Med Surg: Final

A nurse is caring for a client who has COPD and is receiving nebulizer treatments of acetylcysteine. Which of the following client statements indicates the medication is effective?

"I can cough up my secretions more easily now." - Acetylcysteine thins pulmonary secretions, which increases the client's ability to cough up secretions.

A community health nurse is teaching a group of clients about melanoma. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching?

An irregular border

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm3. Which of the following interventions should the nurse include?

Avoid IM injections.

A nurse on a medical surgical unit reviews the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires a revision of his IV therapy prescription?

BUN 29mg/dL. - The client's HCT 54.2% and BUN 29mg/dL indicate dehydration.

A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first?

Characteristics of the cough and sputum

A nurse is caring for client in the PACU who has hypothermia. For which of the following complications should the nurse monitor?

Hypertension. - Hypothermia can cause vasoconstriction leading to hypertension.

A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the nurse expect?

Involuntary muscle spasms

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Lower the client to the floor.

A nurse is caring for a client who is 12hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place a pillow between the client's legs. - The nurse should place a pillow between the client's legs to prevent hip dislocation.

A nurse is caring for a client who has a leg cast and is retuning demonstration on the proper use of crutches while climbing stairs. Determine the proper steps.

Place body weight on the crutches. Advance the unaffected leg onto the stair. Shift weight from the crutches to the unaffected leg. Bring the crutches and the affected leg up to the stair.

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mm HG, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?

Respiratory alkalosis

A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching?

Thoroughly shampoo hair prior to the EEG.

A nurse is providing discharge teaching about improving gas exchange to a client who has emphysema. Which of the following instructions should the nurse include in the teaching?

Use pursed-lip breathing during periods of dyspnea.

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?

Viscous urinary output with clots

A nurse is providing teaching to a client who has tuberculosis (TB) and a prescription for isoniazid. Which of the following instructions should the nurse include?

"You should take this medication on an empty stomach."

A nurse is providing dietary teaching for a client who has chronic kidney disease. The nurse should instruct the client to restrict which of the following foods in his diet?

3oz of salmon - A client who is on a restricted protein diet should avoid foods high in protein, such as 3oz of salmon.

A nurse is teaching a client how to perform a breast self exam (BSE). The nurse should identify which of the following findings as an indication of breast cancer?

A nontender, hard lump that is palpated in one breast

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse take?

Assist the client to a prone position every 4 hr.

A nurse is caring for a client who is in the immediate postoperative period following a total knee arthroplasty. The client has a prescription for a continuous passive motion machine. Which of the following indicates the nurse should adjust the CPM machine setting?

At the time of discharge, the client may have flexion of the knee at 90 but this is not expected in the immediate postoperative period.

A nurse is assessing a client who had moderate sedation and is returning to the medical unit. Assessment findings include heart rate 67/min, respiratory rate 8/min, blood pressure 122/60mmHg, and oxygen saturation 90%. Which of the following action should the nurse take first?

Attempt to arouse the client. - When providing nursing care the nurse should first use the least restrictive intervention; therefore, the nurse should first try to arouse the client to stimulate breathing.

A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take?

Turn the client from side to side.

A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching?

"My diet will have to change to a soft diet after surgery."

A nurse is working in a hospital that is going to receive clients from a mass casualty incident. Which of the following clients should the nurse keep in a private room?

A client who has tuberculosis. - A client who has tuberculosis requires airborne precautions and therefore requires a private room.

A nurse in a long term care facility is caring for four clients. Which of the following clients should be moved to a private room?

A client with shingles. - A client who has shingles requires airborne precautions and therefore requires a private room.

A nurse is caring for a client who is having a febrile reaction while receiving a blood transfusion. The nurse should administer which of the following medications?

