Med surg final

40. After teaching a client how to administer eye drops, the nurse determines that additional teaching is needed when the client makes which statement?

"1l drop the solution into the nasal side of the lower eye sac."

23. An elderly client is scheduled for cataract surgery and asks the nurse, "Will I need to wear pop-bottle lenses after surgery?" Which is the most appropriate response from the nurse?

"An implanted lens has replaced the need for corrective glasses."

24. The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening. What is the nurse's best response?

"Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel."

32. The nurse is reviewing the results of a Hemoccult test with the client. Which question, asked by the nurse, is important to screen for the potential of a false-positive result. Select all that apply.

"Are you prescribed regular strength aspirin daily?" When was the last time that you included red meat in your diet?" Can you tell me the amount of alcohol that you drink on an average week?"

15. After teaching a client how to properly use translingual nitroglycerin spray, the nurse determines that the teaching was successful when the client states which statement? Select all that apply.

"I can spray the drug onto or under the tongue." I should not exceed three metered doses in 15 minutes." I will place one to two metered doses under my tongue at the start of an attack."

13. The nurse is caring for a client with the diagnosis of colon cancer with metastasis to the liver. Which statement made by the client indicates an understanding of the diagnosis?

"My cancer has now spread to my liver."

40. A client who has experienced an initial transient ischemic attack (TIA) states: "Tm glad it wasn't anything serious." Which is the best nursing response to this statement?

"TIA is a warning sign. Let's talk about lowering your risks."

27. A patient who was diagnosed with senile dementia has become incontinent of urine. The patient's daughter asks the nurse why this is happening. What is the nurse's best response?

"The patient is losing sphincter control due to the dementia."

34. A client is prescribed a transdermal opioid. After teaching the client and family how to administer this drug, the nurse determines that the teaching was successful when they make which statement?

"The site should only be cleaned with water before each application."

6. A client, who is at risk for pneumonia, has been ordered influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine?

"Viruses, like influenza, are the most common cause of pneumonia."

18. The nurse is caring for a 37-year-old female client with potential interstitial cystitis. Which question, asked by the nurse, is helpful in suggesting the disease?

"When was your last menstrual period?"

26. The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient?

"You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight."

19. While obtaining a health history, a client tells the nurse that her mother, grandmother, and sister died of cancer. The client wants to know what she can do to keep from getting : cancer. What would be the nurse's best response?

"You can't prevent cancer, but you can have your blood analyzed for tumor markers to see what your risk level is."

2. While obtaining a health history, a client tells the nurse that her mother, grandmother, and sister died of cancer. The client wants to know what she can do to keep from getting cancer. What would be the nurse's best response?

"You can't prevent cancer, but you can have your blood analyzed for tumor markers to see what your risk level is."

33. A nurse is administering a subcutaneous injection to a client. What is the maximum volume that the nurse may administer by this route?

1 ml

9. The nurse is preparing to administer an antiasthmatic drug to a client. The nurse determines the drug should be held and the health care provider notified after noting which respiratory rate on assessment?

10 breaths/min/

26. The nurse is checking the residual content for a client who is receiving intermittent feedings. Which residual content, if obtained, would lead the nurse to delay the feeding?

120 ml

7. The primary health care provider prescribes diazepam 10 mg V to be administered to a client to control their seizures. The nurse would administer this drug over which time frame?

2 minutes

50. A health care provider orders 1000 mL DsW to be infused over a period of 4 hours. If the drop factor is 5 drops/ml., the nurse would calculate the V flow rate to be (Round off answer to whole number.)

21 drops/min

16. A nurse is employed as a gastroenterologist's office nurse. When assessing the client, which objective data would provide useful information for diagnosis?

22-lb weight loss in 2 months

42. A client is ordered an intravenous (M) solution of Ringer's lactate 1000 ml. to infuse at 40 mL/hr. What is the maximum amount of time the nurse should allow this N to hang?

24 hours

7. The nursing instructor is discussing with the nursing class about fluid and electrolyte balance. What would the instructor tell the students that the average daily fluid intake for an adult is?

2500 ml

14. A nursing instructor is teaching a class illustrating the various reactions to antivenins. The instructor determines the class is successful when the students correctly point out clients may react within which time period if they are sensitive to an antivenin?

30 minutes

21. A nursing instructor is teaching a class illustrating the various reactions to antivenins. The instructor determines the class is successful when the students correctly point out clients may react within which time period if they are sensitive to an antivenin?

30 minutes

33. A client asks the nurse about drinking cranberry juice to prevent UTIS. The nurse informs the client that it is safe to use, suggesting an intake of which amount daily?

4 to 8 oz

17. The nurse is preparing to administer insulin to an older client who is frail and has failure to thrive. At what angle will the nurse plan to insert the needle into the client?

45 degrees

14. A 176-lb client with pyelonephritis has been instructed to drink at least 30 ml. of water for each klogram of body weight. The client prefers to drink bottled water and asks the nurse to calculate the number of 16-oz bottles needed to fulfill the daily intake required. Fill in the blank with the total number of 16-oz bottles of water that should be consumed each day.

5 bottles

44. A client is brought to the emergency department with suspected bleeding esophageal varices. Which hemoglobin level should the nurse immediately report to the physician?

5.0 g/dl

39. A nurse is caring for a client receiving an oral antiarrhythmic drug. Which apical pulse rate would lead the nurse to withhold the drug and notify the health care provider immediately?

58 beats/min

3. The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty?

6 hours/

10. A client is prescribed two ophthalmic drugs that are to be administered at about the same time each day. The nurse instructs the client to separate the drug administration by which amount of time?

8 to 10 minutes

6. A client is administered insulin lispro at 8 AM. The nurse would be alert for signs and symptoms of hypoglycemia at about which time?

9 AM.

23. The nurse is preparing to administer insulin to a client with obesity. At what angle will the nurse plan to insert the needle into the client?

90 degrees

34. The nurse is caring for several older clients. Which client would the nurse be especially alert for signs and symptoms of pyelonephritis?

A client with urinary obstruction

42. The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?

A rapid, bounding pulse

34. The client is scheduled for a breast lump excision and sentinel node biopsy. What should the nurse know in planning care for the client with a negative biopsy report?

A wide excision of lump will be performed.

22. The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about?

Absent distal pulses

14. What is one process by which dissolved chemicals move from one area of the body to another?

Active transport

24. The nurse is assessing a client who is to receive multiple vaccinations. Which nursing diagnosis should the nurse prioritize for this client?

Acute Pain

34. The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?

Acute respiratory distress syndrome

25. The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?

Administer an over-the-counter decongestant.

44. A nurse is preparing a teaching plan for a client with edema who is prescribed a diuretic. Which teaching should the nurse prioritize?

Administer early in the day.

19. A client with chronic kidney disease is prescribed epoetin alfa. Which actions should nurse prioritize when administering this drug? Select all that apply.

Administer the drug either intravenously or subcutaneously. Discard any unused portion after administration. receiving dialysis.

37. After teaching a class to a group of nursing students about immunity, the instructor determines that the teaching was successful when the students correctly choose which situation as an example of passive immunity? Select all that apply.

Administration of Crotalidae polyvalent immune Fab for the treatment of a rattlesnake bite Administration of botulism immune globulin to an infant

37. The nurse is caring for a client in shock who is deteriorating. The nurse is infusing N fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client?

Adrenergic drugs

27. A nursing instructor is teaching a class on pituitary gland hormones. The instructor determines the class is successful when the students correctly choose which hormones as being secreted by the anterior pituitary gland? Select all that apply.

Adrenocorticotropic hormone Growth hormone Prolactin

nurse discovers that the child had received an antivenin injection for a snake bite 2 days 23. A child is brought to the health care center for MMR vaccination. On assessment, the before. When should the nurse instruct the caregivers to return for this vaccine for this child?

After 6 to 8 weeks

29. Which nursing observation would indicate that the nurse hold the medication warfarin (Coumadin)?

An INR of 4.8

27. An ileal conduit is created for a client after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care?

Application of an ostomy pouch

3. A client comes into the emergency department with epistaxs. What intervention should the nurse perform when caring for a client with epistaxis?

Apply direct continuous pressure.

33. The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in this client?

Arterial blood gas (ABG) findings

48. The 80-year-old male client on an Alzheimer's unit is agitated and asking the nurse to get his father to come and see him. Which is the nurse's best response?

Ask the client to talk about his father with the nurse

31. The client with a C6 SCl is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?

Assess for bladder distention

34. The nurse is caring for an adult client diagnosed with a left external ear infection. The nurse should perform which ongoing assessment(s) for safe administration of the otic, 1% hydrocortisone, 5 mg neomycin, 10,000 units polymyxin B? Select all that apply.

Assess if pain and drainage have decreased Inspect and palpate for increased pain, redness.

4. The nurse is caring for a male client in the emergency department who is experiencing sudden onset of angina, rated as 8/10 on pain scale with blood pressure 88/50 mm Hg. Which is the priority action?

Assess if the client has taken sildenafil

26. The nurse is caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD?

Assess the characteristics of chest pain.

24. The nurse arrives at the site of a one-car motorvehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next?

Assess the client's airway

7. A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation?

Assist client to increase dietary fiber.

21. The nurse is instructing a client's family members on the most incapacitating symptom of Mėnière's disease. Which nursing instruction associated with the symptom is most helpful?

Assist the client when ambulating.

1. The nurse has finished a teaching session with a client who is prescribed a diuretic to be taken twice a day. The nurse determines the session is successful when the client correctly chooses which times to take the drug?

At breakfast and midafternoon

10. The nurse is preparing to measure the client's abdominal girth as part of the physical examination. At which location would the nurse most likely measure?

At the umbilicus

49. Which of the following advice does the nurse offer clients who are undergoing unsealed radiation therapy to reduce exposure?

Avoid kissing and sexual contact.

25. A nurse is preparing to administer insulin glargine to a client. What precaution should the nurse take when administering this drug?

Avoid mixing glargine with other insulin.

12. The nurse is preparing to teach a olient with renal insufficiency about the recently prescribed bumetanide for hypertension. Which instruction should the nurse prioritizen for this client?

Avoid over the-counter drugs for cold symptoms,

36. When assisting with preparing a client scheduled for a barium swallow, which of the following would be appropriate to include?

