Med-Surg Final

Aspirin is withheld for ________ days prior to surgery if possible because it acts by inhibiting platelet aggregation

7 to 10

A nurse is providing care for a client who has just been diagnosed with early-stage rheumatoid arthritis (RA). The nurse should anticipate the administration of which medication?

Methotrexate

A client with primary hypertension comes to the clinic reporting a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of which condition?

retinal blood vessel damage

The client diagnosed with Type I Diabetes has a Glycosylated Hemoglobin (A1C) of 8.1%. Which interpretation should the nurse make based on this result? A. The result is below normal limits B. The result is within normal limits C. The result is above normal limits D. The result is dangerously high

C. The result is above normal limits

The HCP has ordered a continuous IV infusion of Aminophylline. The client weighs 165 pounds. the infusion order is 0.3mg/kg/hr. The bag is mixed with 500mg of Aminophylline in 250 ml of D5W. At which rate should the nurse set the pump? How many ml/hour?

11 ml/hr

The client is diagnosed with a viral infection and the HCP has prescribed an Antiviral medication to be administered y weight. The client weighs 220 pounds and the order reads 10 mg/Kg/Day to be administered in equally divided doses every 6 hours. How many milligrams will be administered in one dose?

250

The client diagnosed with Cushing's disease has developed 1+ peripheral edema. The client has received IV Fluids at 100 ml/hr for the past 79 hours. The client received IVPB Antibiotics in 50 ml of fluid every 6 hours for 15 doses. How many milliliters of fluid did the client receive?

8650

A patient with cerebral edema would most likely be order what type of solution? A. 3% Saline B. 0.9% Normal Saline C. Lactated Ringer's D. 0.225% Normal Saline

A. 3% Saline

A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? A. Tachycardia, hypotension, and tachypnea B. Tarry, foul-smelling stools C. Diaphoresis and sudden onset of abdominal pain D. Sudden thirst, unrelieved by oral fluid administration

A. Tachycardia, hypotension, and tachypnea

The nurse is caring for an acutely ill client. What assessment finding should prompt the nurse to inform the provider that the client may be exhibiting signs of an AKI

Average urine output has been 10 mL/hr for several hours

A nurse is caring for a client with type 1 diabetes. The client's medication administration record includes the administration of regular insulin three times daily. Knowing that the client's lunch tray will arrive at 11:45 AM, when should the nurse administer the client's insulin? A. 10:45 AM B. 11:30 AM C. 11:45 AM D. 11:50 AM

B. 11:30 AM

A nurse is caring for a client with impaired renal function. A creatinine clearance measurement has been ordered. The nurse should facilitate collection of what samples? A. A fasting serum potassium level and a random urine sample B. A 24-hour urine specimen and a serum creatinine level midway through the urine collection process C. A BUN and serum creatinine level on three consecutive mornings D. A sterile urine specimen and an electrolyte panel, including sodium, potassium, calcium, and phosphorus values

B. A 24-hour urine specimen and a serum creatinine level midway through the urine collection process

A nurse's assessment of a client's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The client states that 2 days ago the client ran in a long-distance race and now it "really hurts to stand up." The nurse should plan care based on the belief that the client has experienced what injury? A. A first-degree strain B. A second-degree strain C. A first-degree sprain D. A second-degree sprain

B. A second-degree strain

An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A. Administer broad-spectrum antibiotics. B. Administer IV fluids. C. Administer IV potassium chloride. D. Administer packed red blood cells.

B. Administer IV fluids.

The nurse writes the client problem of "Fluid Volume Excess (FVE)." Which interventions should be included in the plan of care? Select all that apply: A. Change IV fluid from 0.9% NS to D3W. B. Restrict the Sodium in the client's diet C. Monitor blood glucose levels D. Prepare the client for Hemodialysis E. Weigh the client daily

B. Restrict the Sodium in the client's diet E. Weigh the client daily

Which type of precautions should the nurse implement to protect from being exposed to any of the Hepatitis viruses? A. Airborne Precautions B. Standard Precautions C. Droplet Precautions D. Exposure Precautions