Acetaminophen - The nurse should plan to administer an antipyretic such as acetaminophen for a febrile reaction to a blood transfusion. Diphenhydramine for a mild allergic reaction. Furosemide, a loop diuretic, for circulatory overload. IV antibiotic such as cephalexin for sepsis due to receiving contaminated blood from a transfusion.

A nurse is caring for a client who is receiving total parenteral nutrition. A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take?

Administer 10% dextrose in water until the new bag arrives. - TPN solution have a high concentration of dextrose. If a TPN solution is temporarily unavailable, the nurse should administer 10% or 20% dextrose in water to avoid a precipitous drop in the client's blood glucose level.

A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions that nurse should take.

Administer oxygen via a nonrebreather mask. Initiate IV therapy with a large bore catheter. Insert an NG tube (to monitor the rate of bleeding and prevent gastric dilation). Administer ranitidine (when the client is no longer bleeding to prevent a stress ulcer).

A client who has a history of anxiety disorder reports numbness and tingling in the fingertips and has a pulse rate of 140/min and respirations of 42/min. Which of the following is the nurse's priority intervention?

Apply a nonrebreather mask without oxygen. - The greatest risk to the client is hypocapnia and subsequent development of respiratory alkalosis; therefore, the priority intervention is to assist the client to retain more carbon dioxide, minimizing the potential for development of respiratory alkalosis by using a nonrebreather mask.

A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first?

Ask the client to identify the types of foods she prefers.

A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? (Select all that apply.)

Assess and document the client's vital signs. Verify with another nurse the blood type and Rh of the packed RBCs. Change IV tubing to a set that has a filter.

A nurse in the emergency department is caring for a client who has fruity breath odor, dry mouth, and extreme thirst. Which of the following assessments should the nurse make?

Blood glucose level

A nurse is orienting a newly licensed nurse in the care of a client who has an intra arterial radial catheter. Which of the following should the nurse include?

Check capillary refill distal to the catheter insertion site. - The nurse should check capillary refill distal to the catheter insertion site to monitor for impaired circulation. No blood pressure on the arm. Occlusive dressing over the catheter insertion site should be placed. Maintain patency of the catheter with a continuous infusion of 0.9% sodium chloride.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Check the client's capillary blood glucose level every 4 hr.

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the client's pain level.

A nurse is caring for a client who had an NG tube inserted 1 week ago. Which of the following methods is appropriate to verify placement at this time?

Check the pH of aspirated fluid. - The nurse should check the pH of aspirate to reconfirm placement of the NG tube.

A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider?

Chest petechiae

A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching?

Chicken breast and corn on the cob

A nurse is providing teaching for a female client who has a history of UTIs. Which of the following should the nurse include in the teaching?

Clean the perineum form front to back. - A client who is at risk for developing UTIs should wipe from the front to the back after voiding to avoid bacterial contamination. Should increase intake of ascorbic acid to acidify the urine. Should take showers rather than baths. Should urinate at least every 4hr.

A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture?

Clear fluid coming from the nares

A nurse is providing teaching to a client who was recently diagnosed with constipation predominant irritable bowel syndrome. Which of the following should the nurse include in the teaching?

Consume at least 30g of fiber daily. - Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.

A nurse is assessing a client who has hypokalemia. Which of the following clinical manifestations should the nurse expect?

Decreased peristalsis - Decreased peristalsis is a clinical manifestation of hypokalemia. Facial twitching and hyperreflexia are clinical manifestations of hyperkalemia.

A nurse is planning care for a client who has heart failure. Which of the following prescriptions should the nurse plan to administer to increase cardiac contractility?

Digoxin - The client takes digoxin to increase cardiac contractility.

A nurse is administering meperidine IM in the right deltoid of a client. The nurse aspirates and pulls back blood in the syringe. Which of the following action should the nurse take?

Dispose of the medication. - The presence of blood indicate improper placement of the needle, and the solution and needle are now contaminated. The nurse should dispose of the medication according to facility protocol, and obtain a new dose of medication, syringe, and needle.