Avoid smoking for at least 12 to 24 hours before the procedure.

45. The nurse is providing client teaching for a client undergoing chemotherapy. What dietary modifications should the nurse advise?

Avoid spicy and fatty foods.

17. A client comes to the clinic and tells the nurse that close family members are suspected of having pulmonary tuberculosis. Which vaccine would the nurse predict the health care provider will prescribe as a preventative measure?

BCG vaccine

49. A client comes to the clinic and tells the nurse that close family members are suspected of having pulmonary tuberculosis. Which vaccine would the nurse predict the health care provider will prescribe as a preventative measure?

BCG vaccine

28. A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client?

Bank autologous blood.

31. The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning?

Basic infection control techniques

15. A nurse on the unit sustains a needlestick injury while caring for a client whose infection status is unknown. What would be the best course of action for the nurse to follow?

Be tested for disease antibodies at appropriate intervals.

1. The nurse is caring for an older adult client who has been admitted to the unit with anemia. What would the nurse expect the client to possibly exhibit?

Blood loss from the gastrointestinal or genitourinary tract

33. The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction?

Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle."

46. A client taking metoprolol 50 mg one tablet twice daily begins taking over-the-counter pseudoephedrine. The nurse would assess for which potential reaction? Select all that аpply.

Bradycardic episode Hypertensive episode

12. The nurse is accompanying the client to the diagnostic imaging unit for a magnetic resonance imaging (MRI). Which action, by the nurse, is most important prior to the test?

Calculate drop per minute for intravenous fluids and infuse by gravity.

30. After teaching a group of nursing students about otic preparations, the instructor determines that the teaching was successful when the group correctly chooses which preparations as being used to aid in the removal of cerumen? Select all that apply.

Carbamide peroxide Triethanolamine polypeptide

9. The nurse is teaching the client about the prescribed dexamethasone. The determines the session is successful when the client correctly chooses which potential adverse reactions to be aware of? Select all that apply.

Cataract formation Increased intraocular pressure Ptosis

13. The nurse has four clients who are scheduled to see the physician for "fatigue" and other general symptom complaints. Which client does the nurse determine is at most risk for having chronic fatigue syndrome?

Caucasian female, age 47 years

47. After teaching a group of nursing students about xanthine derivatives, the instructor determines that the teaching was successful when the students correctly state which result of using these medications? Select all that apply.

Cause flushing. Stimulate the CNS to promote bronchodilation. hypoglycemia.

22. When examining the skin of a client who is dehydrated due to fiuid losses from the gastrointestinal tract, which of the following would be most important?

Checking if the mucous membranes are dry

35. The nurse teaches a client receiving an inhaled corticosteroid about the possibility of developing oral thrush. Which actions would the nurse include in the teaching plan as a way to reduce this risk? Select all that apply.

Cleaning the inhaler per package instructions Using proper technique when administering dose Performing strict oral hygiene

45. A client reports taking oral medication for control of sugar problems. Which is the best nursing interpretation of this verbal accounting?

Client has type 2 diabetes mellitus.

11. Which nursing goal is a priority when caring for a client newly diagnosed with vertigo?

Client will remain safe while ambulating in the home.

41. A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. The nurse would observe for which of the following while assessing the client during the procedure?

Client's tolerance for pain and discomfort

30. While the nurse is making intial rounds after coming on shift, a client thrashes about in bed complaining of a severe headache. The client tels the nurse the pain is behind the right eye, which is red and tearing, What type of headache would the nurse suspect this client of having?

Cluster

2. The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe?

Clustering many nursing activities

30. The nurse is caring for a client with a diagnosis of Hodgkin's disease and is aware that there is enlargement of the retroperitoneal nodes when reviewing the review of systems on the physician's history and physical. What symptom is the nurse aware may be indicative of enlargement of the retroperitoneal nodes?

Complaints of a sense of fullness in the stomach and epigastric pain

30. The nurse caring for a client is providing instructions for an upcoming renal angiography. Which nursing action, explained in the preoperative instructions, is essential in the postprocedure period?

Complete a pulse assessment of the legs and feet.

43. A client is started on trimethoprim and sulfamethoxazole for a urinary tract infection. The client reports nausea, anorexda, and abdominal pain. What intervention does the nurse discuss with the client?

Consume the medication with food.

36. When describing the functions of the kidney to a client, which of the following would the nurse include? Select all that apply.

Control of water balance Secretion of the enzyme renin

22. A client asks the nurse why a creatinine clearance test is accurate. The nurse is most correct to reply which of the following?

Creatinine is broken down at a constant rate, and the total amount is excreted by the kidney."

26. A client is hospitalized for an infected decubitus ulcer of the sacral area. The physician is planning to remove the dead and damaged tissue. What type of procedure will the nurse prepare the client for?

Debridement

35. The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration?

Decreased level of consciousness

48. A nurse is preparing to administer exenatide to a client with type 2 diabetes. The nurse will question this order if which condition is noted in the client's medical record?

Diabetic ketoacidosis

48. Which of the following can be considered carcinogens?

Dietary substances

9. Which of the followng can be considered carcinogens?

Dietary substances

11. A client who is being treated for complications related to acquired immunodeficiency disorder syndrome (AIDS) is receiving interferon parenterally as an adjunctive therapy. Why does the nurse understand this route is being used?

Digestive enzymes destroy its protein structure.

18. The nurse is reviewing the patient's arterial blood gas results. The Pa02 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEg/L. What might the nurse expect to observe on assessment of this patient?

Disorientation and tremors

19. A nurse is preparing to teach a client and caregivers about levothyroxine. Which instructions should the nurse prioritize? Select all that apply.

Do not skip a dose unless advised to do so. Therapy is lifelong. Changing brands of the drug is okay.

46. A client is prescribed an otic agent to promote cerumen removal. Which instruction would the nurse include in the teaching plan? Select all that apply.

Do not use the drug if there is ear drainage. Use the drug for no more than 4 days. Call your primary health care provider if dizziness occurs.

36. A nurse is preparing to administer diphenhydramine to a client with bronchial irritation. Which activity should the nurse prioritize during the preadministration assessment?

Document color and amount of any sputum present.

12. What is the reason for chest tubes after thoracic surgery?

Draining secretions, air, and blood from the thoracic cavity is necessary.

18. A nurse needs to administer an injection to a client in the deltoid site. Which action should the nurse perform to avoid the risk of damaging the radial nerve and artery?

Draw an imaginary line at the axilla between the acromion and brachial vessels.

13. An elderly client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client?

Drooling from side of mouth

29. Immediately following cataract removal, which symptom would be most alarming to the nurse?

Dry, tickling cough

15. The nurse is administering trifluridine to a client with epithelial keratitis. The nurse will prioritize which finding on the ongoing assessment of this client?

Edema of the eyes

22. An adult client has developed lymphedema postmastectomy. What is the common method used to promote lymphatic drainage and prevent edema in all clients with lymphedema?

Elevate the affected part of the body.

35. The nurse is developing a plan of care for a client with a UTI who is prescribed an anti- infective drug. Which instruction should the nurse prioritize if the nursing diagnosis of Impaired Urinary Elimination is the most appropriate for this client?

Encouraging a fluid intake of at least 2000 mL/day

46. The nurse is working in a diagnostic testing unit focusing on gastrointestinal studies. For which testing procedure is the nurse correct to assess the gag reflex before offering fluids?

Esophagogastroduodenoscopy

30. The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient's elimination status. What is the nurse's best action?

Establish a bowel and bladder program for the patient.

7. The nurse is caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client?

Examine the legs for color, capillary refill time, and tissue integrity.

42. Which of the following provides the best example of documentation for a client who is presenting with acute bronchitis?

Expectorating moderate amounts of thick, green mucus.

12. A nurse is preparing to administer albumin intravenously to a client. The nurse anticipates noting which reason in the medical record of the client?

Experienced hypovolemic shock due to trauma.

23. An older adult male client is participating in a bladder retraining program as part of the treatment for urinary incontinence. The nurse advises him to wear barrier garments, such as liners and protective pants. Which suggestion would be most appropriate to help the client maintain skin integrity?

Exposing the affected area to air

49. An elderly client is admitted with the diagnosis of retinal detachment and is scheduled for laser surgery and scleral buckling procedure. The nurse anticipates which of the following symptoms to be exhibited in this client? Select all that apply.

Flashing lights Cobwebs in vision field

37. A client with chronic open-angle glaucoma has been prescribed brimonidine tartrate. After administering the drug, the nurse should monitor the client for which potential adverse reaction?

Foreign body sensation

3. A client with congestive heart failure and currently administered digoxin is now prescribed indapamide for edema. Which intervention should the nurse prioritize?

Frequently monitor the client's pulse rate and rhythm.

39. The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin?

Furosemide (Lasix)

19. A client with esophageal cancer has difficulty in swallowing. Which of the following would be appropriate to help the client achieve improved nutrition?

Give high-protein, semiliquid

18. A nurse has determined a client has developed a hypoglycemic reaction. Which interventions should the nurse perform if the client can adequately demonstrate swallowing and gag reflexes?

Give oral fluids or candy.

12. Which assessment finding would contraindicate the use of atropine in a client scheduled for general anesthesia?

Glaucoma

50. The nurse is assessing a cient who is stating gastrointestinal upset and a feeling of bloating. Which type of meal would the nurse anticipate causing these types of symptoms?

Hamburger and French fries

20. A nurse has administered glimepiride to a client with diabetes. Which findings on the ongoing assessment should the nurse prioritize? Select all that apply.

Heartburn Hypoglycemia Nausea

1. The nurse understands that the client should be vaccinated with human papilloma virus (HPV) vaccine per the health care provider's orders. What is this vaccine for?

Helps prevent cervical cancer

6. The nurse understands that the client should be vaccinated with human papilloma virus (HPV) vaccine per the health care provider's orders. What is this vaccine for?

Helps prevent cervical cancer

49. A type 2 diabetic is ordered metformin (Glucophage) as part of the management regime. Which is the best nursing explanation for the action of this drug in controlling glucose levels?

Helps tissues use insulin more efficiently

48. A nurse is preparing to administer iron dextran to a client. The nurse will obtain information on the preadministration assessment to calculate the drug dosage?

Hemoglobin level

40. Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen?

