leg.

A nurse is assessing a dark-skinned client for pallor. What nursing assessment is best to assess for pallor in this client?

Assess the conjunctiva of the eye.

A client is taking ethambutol for tuberculosis. What instructions does the nurse provide the client regarding this drug? (Select all that apply.)

Contact the primary health care provider if preexisting gout becomes worse. Report any changes in vision immediately to the health care provider. You will take this medication along with some others for 8 weeks. Take this medicine with a full glass of water.

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best?

Help the client find things to hope for each day of recovery.

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching?

Grilled chicken breast with glazed carrots

A nurse is assessing a client with lung cancer. What nonpulmonary signs and symptoms would the nurse be aware of? (Select all that apply.)

Gynecomastia in male patients Frequent shaking and sweating relieved by eating "Moon" face and "buffalo" hump General edema

The nurse is preparing to administer a blood transfusion. Which action(s) by the nurse is (are) most appropriate? (Select all that apply.)

Hang the blood product using normal saline and a filtered tubing set. Use gloves to start the client's IV if needed and to handle the blood product. Take a full set of vital signs prior to starting the blood transfusion.

The nurse is learning about endemic pulmonary diseases. Which diseases are matched with correct information? (Select all that apply.)

Hanta virus: found in urine, droppings, and saliva of infected rodents. Histoplasmosis: sources include soil containing bird and bat droppings. Coccidioidomycosis: found in the southwest and far west of the United States.

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.)

History of hypertension History of smoking Hyperlipidemia Atherosclerosis

A nurse assesses a client who is 6 hours postsurgery for a nasal fracture and has nasal packing in place. What actions would the nurse take? (Select all that apply.)

Observe for clear drainage. Assess for signs of bleeding. Watch the client for frequent swallowing. Ask the client to open his or her mouth.

A nurse is assessing a client who is recovering from a lung biopsy. The client's breath sounds are absent. While another nurse calls the Rapid Response Team, what action by the nurse takes is most important?

Obtain pulse oximetry reading.

A nurse assesses a client who is at risk for neck cancer. Which symptoms would the nurse assess for? (Select all that apply.)

Oral mucosa is gray or dark brown Pain when drinking grapefruit juice Oral lesions that are over 2 weeks old Changes in the patient's voice quality

The nurse is assessing a client in sickle cell disease (SCD) crisis. What priority client problem will the nurse expect?

Pain

A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse requires the nurse's mentor to intervene?

Palpates the abdomen in four quadrants.

A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse would cause the supervising nurse to intervene?

Palpating both carotid arteries at the same time

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal?

Participate in blood pressure screenings at the mall.

The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important?

Perform hand hygiene.

The nurse is caring for a client experiencing sickle cell disease crisis. Which priority action would help prevent infection?

Performing frequent handwashing

The nurse is preparing to teach a community group about warning signs of lung cancer. What information does the nurse include? (Select all that apply.)

Persistent coughing Rusty or blood-tinged sputum Dyspnea Hoarseness

A nurse teaches a client who had a supraglottic laryngectomy. Which technique would the nurse teach the client to prevent aspiration?

Swallow twice while bearing down.

Which assessment finding(s) may indicate that a client may be experiencing a blood transfusion reaction? (Select all that apply.)

Tachycardia Fever Bronchospasm Tachypneae. Urticaria Hypotension

Which teaching point is most important for the client with a peritonsillar abscess?

Take all antibiotics as directed.

A nurse is caring for a client who had coronary artery bypass grafting 2 days ago. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.)

Take and record a full set of vital signs per hospital protocol. Ensure that the client wears TED hose or sequential compression devices. Assist the client to the chair for meals and to the commode.

The nurse is caring for a client receiving a unit of whole blood. Which nursing action(s) is (are) appropriate regarding infusion administration. (Select all that apply.)

Use a dedicated filtered blood administration set. Stay with the client for the first 15 to 20 minutes of the infusion. Infuse the transfusion with intravenous normal saline. Monitor and document vital signs per agency policy.