A nurse is providing postoperative care for a client who has two chest tubes in place following a lobectomy. The client asks the nurse the reason for having two chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons?

Draining blood and fluid from the pleural space

A nurse is providing teaching for a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching?

Drink 240mL of water after administration. - The client follow each dose of psyllium with an additional 240mL of liquid. The results should be expected in 12 to 24hr and regularly in 2 to 3days. The client should stir the medication briskly and take it immediately after mixing to prevent clumping. The client should take the medication after meals to prevent appetite suppression.

A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder?

Elevated LDL levels

A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care?

Encourage increased fluid intake.

A nurse is teaching a client about transmission prevention of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes?

Fecal-oral contamination

A nurse is caring for a client who has increased intracranial pressure (ICP) and received mannitol. The nurse recognizes which of the following is an adverse effect of this medication that should be reported to the provider?

Headache - Headache is an adverse effect of this medication. The nurse should notify the provider immediately as this may indicate that the client is experiencing a rebound increase in ICP.

A nurse is caring for a client who has a Stage III pressure ulcer. Which of the following should the nurse use when changing the client's dressing?

Hydrocolloid dressing. - The nurse should use a hydrocolloid dressing to keep the wound bed moist. Adhesive transparent film is used over intact skin. Nonadherent gauze dressing is for a wound that has little to no drainage. Wet to damp dressing is for mechanical debridement.

A nurse is planning care for a client who has thrombophlebitis and a prescription to receive heparin via continuous IV infusion. Which of the following actions should the nurse include in the plan of care?

Infuse the heparin using an electronic IV pump.

A nurse is planning care for a client who has a small bowel obstruction. Which of the following actions should the nurse plan to take?

Inset a nasogastric tube. - Inserting a nasogastric tube will decompress the bowel and may alleviate the obstruction. Position the client in semi Fowler's position to promote peristalsis and facilitate breathing.

A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take?

Instruct the client to perform the Valsalva maneuver during removal.

A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following should the nurse include in the plan of care?

Keep a lead lined container in the client's room. - The nurse should keep a lead lined container and forceps in the client's room in case of accidental dislodgement of the implant. Limit each visitor to i30min per day. Keep all soiled linens in the client's room until the client has the radioactive source removed. The nurse should wear a dosimeter badge to monitor exposure to radiation.

A nurse in the emergency department is caring for a client who is experiencing a heroin overdose. Which of the following is the priority action the nurse should take?

Monitor the client's oxygen saturation. - Using the ABC priority setting framework, monitoring the client's oxygen saturation is the priority intervention.

A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? (Select all that apply.)

Monitor vital signs every 2 hr. Assess neurological status every 4 hr. Keep the client's room darkened.

A nurse is caring for a client who has been taking enalapril. The nurse should assess the client for which of the following adverse effects?

Orthostatic hypotension. - Enalapril is an antihypertensive agent; therefore, the nurse should assess the client for orthostatic hypotension.

A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following action is the highest priority?

Place a tracheostomy tray at the bedside. - The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is place a tracheostomy tray at the client's bedside in case of airway obstruction. Sandbags are used to support the head and neck to prevent stress on the suture line. Opioid medication is used to relieve pain. The client is placed in semi Fowler's position to avoid neck extension.

A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table. Which of the following actions should the nurse take?

Place the syringe in a puncture-proof disposal container.

A charge nurse is observing a newly licensed nurse administer oral medications to a client. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

Places the contents of a time released capsule in applesauce. - The nurse should not open time released medications because they will absorbed into the gastrointestinal tract immediately, which defeats the purpose of a time released capsule.

A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction pillow on the client for which of the following purposes?

Preventing dislocation of the hip during position changes or movement

A nurse is assessing the incision of a client who is postoperative following a colon resection. Which of the following findings requires intervention by the nurse?

Purulent drainage from incision. - Purulent drainage indicates the presence of the infection and requires nursing intervention.