Hemoglobin level of 8.0

8. The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange?

Hemoglobin of 8.5 g/dl

40. A client diagnosed with cancer has his tumor staged and graded based on what factors?

How they tend to grow and the cell type

36. A client has been diagnosed with nephrogenic diabetes insipidus (DI), and the physician is initiating treatment. What medication does the nurse prepare to administer for this client?

Hydrochlorothiazide

48. The nurse is employed in an ear, nose, and throat (ENT) physician's office, obtaining a client history. The nurse documents the followng client statements. Which symptoms may indicate a diagnosis of otosclerosis? Select all that apply.

I can hear best when you put the tuning fork behind my ear." It seems that I increasingly could not hear my kids talk to me. I now notice a ringing in my ears especially when I lay down to sleep at night

35. A nurse is conducting a teaching session for a client newy diagnosed with type 2 diabetes on the importance of monitoring the blood glucose. The nurse determines additional teaching is necessary after the client makes which statement?

I should prick the tip of my finger to get the blood."

4. Which statements said by patients indicate that the nurse's teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.)

I should take my insulin on time every day." I have reliable transportation to dialysis sessions." My aspirin is on a high shelf away from children.

28. The nurse educates a client about using the prescribed otic 0.5% hydrocortisone, 10,000 units polymysán B, 4 drops QID in right ear x 10 days. Which client statements determine the need for further clarification?

I will place the bottle tip into the ear and instill the 4 drops."

45. The nurse is obtaining a visual history from a client who has noted an increased in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis?

Identification of opacities on the lens

8. The nurse is caring for a client diagnosed with bladder cancer and requiring a cystectorny. The nurse overhears the physician instructing the client on the presence of a storma with temporary pouch. In gathering information for the client, which urinary diversion would the nurse select?

Ileal conduit

18. A client with chronic open-angle glaucoma is now presenting with eye pain and intraocular pressure of 50 mm Hg. An immediate iridotomy is scheduled. Which of the following describes the desired effects of this procedure?

Improve outflow drainage

14. Which of the following teaching items would be a priority in maintaining normal pressure range in the eye?

Increase fiber in the diet.

44. During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.)

Increase fiber intake. Decrease physical exercise.

9. A nurse is preparing a teaching session for a client prescribed an anti-bacterial for a UTL Which instruction should the nurse point out in the teaching session?

Increase fluid intake to at least 2000 mL/day.

40. The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon returning to the nursing unit, what does the nurse identify as the client goal?

Increase in the amount of fluids

14. The nurse is preparing to administer ranitidine to a client who is currently receiving warfarin, Which assessment finding should the nurse prioritize for this client?

Increased bleeding

50. A primary health care provider has prescribed a loop diuretic for hypertension in a client with diabetes mellitus. Which assessment should the nurse prioritize?

Increased blood glucose levels

30. A nurse is conducting an ongoing assessment and notes the client is experiencing difficulty bringing up mucus. Which nursing diagnosis should the nurse prioritize for this client?

Ineffective Airway Clearance

43. The nurse is assessing a client who was administered metformin and notes hyperventilation, nausea, and somnolence. The nurse determines which nursing diagnosis should be prioritized for this client?

Ineffective Breathing Pattern

28. Which of the following interventions would be most appropriate for a client with a hiatal hernia and nursing diagnosis of Acute Pain related to reflux of gastric secretions?

Inform the client to remain upright for at least 2 hours after meals.

50. A nurse is preparing a teaching plan for a client and caregiver on the proper use of a dry powder inhaler. Which instructions will the nurse include in this teaching? Select all that apply.

Inhale quickly. Hold breath for 10 seconds.

1. The nurse is instructing a client about the use of pegvisomant for the treatment of acromegaly. How will the nurse instruct to take this medication?

Injected subcutaneously once a day

16. A ollent is having problems with dizziness and complains of the "room spinning." The physician performe the caloric stimulation test. The nurse knows that a diminished response in one eye during the caloric stimulation test is indicative of what?

Inner ear disorder

39. The nurse is caring for a male client who has a significant urinary narrowing secondary to an enlarged prostate. Which nursing action is best to relieve his urinary retention?

Insert a coudé catheter to remove urine from the bladder.

27. The nurse is teaching a caregiver how to instill otic drops in a child. The nurse determines the session is successful when the caregiver correctly administers the drops in which manner? Select all that apply.

Insert a piece of cotton loosely into the ear. Straighten the ear canal. Warm the solution prior to administration.

26. A nurse is preparing to administer insulin to the client. Which interventions should the nurse perform before administering each insulin dose?

Inspect the previous injection site for inflammation.

31. The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician, Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now?

Institute fall precautions due to potential postural hypotension and weak leg muscles.

23. The nurse is preparing a presentation for a group of adults at a local community center about diabetes. Which of the following would the nurse include as associated with type 2 diabetes?

Insufficient insulin production

29. Which factor presents the most likely cause for weight gain in a diabetic client who is controlled with insulin?

Insulin is an anabolic hormone.

22. The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location that contains the most body water?

Intracellular fluid

10. The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order?

Intravenous (IV) 500 mL of 0.9% Naci at 125 mL/hr/

24. The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to assess in order to detect development of the acid-base imbalance for which the patient has highest risk?

Level of consciousness

16. A health care provider has prescribed a medication for a client is diagnosed with euthyroid goiter. The nurse would expect to administer which drug?

Levothyroxine

4. Which of the followng would the nurse expect the physician to order for a client with hypothyroidism?

Levothyroxine sodium/

29. The nurse is caring for a geriatric client and notices polypharmacy. Which diagnostic studies are anticipated?

Liver function studies

39. The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?

Localized calf tenderness

21. The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient?

Low sodium diet

31. A client is suspected to have a pituitary tumor due to signs of diabetes insipidus. What initial test does the nurse assist the client with preparing for?

Magnetic resonance imaging (MRI)

31. The nurse is teaching a client how to properly use a peak flow meter. The nurse determines the session is successful when the client correctly explains which steps? Select all that apply.

Makes sure indicator is at lowest level on scale Stands upright to allow the best inhalation possible Makes sure lips are sealed tightly around the mouthpiece

8. The nurse performs a breast examination on a client and finds a firm, nonmoveable lump in the upper outer quadrant of the right breast that the client reports was not there 3 weeks ago. What does this finding suggest?

Malignant tumor

30. The client's lab values are sodium 166 mEg/L. potassium 5.0 mEg/L, chloride 115 mEg/L, and bicarbonate 35 mEg/L. What condition is this client likely to have, judging by anion gap?

Metabolic acidosis

47. Cancer has many characteristics. What is one of the most discouraging characteristics of cancer?

Metastasis

32. The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus?

Middle-aged Native American woman

3. The nurse working on a bone marrow unit knows that it is a priority to monitor which the following in a client who has just undergone a stem cell transplant?

Monitor the client closely to prevent infection,

49. Which of the following would be most important to ensure that a client does not retain any barium after a barium swallow?

Monitoring the stool passage and its color

19. The nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?

Mucopurulent sputum

28. Which diagnostic test is used to confirm the diagnosis of Armyotropic Lateral Sclerosis (ALS)?

Muscle biopsy

28. A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEg/L. Should the nurse start salt tablets when caring for this client?

No, sodium intake should be restricted.

38. The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

Noisy breathing

42. A nurse is caring for a client with hypertension and anemia. Which action would the nurse include in the plan of care when administering epoetin alfa to the client?

Note the hematocrit value before each dose during therapy.

34. A nurse is caring for a client with diabetes mellitus who is receiving an oral antidiabetic drug. Which ongoing assessments should the nurse prioritize when caring for this client?

Observe the client for hypoglycemic episodes.

45. The school nurse is providing care to a child with a sore throat. With any sign of throat infection, the nurse stresses which of the following?

Obtaining a throat culture

20. What is a primary prevention tool used for colon cancer screening?

Occult blood testing

25. The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium?

Oliguric renal disease

26. The nurse is caring for a client who has a history of urine reflux, To assess the client for this urinary complication, which nursing action is best?

Palpate the client's bladder for distension.

3. Which action would be most appropriate when evaluating a client's neck for thyroid enlargement?

Palpate the thyroid gland gently.

43. The nurse is teaching a client and caregiver the proper technique for administering the prescribed nitroglycerin ointment. Which method should the nurse point out is the best way to determine the amount of ointment to apply?

Paper applicator

24. A client is diagnosed with blepharitis. What symptoms should a nurse monitor in this client?

Patchy flakes clinging to the eyelashes

A 75-year-old woman walks into the emergency department with complaints of "not feeling well." Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings?

Pathologic impairment of sensory responses

20. The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem?

Peripheral arterial disease of the lower extremities

38. A client who is HIV positive is taking zidovudine. Which adverse effects should the nurse ciosely monitor for in this client?

Peripheral neuropathy

34. A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycolelectrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?

Permit the client to drink only clear liquids.

36. A client with megaloblastic anemia is prescribed leucovorin. The nurse would question administration of this drug if which additional disorder is noted in the client's medical record?

Pernicious anemia

46. The public health nurse is giving a talk on the warning signals of cancer to a local community group. Which of the following are the waring signals of cancer? Select all that apply.

Persistent indigestion Unusual bleeding or discharge Sores that don't heal

46. The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?

Place the client in a modified Trendelenburg position.

26. A nurse is preparing to administer ketorolac. The nurse anticipates noting which ocular problem in the client's reçord? Select all that apply.

Postoperative pain after cataract surgery Relief of ocular itching During ocular surgery to prevent miosis

41. A nurse is assessing a client receiving V fluid and electrolyte therapy. Which laboratory test result will the nurse prioritize?

Potassium 2.1 mEq/L

4. A nurse is reviewing the laboratory test results of a client who is receiving diuretic therapy. The nurse determines that the client is at risk for electrolyte imbalance based on which results? Select all that apply.

Potassium 2.9 mEg/L Sodium 124 mEq/L

29. The instructor is talking with a nursing student who is caring for a client with pericarditis. The instructor asks the student to name the main characteristic of pericarditis. What should be the student's answer?

Precordial pain

27. The student nurse is being precepted in the ICU. The student is caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the reabsorption and retention of fluid in the body?

Production of antidiuretic hormone and corticosteroid hormones

14. The nurse is administering a medication to a client with hyperthyroidism to block the production of thyroid hormone. The client is not a candidate for surgical intervention at this time. What medication should the nurse administer to the client?