B. Standard Precautions

The nurse is developing a care plan for the client diagnosed with Type I Diabetes. The nurse identifies the problem (Nursing Diagnosis) "High risk for hyperglycemia Related to Medication noncompliance as evidenced by elevated blood glucose levels currently 200-250 ml/dL. Which statement is an appropriate short term goal? A. The client will demonstrate appropriate Insulin injection techniques prior to discharge B. The client will have a blood glucose level between 90 and 140 mg/dL within 48 hours C. The nurse will perform Blood Glucose monitoring prior to each meal and at HS D. The client will achieve and maintain normal kidney function with 30ml/hr urine output within 48 hours

B. The client will have a blood glucose level between 90 and 140 mg/dL within 48 hours

Which client assessment data are a priority for post-anesthesia care nurse? A. Bowel sounds B. Vital signs C. IV Fluid rate D. Surgical site

B. Vital signs

The client is admitted to a nursing unit from a long term are facility with the Laboratory results populated in the chart. Which condition is a cause for these findings? A. Over hydration B. Anemia C. Dehydration D. Acute Kidney Injury

C. Dehydration

A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? A. Consumes one or more protein drinks daily. B. Takes over-the-counter antacids frequently throughout the day. C. Smokes one pack of cigarettes daily. D. Reports a history of social drinking on a weekly basis.

C. Smokes one pack of cigarettes daily.

Family members are encouraging your client to "tough it out" rather than run the risk of becoming addicted to narcotics. The client is stoically abiding by the family's wishes. Priority nursing interventions for this client should target which dimension of pain? A. Sensory B. Affective C. Socio-cultural D. Behavioral E. Cognitive

C. Socio-cultural

A nurse is working with a family whose 5-year-old child has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care? A. Ensuring that the family knows that impetigo is not contagious B. Teaching about the safe and effective use of topical corticosteroids C. Teaching about the importance of maintaining high standards of hygiene D. Ensuring that the family knows how to safely burst the child's vesicles

C. Teaching about the importance of maintaining high standards of hygiene

A client with human immune deficiency virus (HIV) has sought care because of the recent development of new skin lesions. The nurse should interpret these lesions as most likely suggestive of what situation? A. An adverse effect of anti-retroviral therapy B. Virus-induced changes in allergy status C. A reduction in the client's viral load D. A reduction in the client's CD4 count

D. A reduction in the client's CD4 count

A community health nurse is preparing for an initial home visit to a client discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? A. Enteral feeding via gastrostomy tube (G tube) B. Gastrointestinal decompression by nasogastric tube C. Periodic assessment for esophageal distension D. Administration of injections of vitamin B12

D. Administration of injections of vitamin B12

The nurse is discussing macrovascular complications of diabetes with a client. The nurse would address what topic during this dialogue? A. The need for frequent eye examinations for clients with diabetes B. The relationship between kidney function and blood glucose levels C. The need to monitor urine for the presence of albumin D. The fact that clients with diabetes have an elevated risk of myocardial infarction

D. The fact that clients with diabetes have an elevated risk of myocardial infarction

The public health nurse is participating in a health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be:

Diet therapy and smoking cessation

The nurse is caring for a client who has a fluid volume deficit. When evaluating this client's urinalysis results, what should the nurse normally anticipate?

Increased urine specific gravity

The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. Which item should the nurse integrate into the management of this client's hypertension?

Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion.

A client was fitted with an arm cast after fracturing the humerus. Twelve hours after the application of the cast, the client tells the nurse that the injured arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action?

Prepare the client for opening or bivalving the cast

An inpatient client with acute kidney injury (AKI) has moderate edema to both legs. What resulting skin conditions would increase the client's likelihood of skin breakdown? Select all 2 that apply.

Pruritus Excoriation

The older client is admitted to the Emergency Department from a long term care facility. The client presents with multiple ecchymotic areas over the body. The client is receiving Digoxin, Furosemide, Warfarin and Alprazolam daily. Which order should the nurse request from the HCP?