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following should the nurse plan to administer?

Regular insulin 20 units IV bolus. - Ketoacidosis indicates decreased insulin. Regular insulin is a fast acting insulin and may be effective withi 10min when given IV.

A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory findings to be below the expected reference range?

Serum calcium - A client who has pancreatitis will have decreased serum calcium due to fat necrosis.

A nurse is reviewing laboratory values for a client who has end stage kidney disease. Which of the following laboratory values is the priority finding to report to the provider?

Serum potassium 6.7mEq/L - When using the urgent vs. nonurgent approach to care, the nurse determines the priority finding is serum potassium 6.7mEq/L because this places the client at risk for cardiac dysrhythmias.

A nurse is caring for a client who has pulmonary edema and receiving furosemide 40mg IV bolus 8hr ago. Which of the following is an adverse reaction to furosemide?

Sodium of 125mEq/L - A serum sodium of 125mEq/L indicates a depletion of sodium, which is an adverse effect of furosemide.

A nurse is assessing a client who has aortoiliac disease. Identify the pulse site the nurse should palpate first.

The first pulse site the nurse should palpate is the femoral pulse, because the greatest risk to this client is injury from decreased perfusion to the lower extremities.

A nurse is planning discharge teaching for a client who is postoperative following an ileostomy. Which of the following should the nurse include in the teaching?

The stoma will remain red and moist. - The stoma should remain cherry red and moist. Feces will gradually become thicker and more paste like over time. The client should expect a minimal or a sweet odor of the feces.

A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching?

This identifies if pacemaker cells of my heart are working properly. - Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle.

A nurse is reviewing the laboratory findings of a client who had a myocardial infarction 6hr ago. Which of the following is an expected finding for this client?

Troponin I 8ng/mL - This value is above the expected reference range for Troponin I and is a specific marker of MI.

A nurse is caring for a client who has a stage III pressure ulcer. Which of the following findings contributes to delayed wound healing?

Urine output 25mL/hr. - Inadequate urine output can indicate dehydration, which can delay wound healing.

A nurse is caring for a client who had a left shoulder tendon repair and returned from the PACU 4hr ago. The PACU report included the following: urine output 100mL/hr, blood pressure 120/76mmHg, SaO2 98%, and pain rating of 2 on a pain scale of 0 to 10. Which of the following change in the client's current findings should the nurse report to the provider?

Urine output of 20mL/hr. - The nurse should report a decrease in urine output because it indicates inadequate kidney function.

A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication?

WBC count 2,000/mm3 - This value is below the expected reference range and indicates a risk for severe immunosuppression.

A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The clients asks the nurse about the usual course of MS. Which of the following responses should the nurse make?

"Acute episodes are usually followed by remissions, which can vary in duration."

A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who has herpes zoster. The AP asks the nurse if the herpes zoster is contagious. Which of the following responses should the nurse make?

"Herpes zoster is not contagious to people who have had chickenpox."

An older adult female client reports problems with stress incontinence. Which of the following statements should indicate to the nurse that the client needs further teaching?

"I am limiting my daily fluid intake." - Adequate fluid intake is essential for proper kidney function and health maintenance.

A nurse is caring for a client who had a splint applied for a tibia fracture and received codeine 30mg PO for pain. Which of the following client statements is the highest priority for further intervention and documentation?

"I feel some tingling and numbness in my toes." - When using the urgent vs nonurgent approach to care, the nurse determines the priority finding is tingling and numbness in the toes because this indicates a risk for circulatory and neurological impairment.

A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching?

"I need to lie still in bed during my brachytherapy treatment."

A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?

"I should check my heart rate at the same time each day."

A nurse is providing education to a client who has been prescribed thromboembolic elastic stockings for peripheral venous disease. Which of the following client statements indicates the need for further teaching on appropriate use of the stockings?