Propylthiouracil

48. The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior?

Prothrombin time (PT)

18. A client has had oral anticoagulation ordered. What should the nurse monitor for when the client is taking oral anticoagulation?

Prothrombin time (PT) or international normalized ratio (INR)

43. A nurse is teaching the caregiver of a young client about the varicella vaccine which the primary health care provider has prescribed. The nurse should point out which facts to the child and caregivers? Select all that apply.

Provide the date for return for the next vaccination. Discuss common adverse reactions. Instruct the parents to ensure the medical record is up-to-date. Explain the benefits of immunization. Explain the risk of contracting vaccine-preventable diseases,

5. The nurse is caring for an 8-year-old and anticipates that the client has otitis externa from symptoms stated on the history. Which symptoms, from the history and physical examination, would confirm the diagnosis?

Pus noted in the ear canal

17. The nurse is scheduling gastrointestinal (GI) diagnostic testing for a client. Which Gl test should be scheduled first?

Radiography of the gallbladder

32. The major advantage for giving a client medication via intravenous (M) route is which of the following?

Rapid distribution of the drug to all target tissues

23. When conducting a health history assessment, the nurse would want to know what most important information about the patient's elimination status? (Select all that apply.)

Recent changes in elimination patterns Discomfort or pain with elimination Changes in color, consistency, or odor of stool or urine List of medications taken by patient

22. A hospital is in the process or replacing the current stock of conventional syringes needles with new, redesigned models. What is the priority outcome that is sought by this change?

Reduction in nurses' risks of needlestick injuries

22. The nurse is discharging a client after a cardiac catheterization. What would the nurse Include in the discharge teaching?

Report any numbness, tingling, or sharp pain in the extremity.

25. The nurse is caring for a 64-year-old client in a clinic being treated for excessive cerumen with carbamide peroxide. The nurse should report which contraindication(s)? Select all that apply.

Reports pain in ears Recent ear surgery Ear drum is perforated

17. The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client?

Respiratory distress

12. A client with cerebral edema is prescribed mannitol. Which assessment should the nurse prioritize during the ongoing assessment?

Response of pupils light.

17. The nurse is caring for a client in the compensation stage of shock. The nurse knows that one of the body's mechanisms of compensation in this stage of shock is the renin- angiotensin-aldosterone system. What does this system do?

Restores blood pressure

13. An 18-month-old child is brought to the emergency department by his parents explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in?

Right upper lung

17. A client who is receiving diuretic therapy comes to the clinic for a follow-up visit. The client states that their mouth is often dry and that they are "urinating like there is no tomorrow." Assessment reveals dry mucous membranes and decreased skin turgor. Which nursing diagnosis would the nurse most likely prioritize?

Risk for Deficient Flud Volume

43. A nurse in a health care facility is caring for a client who is receiving an antiemetic to control vomiting related to chemotherapy. Which nursing diagnoses should the nurse prioritize for this client's care plan?

Risk for Imbalanced Fluid Volume

45. A client is prescribed a bowel evacuant in preparation for a colonoscopy. The client reports "going to the bathroom about every 30 to 45 minutes" and their stools are "like water." The client also reports being thirsty and mouth feels dry. Which nursing diagnosis would the nurse most likely prioritize?

Risk for Imbalanced Fluid Volume

8. A health care provider has prescribed methimazole for an elderly client with hyperthyroldism who lives alone. Which potential nursing diagnosis should the nurse prioritize for this client?

Risk for Ineffective Health Management

2. A client is prescribed nitrate therapy as treatment for angina. On a follow-up visit to the clinic, the client reports dizziness and weakness after taking the medication to the nurse. Which nursing diagnosis should the nurse prioritize for this client?

Risk for Injury

3. client receiving ophthalmic drugs reports blurred vision. The client tells the nurse, "I almost fell yesterday." The nurse will prioritize which nursing diagnosis for this client?

Risk for Injury

1. The nurse Is caring for a client who has taken hydantoins for several years. The nurse noted that the client has an unsteady gait, dizziness, nystagmus, acute confusion, a non- raised red rash on one arm, and has not been to the dentist for 2 years. Based upon the findings, what is the priority nursing diagnosis?

Risk for injury related to untoward effect of hydantoin

39. The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?

Serum antibodies for H. pylori

2. The nurse is providing care to a client who has had a percutaneous liver biopsy. The nurse would monitor the client for which of the following?

Signs and symptoms of bleeding

10. A patient presents to the emergency room complaining of vomiting with severe back and leg pain. The patient's home medications include daily oral corticosteroids. Vital signs reveal a low blood pressure and there are peaked T waves on the electrocardiogram. What is the nurse's priority intervention?

Start an intravenous line

5. A nurse is monitoring a client who is receiving V electrolytes. Which priority action should the nurse take if the following are noted on the assessment of the intravenous site: redness, edema, warmth, and pain?

Stop the current infusion and restart the infusion in another vein.

27. A client is admitted with arrhythmias and placed on cardiac monitoring and prescribed an antiarrhythmic. Which finding on ongoing assessment should the nurse immediately notify the primary health care provider?

Sudden change in mental state

8. The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse's best action to provide recreational activities during the rehabilitation phase?

Suggest use of talking books.

4. The nurse is assisting the physician in a percutaneous liver biopsy. In which position would the nurse assist the client to assume?

Supine position

37. A client has been prescribed glucocorticoids for the treatment of congenital adrenal hyperplasia. Which should the nurse prioritize on the ongoing assessment for the client?

Take and record vital signs every 4 to 8 hours.

47. The nurse is caring for a client with a valvular disorder of the heart. What intervention should the nurse perform before administering the prescribed beta-blockers to clients with valvular disorders of the heart?

Take the client's apical pulse.

28. A nurse is preparing discharge teaching for a client who is prescribed glucocorticoid therapy. Which instructions should the nurse point out in the teaching plan for the client and caregivers?

Take the oral drug with meals or snacks.

42. The nurse is caring for a client who is following a treatment plan to decrease urinary tract infections. Which of the following indicates the need to change the treatment plan?

The client exhibits continued symptoms.

38. The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?" Given the client's condition, which statement is most correct?

The client is in shock because the blood volume has decreased in the system."

9. A client who is frightened of needles has been told that he will have to have an intravenous (V) line inserted. The client's blood pressure and pulse rate increase, and the nurse observes the pupils dilating. What does the nurse recognize has occurred with this client?

The client showing the fight-or-flight response.

31. The nurse is teaching the client about the upcoming endoscopic retrograde cholangiopancreatography (ERCP). Although the nurse instructs on several pertinent points of care, which is emphasized?

The client will change positions frequently throughout the procedure.

7. The nurse is caring for a client who has presented to the walk-in clinic. The client verbalizes pain on urination, feelings of fatigue, and diffuse back pain. When completing a head-to-toe assessment, at which specific location would the nurse assess the client's kidneys for tenderness?

The costovertebral angle

25. What is blood pressure?

The force produced by the volume of blood in arterial walls

28. The nurse is providing supportive care to a cllent recelving hemodialysis in the management of acute renal failure. Which statement from the nurse best reflects the ability of the kidneys to recover from acute renal fallure?

The kidneys can Improve over a period of months.

42. The nurse is completing a corneal light reflex test using a penlight. Which result would indicate a normal test result?

The light reflection is in the same spot on each eye.

32. An older adultclient, who leads a sedentary lifestyle, and a younger client, who has a very stressful and active lifestyle, require a vaccine against a particular viral disorder. The nurse knows that in one of these clients, the vaccine will be less effective. In which client is the vaccine more likely to be less effective and why?

The male client because of his age

47. A client's family member asks what hematopoiesis is. What should the nurse tell the family member?

The manufacture and development of blood cells

6. A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have?

The nurse ensures a written consent is obtained prior to testing.

44. The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern?

The patient has lost 10 pounds (4.5 kg) during the last month.

2. A client is scheduled to have a prick test to determine what specific allergens are creating problems for the client. What should the nurse inform the client is involved with the testing?

The skin will be scratched, and applying a small amount of the liquid test antigen to the scratch, usually on the back.

37. The nurse is caring for a client who is brought to the emergency department after being found unconsclous outside in hot weather. Dehydration is suspected. Baseline lab work Including a urine specific gravity is ordered. Which relation between the client's symptoms and urine specific gravity is anticipated?

The specific gravity will be high.

38. A client with several calculi in the ureter is scheduled for extracorporeal shock wave lithotripsy (ESWL). Which teaching statement by the nurse best describes the procedure?

The stone is identified via fluoroscopy and then shock waves are used to shatter the stones.

35. Which nursing instruction is correct to provide the client following a barium enema?

The stools may be a white or clay colored.

11. The nuree is caring for a client with a urinary tract infection anda urethral stricture. Which complication of the condition ie the primery cause of infection?

There is a backflow of urine causing a diverticulum.

27. A client is volunteering to donate blood for the second time and was mailed a letter telling him that he has type AB blood. If the client requires a blood transfusion in the future, what type of blood must he receive?

They can receive blood from persons with any type of blood if the Rh factor is compatible.

4. The nurse is performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would the nurse ask the client about the use of herbal supplements?

They may prolong bleeding.

32. The nurse is studying for a physiology test over the respiratory system. What should the nurse know about central chemoreceptors in the medulla?

They respond to changes in CO2 levels and hydrogen lon concentrations (pH) in the cerebrospinal fluid.

11. During a nutritional assessment, the nurse calculates that a female patient's BMI is 27. The nurse would advise the patient to follow which of these recommendations?

This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to weight. surgery?

47. Which group of clients should not receive potassium iodide?

Those who are allergic to seafood

7. A nurse is preparing a teaching session for a client who is prescribed miglitol. The nurse would instruct the client to administer this drug at which time?

Three times a day with the first bite of a meal

13. A clent comes to the occupational health nurse complaining of eye irritation. The client works in a dusty, outdoor environment. Why should the nurse advise perlodic blinking to this client?

To clear the dust and particles from the surface of the eyes

7. A client that is HV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication does the nurse expect that the client will take for the treatment of this infection?

Trimethoprim-sulfamethoxazole

15. At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia?

Tumor that secretes excessive antidiuretic hormone (ADH)

41. The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement?

Turn the client to the side and allow the client to sleep.

13. A client with type 2 diabetes asks the nurse why he can't have a pancreatic transplant. Which of the following would the nurse include as a possible reason?

Underlying problem of insulin resistance

21. The nurse is assessing a client brought to the emergency department for systemic complications after a traumatic event. Which assessment finding is most suggestive of an intact urinary tract?

Urine output is pink and noted at 300 mL

47. A client has exhibited.repeated return of hordeolum (sty). Which assessment finding is most important in determining care for this client?

Use of mascara

The nurse is caring for a client who has chronic urinary retention and discussing the options. When discussing care, which intervention is considered first?

Using the Credé's maneuver

34. A group of student nurses are preparing for a health fair and will be administering vaccines to the public. The instructor determines the group is well prepared after noting they are prepared to document which information after each administration? Select all that apply.

Vaccine lot number Vaccine expiration Route and site of vaccine administration

41. The nurse is preparing to administer erythromycin otic to a client. The nurse will question this prescription if which diagnosed eye disorder is noted in the client's medical record? Select all that apply.

Varicella infection Fungal infection Mycobacterial infection Epithelial herpes simplex keratitis

10. What is the difference between respiration and ventilation?

Ventilation is the movement of air in and out of the respiratory tract.

45. A nursing instructor is teaching the concept of immunity. The instructor determines that the session was successful when the students correctly choose that cell-mediated immunity protects the body against what type of infections? Select all that apply.

Viral Fungal Bacterial

46. Which important teaching point should the nurse include in the plan of care for a patient diagnosed with Cushing's disease?

Wash hands frequently

30. The nurse is monitoring a client who has recently begun levothyroxine therapy. Which assessment findings will the nurse prioritize when conducting the ongoing assessment? Select all that apply.

Welght loss Elevated body temperature Tachycardia Insomnia

21. In order to provide the best intervention for a patient. the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide?

What specific type of pathogen is causing an infection.

15. The caregivers of a young child present to the emergency department wth reports that the child ingested something they shouldn't have. Which assessments should the nurse prioritize before administering an antiemetic to this young client? Select all that apply.

What time was the substance ingested What chemicals or substances were ingested? What is the client's blood pressure?

39. A client is admitted to an acute care facility with a diagnosis of appendicitis. Which laboratory results demonstrate the client's leukocytosis?

White blood cell (WBC) count of 22,000 cells/mm3

44. A nurse is caring for a client who is prescribed 1% hydrocortisone/4.71 mg neomycin for bacterial infection of the èxternal auditory canal. Which instructions should the nurse utilize when administering the otic solution?

With the client upright, remove the solution running out of the ear with gauze.

46. A nurse has administered nitrofurantoin to a client who is now reporting dyspnea, chest pain, and is coughing. Which action should the nurse prioritize?

Withhold the drug and contact the primary health care provider.

45. A nurse administers chiorothiazide to a client with renal compromise. Which action should the nurse prioritize after noting the BUN level is rising?

Withhold the next dose of the drug.

50. What is the nurse's best response about developing diabetes to the patient whose father has type 1 diabetes mellitus?

You have a greater susceptibility for development of the disease because of your family history."

38. An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse's best response?

You should see an improvement in the next week or so. Call if this continues."

19. The nurse is caring for a client with infective endocarditis. The nurse teaches the client that he will have to take antibiotics periodically for the rest of the client's life. The client wants to know why. What would be the nurse's best answer to the client?

You will be vulnerable to infective endocarditis for the rest of your life."

47. The nurse is instructing the client on frequent sensations experienced when a contrast agent is injected into the body during diagnostic studies. Which sensation is most common?

a warm sensation

11. The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?

abdominal distension

19. A client has undergone a renal transpiant and returns to the health care agency for a follow-up evaluation. Which finding would lead to the suspicion that the client is experiencing rejection?

abdominal pain

29. The nursing instructor is teaching a group of nursing students comparing the different classes of diuretics. The instructor determines the session is successful when the students correctly choose which drugs as affecting carbonic anhydrase? Select all that apply.

acetazolamide methazolamide

20. The nurse is reviewing lab work for a client whose blood CO2 level is elevated. The nurse is most correct to suspect an impairment of which?

alveoli

36. A nurse should read the instructions stated on a vial container before reconstituting it and administering it to a client. Which instructions are stated on the label of a vial container?

amount of diluent to be added

32. Which of the following diagnostic tests would the nurse expect to be ordered to determine the details of the arterial supply to the kidneys?

angiography

17. A nurse is teaching a client on the use of the otic drops, which contain 1% hydrocortisone, 2% acetic acid, 3% propylene glycol, 0.015% sodium, and 0.02% benzethonium chloride. The nurse should point out the preparation exerts the action of which category? Select all that apply.

antibacterial antifungal corticosteroid

25. The nurse is employed in an urologist office. Which classification of medication is anticipated for clients having difficulty with urinary incontinence?

anticholinergic

25. The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated?

antihistamine

40. A nurse in the emergency department is assessing a client who has been bitten by a coral snake. Which drug does the nurse predict the client will be given as treatment?

antivenin

31. The nurse is teaching a client about the prescribed metolazone and providing suggestions for foods to eat which will help increase potassium consumption. The nurse determines the teaching is successful after the client correctly chooses which foods? Select all that apply.

asparagus salmon bananas peanuts

50. Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing?

audiologist

12. The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other?

awaken the client every two (2) hours

5. The nursing instructor is teaching a session explaining the various drugs used to treat urinary tract infections. The instructor determines the session is successful when the students correctly choose which organ as most often affected by infections?

bladder

1. After teaching a group of nursing students about various ophthalmic drugs, the iInstructor determines that the teaching was successful when the students correctly choose which drug as a carbonic anhydrase inhibitor?

brinzolamide

32. When caring for a client with angina, the nurse instructs the client to place the nitroglycerin tablet between the cheek and the gums. Which form of nitroglycerin is the nurse administering?

buccal

11. A nurse is monitoring a cllent who is prescribed short-term high-dose methylprednisolone. Which assessment findings should the nurse prioritize? Select all that apply.

buffalo hump moon face

2. Following a parathyroidectomy, which electrolyte should the nurse most closely monitor?

calcium

49. The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis?

chemical irritation

9. The nurse is caring for a client with thrombophlebitis. When assessing this client, what would be most important to assess for?

chest pain and dyspnea

18. The nurse is assessing a 6-year-old child in the emergency department (ED) who was brought in by the mother. The child was stung by a bee and is allergic to bee venom. The child is now having trouble breathing, and is vasodilated, hypotensive, and broken out in hives. What does the nurse suspect is wrong with this child?

child is having an allergic reaction and going into anaphylactic shock.

33. When a client's gallbladder has decreased ability to release bile when he is having a high fat content meal, what hormone is not released to stimulate contractions of the gallbladder?

cholecystokinin

30. The nurse is caring for an older adult client with an V infusing at 100 mL/hr. What should the nurse monitor this client for?

circulatory overload

6. The nurse is instructing a client prior to a colonoscopy. The client states, "Why do I have to drink this disgusting liquid?" The nurse is most correct to verbalize the goal of the oral preparation as which of the following?

cleanse the bowel to promote clear visualization of structures"

3. A pacemaker is the treatment of choice for what cardiac arrhythmia?

complete heart block

42. The nurse is assessing a client of color for jaundice. In which location would the nurse assess for discoloration? Select all that apply.

conjunctiva hard palate gums sclera

37. What happens to the diaphragm during inspiration?

contracts and flattens.

5. Which of the following would be considered a mechanical defense mechanism?

coughing

43. A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?

decompensation

33. A client with diagnosed aortic stenosis is exhibiting fatigue, shortness of breath on exertion, and systolic murmur. Which of the following would the nurse list as the most concerning nursing diagnosis?

decrease cardiac output

25. A nurse is preparing to teach a client about the antacid magnesium oxide which the health care provider has prescribed. Which adverse reactions should the nurse point out to the client? Select all that apply.

dehydration diarrhea hypotension

47. A client has a full bladder. Which sound would the nurse expect to hear on percussion?

dullness

41. A nurse is conducting a preadministration assessment of a client prescribed the MMR and varicella vaccine. The nurse will question this order if which allergic reaction is noted in the client's past history? Select all that apply

eggs Neomycin Gelatin

19. A nurse is preparing to administer otic drops which contain benzocaine, antipyrine, and glycerin. The nurse predicts these drops provide which type of action? Select all that apply.

emolient local anesthetic analgesic

48. The nurse is instructing a 3-year-old's mother regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as normal finding for this age group?

enuresis

17. A group of students are reviewing material about endocrine system function. The students demonstrate understanding of the information when they identify which of the following as secreted by the adrenal medulla?

epinephrine

33. The nurse is providing community education at the mall. The nurse is instructing on the muscular tube that connects the mouth to the stomach. The nurse outlines this structure on a drawing and labels it with which of the following?

esophagus

39. A client is admitted to the health care facility with acute glaucoma. After administering the prescribed ophthalmic drugs, the nurse continues to assess the client for pain relief at which frequency?

every 2 hours

1. The nurse is caring for a client status postnasal polypectomy. What would the nurse instruct this client to report?

excessive swallowing

41. A clent is admitted with the diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNKS) following steroids therapy. Which of the following symptoms are associated with HHNKS? Select all that apply.

extreme thirst poor skin turgor

31. When assessing an infant for a possible ear infection, which behaviors would the nurse note? Select all that apply.

fever irritability ear tugging change in behavior

22. A client with type 1 diabetes mellitus is receiving short-acting insulin to maintain control of blood glucose levels. In providing glucometer instructions, the nurse would instruct the client to use which site for most accurate findings?

finger

38. A client asks the nurse if it would be okay to take ginger to aid with digestion. Before telling the client it is okay to take ginger, the nurse should assess the client's history for which medical conditions? Select all that apply.

gallstones hypertension

32. A nurse is preparing to administer an ophthalmic solution to a client who is diagnosed with a bacterial ocular infection. Which drug would the nurse predict that will be prescribed? Select all that apply.

gatifloxacine tobramycine

39. When teaching a client who is receiving cytomegalovirus immune globulin, the nurse would alert the client to the possibility of which reaction? Select all that apply.