"I should fold the stockings down halfway if my legs get too hot." - The client should not fold down the stockings or push them down because this action will make them too tight and will impair circulation.

A nurse is providing teaching to a client who is receiving IV heparin. Which of the following client statements indicates an understanding of the instructions?

"I will ask my wife to bring me my electric razor." - The anticoagulant effect of heparin increases the risk of bleeding; therefore, the client should use an electric razor to reduce the risk of cuts and bleeding during shaving. The client should avoid suppositories for constipation or flossing because risk of bleeding.

A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching?

"I will need to take methotrexate even if I'm in remission."

A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates understanding of the teaching?

"I will notify my doctor before I have dental procedures."

A nurse is providing teaching for a client who has a new diagnosis of fibrocystic breast condition. Which of the following statements by the client indicates a need for further teaching?

"I will stop taking my birth control pills" - A client who has fibrocystic breast condition should continue taking oral contraceptives to decrease estrogen overstimulation. A client should add vitamin C rich food, but limit sodium rich food intake. A client may be prescribed a diuretic to decrease breast engorgement.

A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching?

"I will use lemon and glycerine swabs after meals."

A nurse in a provider's office is educating a client who is to have an endometrial biopsy. Which of the following statements by the client indicates an understanding of the teaching?

"My doctor will remove a tissue specimen from inside my uterus." - An endometrial biopsy involves removal of a sample of the endometrial tissue, which lines the uterus.

A nurse is providing teaching for a client who has a prescription for ciprofloxacin for a urinary tract infection. Which of the following instructions should the nurse include in the teaching?

"Restrict your caffeine intake while taking this medication." - The client should restrict caffeine intake to reduce CNS stimulation. The client should avoid products containing calcium for 6hr before or 2hr after taking ciprofloxacin. The client should not crush ciprofloxacin because it's an extended release tablet.

A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight management program. The nurse determines that the client gained 1.36 kg (3 lb) in the past week. Which of the following statements should the nurse make?

"Were there any issues last week that kept you from focusing on your diet?"

A nurse is caring for an older adult client who has cancer and is prescribed an opioid analgesic for pain management. Which of the following should the nurse include in the teaching?

"You should increase your fiber intake to prevent constipation." - Opioids slow peristalsis in the gastrointestinal tract causing constipation. The client should take opioid with food to prevent nausea. Many medications, including aspirin and aminoglycosides, can cause ringing of the ears, but not opioids. Rifampin can turn the urine orange, but not opioids.

A nurse is providing teaching about antiretroviral medication therapy to a client who has a new diagnosis of AIDS. Which of the following statements should the nurse include in the teaching?

"You should take antiretroviral medications on a routine schedule."

A client comes to the clinic and requests sildenafil to treat his erectile dysfunction. Which of the following is an appropriate statement for the nurse to make to the client?

"You will not be able to use sildenafil if you are taking nitroglycerin." Nitroglycerin and sildenafil can both cause vasodilation and can lead to significant hypotension if taken together.

A nurse is caring for a client who is prescribed dopamine 3mcgkg/min. The available dosage is dopamine 500mg/250mL 0.9% sodium chloride. The client weights 220lb. The nurse should set the IV infusion pump to deliver how may mL/hr?

220/2.2 = 100kg 3mcg x 100 = 300mcg/min 300mcg/min x 60 = 18mg/hr 500/250 = 2mg/ml 18/2 = 9mL/hr

A client has a prescription for total parenteral nutrition at a rate of 3L/24hr. The prescription calls for a 50% infusion rate for the first 24hr. The nurse should recognize that the client will receive how may milliliters in the first 48hr?

4,500 - The client is receive 3,000mL per 24hr, but only half that amount for the first 24hr. So, the client would receive 1,500mL in the first 24hr and the full 3,000mL in the second 24hr, for a total of 4,500mL for the first 48hr.

A nurse is preparing to administer amikacin 500mg by intermittent IV bolus to a client. Available is amikacin 500mg in dextrose 5% in water (D5W) 200ml to infuse over 30min. The nurse should set the IV pump to deliver how many mL/hr?

400mL/hr

A nurse is preparing to care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse assess first?

A client who has emphysema and reports dyspnea

A nurse on a medical unit is assessing with the emergency response plan following an external disaster. Which of the following clients should the nurse recommend for early discharge?

A client who is scheduled for a left sided cardiac catheterization to confirm coronary artery disease. - This client is scheduled for a diagnostic evaluation for a chronic condition. There is no indication of a need for continued acute care; therefore, the nurse should recommend this client for early discharge.

A nurse is caring for a client following application of a cast to the lest lower extremity. Which of the following findings should the nurse report to the provider?

An increase in the amount of drainage. - The nurse should report an increase in drainage, which may indicate infection or an improperly fitting cast. Expect to find cold areas on the cast as the cast dries.

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take?

Apply lateral pressure to the client's nose for 10 min.

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?

Apply pressure to the puncta after instilling the medication.

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?

Ask the client about first aid performed at the scene.

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

Ask the client to identify the specific food allergies.

A nurse is caring for a client who has hepatic encephalopathy. A decrease in which of the following laboratory values indicates the treatment has been effective?

Blood ammonia - Toxic substances absorbed by the intestines are not broken down, leading to increased ammonia levels.

A nurse is providing care a client who is in the PACU following a colonoscopy. The client reports increased abdominal pain; his skin is pale, cool, and diaphoretic; and his abdomen is distended. Which of the following is the priority assessment?

Blood pressure. - When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority assessment is the client's blood pressure to determine if the client is experiencing shock.

A nurse is planning teaching for a client who has acute kidney failure. Which of the following over the counter medications should the nurse recommend as safe for this client?

Calcium carbonate - Calcium carbonate is safe for clients who have acute kidney failure. Acetaminophen and Gentamicin are nephrotoxic. Magnesium hydroxide is contraindicated for clients who have AKF.

A nurse is caring for a client who is postoperative following an amputation of three toes. Which of the following should the nurse assess first?

Color of the extremity. - The greatest risk to this client is injury from impaired tissue perfusion; therefore, the priority assessment is the color of the extremity.

A nurse is caring for an older adult client who has heart failure and is receiving a blood transfusion. For which of the following should the nurse monitor?

Crackles in the lungs. - Crackles in the lungs indicate fluid overload, which is a risk during blood transfusion for older adult client who have heart failure.

A nurse is reviewing the health record of a client who is scheduled for allergy testing. For which of the findings should the nurse plan to postpone the testing and report to the provider?

Current medications. - The client should discontinue prednisone, a glucocorticoid, for up to 4wk before allergy testing to avoid suppressing the immune response.

A nurse is providing teaching to a client who has tuberculosis and prescriptions for rifampin and ethambutol. The nurse should identify which of the following findings as an adverse effect of these medications that the client should report to the provider?

Decreased visual acuity

A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?

Diaphoresis

A nurse is caring for a client who is in an acute care facility and is at risk for seizures. which of the following precautions should the nurse implement?

Ensure that the client has a patent IV. - IV access is necessary in the event that the client requires medication to stop seizure activity.

A nurse is preparing to present a program about prevention of atherosclerosis at a heath fair. Which of the following recommendations should the nurse plan to include?

Follow a smoking cessation program. Maintain an appropriate weight. Eat a low fat diet.

A nurse is caring for a client who sustained full thickness burns over 70% of the total body surface area 6days ago. Which of the following findings should the nurse report to the provider?

Glasgow Coma Scale score of 9. - The nurse should report a Glasgow Coma Scale score of 9 because this indicates a neurological deficit.

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) should the nurse don prior to providing client care? (Select all that apply.)

Gown Gloves

A nurse is caring for a client who has a cervical spinal cord injury sustained 1month ago. Which of the following manifestations indicates the client is experiencing autonomic dysreflexia?