headache chills urticaria angioedema

20. The nurse is preparing to teach a client diagnosed with glaucoma about the medication which the primary health care provider has prescribed. Which adverse reactions should the nurse point out in the session? Select all that apply.

headache blurred vision tearing ocular burning

5. The nurse is caring for a patient who has undergone a thyroidectomy. Which patlent complaint is highest priority requiring further evaluation?

hoarsness

21. Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia?

hypomagnesemia

44. A nurse is preparing to administer bicarbonate to a client who is also prescribed fluoroquinolones. Which potential situation will the nurse carefully monitor the client for after administering these two drugs?

increased risk of crystalluria

7. The nursing instructor is discussing with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it Points: as a procedure performed for diagnostic purposes or to aspirate accumulated excess fluid or air from the pleural space. What would the instructor tell the students purulent fluid indicates?

infection

5. When examining the abdomen of a client with complaints of nausea and vomiting, which of the following would the nurse do first?

inspection

14. A client is admitted in acute renal failure and prescribed mannitol. The nurse prepares to administer this drug via which route?

intravenously

6. A client is admitted in acute renal failure and prescribed mannitol. The nurse prepares to administer this drug via which route?

intravenously

45. The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for?

iodine allergy

22. A nurse is teaching a client about the use of the otic drops containing 1.4% benzocaine, 5.4% antipyrine, and glycerin. The nurse would point out which possible adverse reactions to the client? Select all that apply.

irritation pruritus burning

20. A nursing instructor is teaching her class about burns. The instructor relates the following scenario: A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client?

kidney stones and blood clots

35. A client is admitted to the emergency department in hypertensive crisis. The nurse will prioritize which assessment to monitor for potential damage as this client receives emergent treatment? Select all that apply.

kidneys eyes heart

8. A client with lymphedema in the left arm has weeping from the skin and has a small 2-cm ulcer on the upper arm. What test does the nurse anticipate the client will be prepared for?

lymphangiography

9. The nurse is caring for a client who has just had total parenteral nutrition (TPN) ordered. The nurse is correct when informing the client that TPN is used for what?

meet the client's caloric and nutritional needs

29. A nurse has administered ammonium chloride to a client as prescribed. Which assessment finding will the nurse prioritize?

metabolic acidosis

15. A nurse is preparing to administer vasopressin to a client. The nurse will exercise caution if which disorder is noted in the client's medical history? Select all that apply.

migraine headaches angina seizure disorders asthma

42. The nurse is teaching a client about the dietary restrictions related to his diagnosis of hyperparathyroidism. What foods should the nurse encourage the client to avoid?

milk

6. A nurse is teaching a client with glaucoma about the prescribed eye drops. The nurse emphasizes the importance of therapy to prevent which complication? Select all that apply.

nerve damage blindness visula loss

18. The nurse is instructing the client with sickle cell disease about the use of an inhaled vasodilator that may reduce sickling. What medication is the nurse instructing the client about?

nitric oxide

2. The nurse is assisting with the administration of a caloric stimulation test. Which response would the nurse document as an expected response?

nystagmus

44. A nursing instructor is teaching a group of nursing students about type 2 diabetes. The Instructor determines the session is successful when the students correctly choose which as a risk factor for individuals developing type 2 diabetes?

obesity

12. A client is experiencing gastrointestinal (GI) bleeding from ruptured esophageal varices. What medication does the nurse prepare for administration that mimics the actions of somatostatin that will reduce the GI bleeding?

octreotide

21. A client is diagnosed with an infection with H. pylori. The nurse anticipates the client will be prescribed which drug in combination with an antibiotic? Select all that apply.

omeprazole lansoprazole

36. The nurse is assisting in providing coordination of services between the physician's office and vision specialist's office for a client who is being referred for potential retinal surgery. Which eye care specialist will the nurse make the referral to?

ophthalmologist

11. The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see?

pH low, PaCO2 high, HCO3 high

8. The nurse is working with clients with digestive tract disorders. Which of the following organs does the nurse realize has effects as an exocrine gland and an endocrine gland?

pancreas

5. A nursing instructor is teaching a session illustrating the various forms of immunity utilized by the human body. The instructor determines the session is successful when students correctly choose which type of immunity as developing after the use of ready- made antibodies from animals?

passive immunity

35. A client would like to use carbamide peroxide and asks the nurse if this is okay. The nurse would caution the client to avoid using this product if which situation is present? Select all that apply.

perforated eardrum ear drainage

16. The nurse is teaching a client with arrhythmia about the prescribed verapamil. Which potential adverse reaction should the nurse point out to the client?

peripheral edema

48. A client is prescribed an inhaled corticosteroid. The nurse would instruct the client about which as a possible adverse reaction? Select all that apply

pharyngeal irritation fungal infection

15. A client with a nonproductive cough is prescribed codeine sulfate. The nurse will question this order for clients with which history?

premature infant

37. A client receiving antiarrhythmic therapy develops a new arrhythmia potentially due to the administration of the drug. The nurse predicts this is related to which reaction?

proarrhythmic effect

41. The nurse is preparing to administer a codeine-containing antitussive to a client. The nurse will exercise caution if which additional situation is noted in the client's medical history? Select all that apply.

prostatic hypertrophy pregnancy convulsive disorder

36. A nurse is preparing to administer V fat emulsions to a client. The nurse will exercise caution when administering this solution after discovering the client also has which disorder noted in the medical record?

pulmonary disorder

33. The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGS) to determine various factors related to blood oxygenation. What site can ABGS be obtained from?

puncture at the radial artery

12. A forest ranger arrives at a community clinic for prophylactic vaccination. The nurse predicts the health care provider will prescribe which vaccine for this client?

rabies vaccine

18. When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the physician?

really don't like to be in small, enclosed spaces."

26. A nurse is preparing to administer carbamazepine to a client. The nurse should question the health care provider about this order if which disorder is noted in the client's history?

renal impairment

43. The nurse is caring for a client ordered multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?

retinal angiography

4. A client who is right-handed is to receive a booster injection for a previous vaccination. The nurse prepares to administer the injection at which site?

right arm

42. The nurse is completing a teaching session with a client with heart failure. The nurse determines that additional teaching is needed about the cardiotonic drug therapy when the client states which comment?

should call if my pulse rate is below 80 beats per minute.

9. The nurse is answering questions regarding fecal matter for a client who is scheduled for a colon resection, The client is asking questions regarding the composition of the fecal matter and when it becomes a formed mass. The nurse is most correct to state at which location?

sigmoid colon

13. The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body?

small Intestine

37. The nurse is caring for a geriatric client experiencing diarrhea. When instructing on the body sité where water and electrolytes are absorbed, the nurse is most correct to instruct on which location?

small bowel

1. After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected?

stomach

13. A nurse is preparing to administer methenamine to a client for UTI The nurse will question this order if the client is noted to be allergic to which substance?

tartrazined

38. A health care provider has ordered an lodine procedure for a client with thyroid dysfunction. What should the nurse prioritize in the preadministration assessment for the client? Select all that apply.

temperature pulse weight allergy history

28. The nurse is caring for a client diagnosed with coryza, possibly from the rhinovirus. Vital signs are temperature: 101.2°F, pulse: 72 beats/minute, respirations: 28 breaths/minute, and blood pressure: 112/70 mm Hg. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are course in the bases. Which afternoon assessment finding suggests the advancement to an infectious process?

temperature rise

31. A client needs additional information about her heart condition. The client states to the nurse, "What is considered the pacemaker of the heart?

the SA node

32. A client diagnosed with cancer has his tumor staged and graded based on what factors?

they tend to grow and the cell type

47. The nurse is teaching a health class in the local public health center, What instructions should the nurse provide as the single most important measure to prevent the spread of infection?

thorough handwashing

40. A client with an immunodeficiency disorder does not have an adequate number ofT lymphocytes in order to improve his immune function. Which gland should be investigated for dysfunction?

thymus

4. The nurse is conducting an assessment on a client who is reporting ear pain. Which factors should the nurse prioritize in the assessment questioning? Select all that apply.

tinnitus feeling of fullness in the ear change in hearing dizziness

43. The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer, What risk factors would the nurse be sure to include in the workshop? Select all that apply.

tobacco industrial polluants alcohol

14. A nurse is caring for a client who has frequent upper respiratory infections. Which structure is most helpful in protecting against infection?

tonsils

13. What is the best technique to identify structural changes in the mitral valve?

transthoracic echocardiogran

24. The nurse has administered gonadotropin to a client. Which assessment finding should the nurse prioritize?

visual disturbances

46. A client with respiratory depression is prescribed appropriate treatment by the health care provider. The nurse will monitor the client for which potential reaction?

vomiting

39, The client is scheduled for a breast lump excision and sentinel node biopsy. What should the nurse know in planning care for the client with a negative biopsy report?

wide excision of lump will be performed.

11. The nursing instructor is teaching a group of students about the various medications used to treat hypertension. After the session the instructor determines the session is successful when the students correctly connect which actions with calcium channel blockers? Select all that apply.

❤️Decreased blood pressure ❤️Increased oxygen supply to the heart ❤️Reduced workload on the heart ❤️Relaxation of blood vessels

36. The nurse is teaching a client, who has been prescribed warfarin, about maintaining a consistent intake of foods with vitaminK The nurse determines the client is prepared after correctly choosing which foods as high in vitamin K? Select all that apply.

🐟fish yogurt cauliflower broccoli

49. The student nurse is preparing to administer heparin subcutaneously to a client. The Instructor determines the student is well prepared by articulating which steps? Select all that apply.

🔅Apply firm pressure after injection 🔅Pinch a fold of skin 🔅Change sites for each dose

46. A nursing instructor is teaching a class on the actions of the different classes of diuretics. Which drugs will the instructor point out as exerting action on the loop of Henle and distal and proximal tubules? Select all that apply.

🔅Bumetanide 🔅Furosemide

50. The nurse is preparing to administer an antivenin to a client. The nurse will explain to the client that the antivenin will provide passive, transient protection against bites from which organisms? Select all that apply.

🔅Copperhead snake 🔅Black widow spider 🔅Rattlesnake

26. The nurse is preparing to administer ferrous to a client. The nurse will question this order if which disorder is noted in the cient's medical history? Select all that apply

🔅Hemochromatosis 🔅Hemolytic anemia

16. A client is prescribed amitriptyline, an antidepressant for incontinence. The nurse understands which of the following reasons that this drug is an effective treatment? Select all that apply.

🔅Increases bladder neck resistance 🔅Decreases involuntary bladder contractions

6. A nursing instructor is teaching a class on the action of statin drugs. The instructor determines the class is successful after the students correctly choose which actions? Select all that apply.

🔅Inhibit cholesterol production 🔅Decrease cholesterol absorption in GI tract 🔅Promote cholesterol breakdown

5. The nurse is mentoring a new graduate nurse, caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would the nurse respond? Select all that apply.

🔅Injury to the laryngeal nerve 🔅Infection 🔅Aspiration

27. A client is administered a bronchodilator during an acute asthma attack. As the client's condition improves the nurse will prioritize which assessments? Select all that apply.

🔅Intake 🔅output 🔅lung sounds 🔅accessory muscle use

15. A nursing instructor is teaching a class on the different types of blood cells. The instructor will point out which actions as functions of the various blood celis? Select all that apply

🔅Leukocytes supply cells with oxygen from the tungs. 🔅Megakaryocytes control bleeding from tears in tissues. 🔅Leukocytes protect the body from organisms. 🔅Erythrocytes supply cells with oxygen from the lungs.

29. The nurse is teaching a client with asthma how to administer the necessary medications in a time of crisis. The nurse determines the session is successful when the client correctly chooses which medication s are to be used as rescue inhaler? Select all that apply

🔅Metaproterenol 🔅Albuterol

41. The nurse is conducting the ongoing assessment on a client who is prescribed anticoagulant. The nurse will alert the health care provider if which findings are noted on the assessment? Select all that apply.

🔅PT exceeds 1.5 times the control value. 🔅INR is greater than 3.0. 🔅There is evidence of bleeding.

21. A nurse is preparing to administer the prescribed digoxin. After appraising the morning laboratory results, the nurse determines caution is warranted with which result? Select all that apply.

🔅Potassium 3 mEg/L 🔅Magnesium 1.0 mEq/L 🔅calcium 4.3 mEq/L

28. The nursing instructor is teaching a class about the actions of anticoagulants. The instructor determines the class is successful when the students correctly choose which as actions of anticoagulants? Select all that apply.

🔅Prevent extension of a thrombus. 🔅Prevent formation of a thrombus.

20. The nurse is preparing to administer IGM to some clients. The nurse will question this prescription if which information is noted in the client's medical record? Select all that apply.

🔅Receiving vancomycin 🔅Diabetes mellitus 🔅Age 65 ye ars or older 🔅Pre-existing renal disease

16. A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.

🔅Respond to thirst. 🔅Drink at least eight glasses of fluid each day. 🔅Drink water as an inexpensive way to meet fluid needs.

9. A nurse is preparing a care plan for a client with megaloblastic anemia.. When discussing nutritional recommendations, which foods should the nurse prioritize? Select all that apply.

🔅Salmon 🔅Chicken 🔅Wheat bread 🔅Collard greens

23. The public health nurse is giving a talk on the warning signals of cancer to a local community group. Which of the following are the warning signals of cancer? Select all that apply.

🔅Sores that don't heal 🔅Unusual bleeding or discharge 🔅Persistent indigestion

40. What disease processes contribute to chronic heart failure? Select all that apply.

🔅Tachydysrhythmias 🔅Renal failure 🔅Valvular dlsease

21. The nursing instructor is teaching a session on the thyroid and its hormones. The instructor determines the class is successful when the students correctly choose which hormones as originating in the thyroid gland? Select all that apply.

🔅Thyroxine 🔅Tri-lodothyronine

1. The nurse is conducting an ongoing assessment after the administration of an antihypertensive. Which findings should the nurse prioritize? Select all that apply.

🔅Weight gain of 2 Ib. or more per day 🔅Edema

34. A client is admitted to the emergency department with reports of anginal pain. Which assessments should the nurse prioritize? Select all that apply.

🔅apical pulse 🔅radial pulse 🔅blood pressure 🔅respiratory rate

3. The nursing instructor is discussing allergic reactons with her clinical group. What allergic reactions would the nursing instructor talk about? Select all that apply.

🔅atopic 🔅immune complex 🔅cytotoxic

35. A nurse is preparing to teach a client about the sargramostim which has been prescribed. Which adverse reactions should the nurse caution the client about related to this drug? Select all that apply.

🔅bone pain 🔅rash 🔅nausea

20. The nurse is preparing to administer nitrofurantoin to a client with a UTI. The nurse will carefully monitor the client after administering the drug if which disorder is documented in the client's medical record? Select all that apply.

🔅cerebral arteriosclerosis 🔅diabetes 🔅Glucose-6-phosphate dehydrogenase (G6PD) deficiency

24. A client presents to the clinic with a cough that is getting worse. The client reports having used over-the-counter dextromethorphan. Which findings on assessment should the nurse prioritize after noting the client is prescribed phenelzine? Select all that apply.

🔅coma 🔅fever

24. The nurse has administered atorvastatin to a client. Which assessment findings should the nurse prioritize? Select all that apply.

🔅constipation 🔅insomnia 🔅headache

10. The nurse is preparing to administer amiloride to a client. The nurse will exercise caution if the client is diagnosed with which disorder? Select all that apply.

🔅diabetes 🔅gout 🔅hepatic disease

15. A nurse is administering amiloride to several clients. The nurse should prioritize monitoring the serum potassium levels for clients with which noted disorder? Select all that apply.

🔅diabetes 🔅renal disease

48. A client has been receiving a diuretic as prescribed. Which findings on the ongoing assessment should the nurse prioritize? Select all that apply

🔅dry mouth 🔅muscle cramps 🔅tachycardia

8. The nurse is assessing a client diagnosed with left ventricular dysfunction. Which symptoms would the nurse most likely assess? Select all that apply.

🔅dyspnea 🔅moist cough

26. A client is prescribed normal saline M. The nurse will exercise caution after noting disorders in the client's medical record? Select all that apply.

🔅edema 🔅hypoproteinemia 🔅renal impairment

10. A nurse is conducting a preadministration assessment of a client prescribed the MMR and varicella vaccine. The nurse will question this order if which allergic reaction is noted in the client's past history? Select all that apply.

🔅eggs 🔅neomycin 🔅gelatin

17. A group of nursing students are analyzing the various triggers for arrhythmias. The instructor concludes that the students grasp the information by correctly choosing which factors as a potential trigger for an arrhythmia? Select all that apply

🔅electrolyte imbalance 🔅hypoxia 🔅emotional stress 🔅heart disease

25. The nurse has administered methoxy polyethylene epoetin beta to a client with chronic kidney disease. Which findings on the ongoing assessment should the nurse prioritize?Select all that apply.

🔅fatigue 🔅hypertension 🔅arthralgia

33. A nursing instructor is teaching the concept of immunity. The instructor determines that the session was successful when the students correctly choose that cell-mediated immunity protects the body against what type of infections? Select all that apply.

🔅fungal 🔅viral 🔅bacterial

16. A nurse is preparing to administer oprelvekin to a client. The nurse would administer the drug cautiously to the client if which disorder is noted on the preadministration assessment? Select all that apply.

🔅heart failure 🔅renal failure 🔅atrial fibrillation

10. The nurse is preparing to administer a diuretic to a client. The nurse should question this order if which disorder is noted in the client's history? Select all that apply.

🔅hyponatremia 🔅hypokalemia 🔅anuria

16. An elderly client is prescribed an antihistamine. Which finding on the ongoing assessment should the nurse prioritize? Select all that apply.

🔅hypotension 🔅dry mouth 🔅sedation

38. The nurse is monitoring a client who is receiving intravenous heparin. Which assessments should the nurse prioritize for this client? Select all that apply.

🔅itching 🔅inflammation 🔅pain 🔅tenderness

30. The nurse is preparing a presentation for a local health fair to explain various aspects of hypertension. Which factors should the nurse include when pointing out various risk factors which can increase the potential of developing hypertension? Select all that apply.

🔅lack of potassium in the diet/ 🔅chronic alcohol use 🔅obesity

50. The nurse is preparing to teach a group of middle-aged client's ways to reduce hypertension. Which instructions should the nurse point out during this session? Select all that apply

🔅lose weight 🔅reduce stress 🔅stop smoking

40. A nurse conducts a daily urine pH as part of the ongoing assessment of a client with a UTL The nurse will utilize this test to establish the effectiveness of which drugs? Select all that apply.

🔅nitrofurantoin 🔅methenamine

49. A nurse notes on assessment of a client receiving furosemide a decrease in urinary output. Which drugs should the nurse suspect is affecting the diuretic? Select all that apply.

🔅phenytoin 🔅naproxen 🔅Ibuprofen

41. A nurse is educating a client receiving sulfamethoxazole/trimethoprim about common dermatologic adverse reactions. The nurse determines the session is successful when the client correctly chooses which reactions to watch for? Select all that apply.

🔅rash 🔅pruritus 🔅photosensitivity

44. The nurse is preparing to administer furosemide to a client. Which factors should the nurse prioritize on the preadministration assessment? Select all that apply.

🔅respiratory rate 🔅pulse 🔅weight 🔅temperature

23. The nurse is preparing a teaching session for a client who is being discharged with a prescription for clopidogrel. Which potential adverse reactions should the nurse point out are associated with this drug? Select all that apply.

🔅skin rash 🔅constipation

24. The nurse is preparing to administer furosemide to a client. Which factors should the nurse prioritize on the preadministration assessment? Select all that apply.

🔅temperature 🔅pulse 🔅weight 🔅respiratory rate

5. A nurse is analyzing the chemistry profile of a client diagnosed with hyperlipidemia. Which measurements will the nurse prioritize on the lipid profile? Select all that apply.

🔅total cholesterol 🔅LDL 🔅tryglyceride

23. The nurse is preparing to administer an antitussive to a client. Which assessments will the nurse prioritize in the preadministration assessment? Select all that apply.

🔅type of cough 🔅temperature 🔅sputum presence

2. What are the conditions that make up Virchow's triad? Select all that apply.

🔅venostasis 🔅disruption of the vessel lining 🔅hypercoagulability

37. The nurse is caring for a clilent who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer?

Allergic reaction to the imaging material

19. The client complains that the intravenous (M) site is stinging. No signs of infiltration or inflammation are assessed, but the nurse notices the rate is running faster than ordered. Which action should the nurse take first?