Heart rate 52/min - Bradycardia is a manifestation of autonomic dysreflexia.

A client presents to the clinic for a 1 week follow up visit after hospitalization for heart failure. Based on the information in the chart, which of the following findings should the nurse report to the provider?

Heart rate 55/min - This heart rate is a significant drop from baseline, and it can indicate the development of digoxin toxicity.

A nurse is caring for a client who has biliary colic. Which of the following should the nurse administer?

Hydromorphone - The nurse should administer hydromorphone to manage the client's pain caused by biliary colic.

A newly licensed nurse is caring for a client diagnosed with methicillin resistant Staphylococcus aureus (MRSA). Which of the following statements by the nurse indicates a need for further training?

I will need to move the client to a room with negative air flow." - A client who has MRSA does not require a negative pressure airflow room because the mode of transmission is not airborne. The nurse should follow standard precautions and were a mask whenever there is a risk of splashing of body fluids. Should follow contact precautions, and wear a gown to prevent cross contamination and use dedicated equipment when assessing the client to prevent cross contamination with other clients.

A nurse is admitting a client who has a positive culture for Clostrididum difficile. Which of the following actions should the nurse take?

Implement contact precautions for this client. - The nurse should implement contact precautions for a client who has C. difficile because the mode of transmission is direct contact. The nurse should use soap and water for hand hygiene. Alcohol based clensers do not kill the spores of the pathogen.

A client who has emphysema is receiving mechanical ventilation. The client appears anxious and restless, and the high pressure alarm is sounding. Which of the following actions should the nurse take first?

Instruct the client to allow the machine to breathe for him. - When providing nursing care, the nurse should first use the least restrictive intervention. Because anxiety and restlessness indicate that the client is "fighting the ventilator," the nurse should first provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Pancuronium is administered to increase the client's tolerance of mechanical ventilation. (But it's not the first action)

A nurse is reviewing the ABG values of a client who has COPD. The client's laboratory values are pH 7.31, PaCO2 68mmHg, CO3- 26mEq/L, and PaO2 75mmHg. Which of the following findings should the nurse expect?

Kussmaul respirations. - The client's ABG values indicate respiratory acidosis with manifestations of Kussmaul respirations. Hyperreflexia, hypertension, or tetany are expected findings in a client who has respiratory alkalosis.

A nurse is caring for a client who has been having frequent premature ventricular contractions. The client's potassium level is 3.8mEq/L. Which of the following medications should the nurse administer?

Lidocaine - The nurse should administer lidocaine, an antidysrhythmic for short term treatment of ventricular dysrhythmias.

A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2days ago. Which of the following action should the nurse take first after hearing a murmur.

Listen with the client on his left side. - When providing nursing care, the nurse should first use the least invasive intervention; therefore, when the nurse hears a murmur, the first action the nurse should take is to place the client on his left side and listen to his heart again.

A nurse is caring for a client following a lumber puncture. Which of the following actions should the nurse take?

Maintain the client in a dorsal recumbent position. - The nurse should maintain the client in a dorsal recumbent position. Should not place a pillow under the client's knees because it can impede circulation. Should encourage fluid intake to replace lost cerebrospinal fluid. Should be maintained in a supine position for 1 to 12hr following the procedure.

A nurse is assessing a client who has a stage 2 pressure ulcer. Which of the following findings should the nurse recognize as a sign that the ulcer is healing?

Moist, bright red surface in the wound bed. - A moist, bright red wound bed indicates healing is taking place. Erythema surrounding the wound indicates inflammation and irritation. Brown, denatured collagen indicates necrotic tissue. Dry, hard tissue indicates poor local arterial blood supply and lack of healing.

A nurse on a medical unit is planning care for a client who has dehydration. Which of the following is the priority assessment?