Reset the drip rate.

6. While administering a medication via a syringe, a client sharply moves and the nurse accidentally encounters a needlestick. What is the priority nursing action?

Report the needlestick to the nurse manager.

6. The nurse is monitoring a client who has received naloxone as emergent treatment. Which reaction should the nurse prioritize if noted on the ongoing assessment?

tremors

31. A nurse needs to administer a prescribed heparin injection to a client subcutaneously. Which syringe ensures accuracy when administering heparin subcutaneously?

tuberculin syringe

43. A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an antileptic. What should the nurse suggest to the client?

use caution while driving or performing hazardous activities.

28. A client arrives at the emergency department complaining of severe diarrhea and vomiting that began after ingesting a hot dog at the ball park 6 hours ago. How does the nurse understand that the contaminated food was transmitted to the client?

vehicle

44. The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.

🔅Administer mild sedatives 🔅Ensure the pulse oximeter reading is higher than 93% 🔅Administer stool softeners daily

21. A client is receiving an opioid analgesic. Assessment reveals that the respiratory rate has dropped. Which steps would the nurse expect to implement? Select all that apply.

🔅Coaching of the client to breathe 🔅Naloxone administration

40. A nurse has to administer a subcutaneous injection to a client. For which client can the nurse administer a subcutaneous injection at a 90-degree angle?

obese clients

20. The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?

Report any febrile illness

16. The intensive care unit nurse is caring for a client with a transmissible spongiform encephalopathy. The nurse knows that this type of encephalopathy is caused bywhat type of infectious agent?

prion

41. Which action by a licensed practical nurse (LPN) requires immediate intervention by the registered nurse (RN)? (Select all that apply.)

🔅flushing an implanted central venous access device 🔅administering packed red blood cells to a client with anemia

32. A nurse has administered naloxone to a client emergently. The nurse will continue to monitor the client for the development of which possible adverse reactions? Select all that apply.

🔅nausea 🔅tremors 🔅tachycardia

42. A nurse is monitoring a client who is receiving an opioid for pain management. Which adverse reaction will the nurse monitor this client for? Select all that apply.

🔅respiratory depression 🔅miosis 🔅constipation

24. A group nursing students have begun learning about the rationale technique administering injections. The students should identify which of the following parts of a syringe? Select all that apply.

🔅tip 🔅plunger 🔅barrel

29. A nurse is conducting an assessrment on a dient who is admitted with Parkinson disease. Which potential findings wll the nurse anticipate noting on the physical assessment? Select all that apply.

🔅tremors 🔅slurred speech

17. A nurse is conducting an ongoing assessment of a client who is prescribed trimethadione. Which findings on the assessment should the nurse prioritize and contact the primary health care provider? Select all that apply.

🔅visual disturbance 🔅easy bruising 🔅fever 🔅sore throat

27. As part of a postsurgical client's regimen for deep vein thrombosis prevention, she is to receive 5000 units of heparin subcutaneously b.i.d. How can the nurse reduce this client's risk of bruising at the injection sites?

By changing the needle after withdrawing the drug from the vial

36. The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications?

Carbidopa makes more levodopa available to the brain.

50. The nurse is caring for a client who has had intracranial surgery and is being discharged home. What instructions would the nurse give the client besides instructions on the medication?

Expect sensory changes, such as hearing a clicking souund around the bone flap.

49. What would the nurse do to best assist the client in increasing peristalsis and encouraging defecation after suffering from a neurologic deficit?

Help the client to the bathroom at a particular time each day.

23. The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?

Herniation occurs through the foramen magnum.

27. A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client disturbed, and the choreiform movements are worsening. Which nursing diagnosis best verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is reflects the needs of this client?

Hopelessness

9. The nurse is caring for a 55-year-old client on a rehabilitated unit following a cerebrovascular accident (CVA). The nurse is instructing on range-of-motion exercises when the client begins to cry. The client states she has always taken care of the family and does not want to be a burden. Which nursing diagnosis would the nurse add to the plan of care?

Ineffective Role Performance related to inability to function in family role

35. The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement?

Initiate seizure precautions

33. The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside?

Intubation tray and suction apparatus

34. A client is scheduled for a test that requires an NPO status and has been ordered 5% dextrose in water (DsW). The nurse understands which of the following to be the best rationale for this action?

Isotonic solutions maintain body fluid balance.

10. The client asks the nurse why it is necessary to prime the intravenous tubing. What is the best response by the nurse?

It eliminates air and potential of complications."

39. A client has developed a hepatic injury related to the administration of tolcapone. Which activity does the nurse anticipate will be added to the plan of care for this client?

Perform regular blood tests of the client

50. The nursing instructor is teaching student nurses about venipuncture techniques and possible complications from the procedure. What can happen if the venipuncture device is left in the clients' vein too long?

Phlebitis can develop.

4. A nurse needs to administer an intramuscular injection to a thin and frail elderly client. Which of the following actions should the nurse perform to avoid striking the bone when injecting?

Pinch the muscular tissue.

16. The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis?

Positive Kernig's sign and nuchal rigidity

38. A nurse spills a bottle of antine stic drug on the unit floor. What should the nurse do to avoid self-contamination with the antineoplastic drug?

Pour a 70 percent alcohol solution over the drug spill.

49. Before instilling any additives to a client's medication lock, normal saline is used to flush the device. Which of the following provides the best rationale for this action?

Prevents drug/solution incompatibilities

8. A nurse is showing an older adult client the correct method of self-administering an insulin injection at home. What should the nurse tell the client in order to avoid lipoatrophy and lipohypertrophy?

Rotate the site with each injection.

19. A home health nurse is assisting the wheelchair-dependent, post-cerebrovascular accident client in transition from the rehabilitative center to home. Which of the following concerns would the nurse address first when assessing the client's home?

Steps to the front door

10. Which nursing assessment finding is most indicative of a hemorrhagic stroke?

Sudden onset of breathing alterations

18. The nurse is performing a Glascow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client's GCS one (1) hour ago was scored at 10. Which data indicates the client is improving?

The current GSC rating is 12.

develops acute pain while the drug is being administered. Which factor should the nurse 47. A nurse is caring for a client who is receiving naloxone intravenously. The client investigate first?

The drug was administered as too rapid a dose.

3. The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first?

Turn the client to the side to allow the secretions to drain from the mouth

5. When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data?

When, if any, was your last narcotic use?

13. A nurse needs to combine two different prescribed drugs in a syringe and then administer them to a client with influenza. Which precaution should the nurse take when combining drugs?

Withdraw exact amounts of each drug from each container.

46. A nurse is administering an intramuscular injection to a client using the Z-track method. Which action should the nurse perform to prevent leaking and ensure sealing of medication in the subcutaneous and dermal layers of tissue?

Withdraw the needle and release taut skin immediately after injection.

45. The nursing instructor is discussing about the different types of V fluids with the nursing students. What type of fluid would the instructor tell the students to be used replace circulating blood?

colloid solutions

1. A client comes to the clinic with complaints of fever, chills, and coughing and is found be positive for influenza. The nurse is aware that the flu is transmitted from one infected person to another. What type of infection is this considered?

community-aquired

29. The emergency department nurse is caring for a client who has just been admitted by ambulance for a suspected myocardial infarction. The physician orders V fluids of normal saline to be hung at 100 mL/hr. The nurse knows that this is what type of IV solution?

crystalloid

43. The nurse caring for a client with an intravenous infusion is looking up her institution's policy on changing M equipment used in a venipuncture. When is most V tubing changed?

every 72 hours

12. A nurse needs to administer an intradermal injection to a client. What is the most common site for administering an intradermal injection?

forearm

48. The nurse would expect to hang which of the following intravenous (M) solution to a client with cerebral edema?

hypertonic solution

8. The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae with bone from which location?

iliac crest

37. A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which injection can be administered at this angle?

intradermal

25. After administering medication to a client subcutaneously, the nurse removes the needle at the same angle at which it was inserted. Which explains the nurse's action?

minimizes tissue trauma to the client

11. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

oral anticoagulant medication

44. The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating which element?

portal of entry

15. A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?

schedule for a STAT CT scan of the head

3. A postoperative total hip replacement client is to receive salvaged blood through the cell saver system. The nurse is most concerned about which possible transfusion reaction?

septic reaction

45. A client with a terminal illness is prescribed an opioid for pain management. The nurse should carefully monitor the client for development of which adverse reaction?

severe anorexia

14. A nurse is bunching the tissue of a client when administering a subcutaneous injection to that client. What is the reason for bunching when injecting subcutaneously?

to avoid instilling medication within the muscle

14. The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?

traction with weights and pulleys

11. The nurse is preparing to withdraw medication from an unbroken glass ampule. Which nursing actions are appropriate? (Select all that apply.)

🔅Invert the ampule to withdraw medication. 🔅Avoid allowing the needle to touch the outside of the ampule. 🔅Tap the top of the ampule.

4. A nurse is working at a substance abuse clinic. The nurse would expect to administer which drug in the treatment and management of opioid dependence? Select all that apply.

🔅Levomethadyl 🔅Methadone

35. There are limited infusion pumps available on the nursing unit, Which client has the greatest need for accurate fluid monitoring? Select all that apply.

🔅Older adult receiving potassium chloride in the solution 🔅Middle-aged adult receiving medication for congestive failure

7. The nurse assesses the patient and notes all of the following. Select all of the findings that indicate the systemic manifestations of inflammation.

🔅Oral temperature 38.6° C/101.5" F 🔅Patient reports, "I'm tired all the time. I haven't felt like myself in days." 🔅WBC 20 cells/McL x 10 9/L/

22. Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply.

🔅Purpura of hands and feet 🔅Cloudy cerebral spinal fluids

2. A nurse works for a facility that does not utilize modified safety injection equipment. How will the nurse prevent needlesticks? (Select all that apply.)

🔅Scoop the cap back onto a used needle without touching the cap. 🔅Leave needle uncapped and dispose in closest biohazard container.

20. Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.)

🔅Uninsured or underinsured status 🔅Inadequate nutrition 🔅High cost of medications

38. The nurse has administered carbidopa/levodopa to a client. Which findings should the nurse prioritize on the ongoing assessment? Select all that apply.

🔅choreiform movements 🔅dry mouth 🔅anorexia