Muscle strength. - The greatest risk to this client is injury from falls; therefore, the priority assessment is muscle strength to prevent falls.

A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care?

Offer the client a bedpan every 2 hr.

A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, BP 78/40mmHg, and respiratory rate 30/min. Which of the following action should the nurse take?

Perform synchronized cardioversion. The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia.

A nurse is caring for a client who is having a tonic clonic seizure while in bed and has become cyanotic. Which of the following actions should the nurse take?

Prepare to suction the client's airway. Loosen restrictive clothing on the client. The nurse should not restrain the client or inset anything into the client's mouth. The nurse should keep the client flat on her back or turned onto her side during a seizure to prevent aspiration.

A client recovering from surgery is admitted to the PACU. The client's blood pressure is 90/55mmHg, and the client is reporting nausea. Which of the following position s is appropriate for this client?

Side-lying - To prevent any further drop in blood pressure, the nurse should keep the client's head flat and maintain the client in a side lying position to prevent aspiration if vomiting occurs.

When administering RBCs to a client, which of the following actions should the nurse take?

Stay with the client during the first 30min of the infusion. - The nurse should stay with the client for at least 30min, as most transfusion reaction manifest during the infusion of the first 50 to 100mL of the blood product. Blood should be administered with 0.9% sodium chloride solution and never with lactated Ringer's solution or with a solution that contains dextrose. Blood products should be administered as soon as possible after obtaining them from the blood bank to decrease the risk of bacterial growth. Blood components are viscous and needle should be an 18 or 19 gauge.

A nurse is providing teaching for a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions?

Suppressing gastric acid production. - Omeprazole is a proton pump inhibitor, which relieves symptoms of gastric ulcers by suppressing gastric acid production.

A nurse is assessing a client following an IV urography. Which of the following is the highest priority finding?

Swollen lips. - Swollen lips indicates this client is at greatest risk for an anaphylactic reaction to the contrast media; therefore, this is the priority finding.

A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse make? (Select all that apply.)

Take allopurinol as prescribed. Exercise several times a week. Limit intake of foods high in purine.

A nurse is caring for a client who had a nephrostomy tube inserted 12hr ago. Which of the following findings should the nurse repot to the provider?

The client is reporting back pain. - The nurse should report back pain, which can indicate that the nephrostomy tube is dislodged or clogged. The nurse should notify the provider also if there is a decrease in urinary output. Red tinged urine is an expected finding for the first 12 to 24hr hollowing a nephrostomy tube insertion. A low grade fever is expected in the first 24 hr.

A nurse is caring for a client who is in pulseless ventricular tachycardia. The nurse should recognize that which of the following assessment findings requires defibrillation?

The client is unconscious. - Lack of consciousness indicates that the client has become unstable and requires emergency defibrillation.

A home health nurse has been assigned to a client who was recently discharged from a rehabilitation center after experiencing a right hemispheric cerebrovascular accident. Which of the following neurological deficits should the nurse expect to find during assessment of the client?

Visual spatial deficits. Left hemianopsia. One side neglect.

A nurse working in the postoperative care unit is assessing a surgical client who received general anesthesia. Which of the following findings should the nurse report to the provider?

Warm, red area on calf. - A warm, red area on the calf may indicate the presence of a deep vein thrombosis. The nurse should report this finding to the provider.

A nurse is assessing a client who is taking carvedilol for heart failure. Which of the following findings should the nurse report to the provider?

Weight gain. - Weight gain in a client who has heart failure indicates that the medication is not effective and the client's condition is worsening. Fatigue, diarrhea, and orthostatic hypotension are expected findings.

A nurse is planning client education regarding a peripherally inserted central catheter (PICC). The nurse should instruct the client that an advantage of using a PICC is that it

can be inserted in the upper extremity. - Using this insertion site decreases the risk of infection because there are fewer types and numbers of organisms on the upper extremities as compare to the torso where the client would have a nontunneled percutaneous central catheter.