STAT INR

A nurse practitioner is assessing a client who has a fever, malaise, and a white blood cell count that is elevated. What principle should guide the nurse's management of the client's care?

infection is most likely cause of the clients change in health status

A 35-year-old man is seen in the clinic because the client is experiencing recurring episodes of urinary frequency, dysuria, and fever. The nurse should recognize the possibility of what health problem? A. Chronic bacterial prostatitis B. Orchitis C. Benign prostatic hyperplasia D. Urolithiasis

A. Chronic bacterial prostatitis

The client comes to the emergency department reporting pain in the left lower leg following a puncture wound from a nail in the plywood board. The left leg is reddened with streaks, edematous and hot to touch and the client has a temperature of 108 degrees F. Which condition would the nurse suspect the client is experiencing? A. Cellulitis B. Deep vein thrombosis C. Impetigo D. Lyme disease

A. Cellulitis

A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal? A. Client will accurately identify foods that trigger symptoms. B. Client will demonstrate appropriate care of his ileostomy. C. Client will demonstrate appropriate use of standard infection control precautions. D. Client will adhere to recommended guidelines for mobility and activity.

A. Client will accurately identify foods that trigger symptoms.

The nurse is assessing a 70 year old client diagnosed with pneumonia. Which clinical manifestations should the nurse expect to assess in the client? Select all 3 that apply: A. Confusion and lethargy B. High fever and chills C. Frothy sputum and edema D. Bradypnea and jugular vein distention E. Low body temperature and cough

A. Confusion and lethargy B. High fever and chills E. Low body temperature and cough

A client has come to the clinic reporting pain just above her umbilicus. When assessing the client, the nurse notes Sister Mary Joseph nodules. The nurse should refer the client to the primary provider to be assessed for what health problem? A. GI malignancy B. Dumping syndrome C. Peptic ulcer disease D. Esophageal/gastric obstruction

A. GI malignancy

A client presents to the clinic reporting vomiting and burning in the mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what? A. Infection with Helicobacter pylori B. Excessive stomach acid secretion C. An incompetent pyloric sphincter D. A metabolic acid-base imbalance

A. Infection with Helicobacter pylori

A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? A. Insertion of a nasogastric tube B. Insertion of a central venous catheter C. Administration of a mineral oil enema D. Administration of a glycerin suppository and an oral laxative

A. Insertion of a nasogastric tube

Correlate the association between body fluid compartments. Match the fluid space in Column II with an associated factor in Column I A. Third space fluid shift______ B. Space where plasma is contained ____ C. Comprises the intravascular, interstitial and trans-cellular fluid______ D. Comprises about 60% of body fluid______ E. Comprises fluid surrounding cells_______ Interstitial space, Extracellular fluid, Intravascular fluid volume deficit, Intravascular space, intracellular space

A. Intravascular fluid volume deficit B. Intravascular space C. Extracellular fluid D. Intracellular fluid E. Interstitial space

A nurse is caring for a client who has been diagnosed with psoriasis. The nurse is creating an education plan for the client. What information should be included in this plan? A. Lifelong management is likely needed. B. Avoid public places until symptoms subside. C. Wash skin frequently to prevent infection. D. Liberally apply corticosteroids as needed.

A. Lifelong management is likely needed.

The nurse planning the care of a client diagnosed with SIADH. Which interventions should be implemented? Select all that apply: A. Restrict fluids per Health Care Provider order B. Assess level of consciousness every 2 hours C. Provide an atmosphere of stimulation D. Monitor urine and serum osmolality E. Weigh the client every 3 days

A. Restrict fluids per Health Care Provider order B. Assess level of consciousness every 2 hours D. Monitor urine and serum osmolality

A client with type 2 diabetes has been managing his blood glucose levels using diet and metformin. Following an ordered increase in the client's daily dose of metformin, the nurse should prioritize which of the following assessments? A. Reviewing the client's creatinine and BUN levels B. Assessing the client for signs of impaired liver function C. Monitoring the client's level of consciousness and behavior D. Monitoring the client's neutrophil levels

A. Reviewing the client's creatinine and BUN levels

The nurse received a report that the elderly postoperative client became confused during the previous shift. Which client problem would the nurse include in the plan of care? A. Risk for injury B. Altered comfort level C. Impaired circulation D. Impaired skin integrity

A. Risk for injury

A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A. Two to three soft bowel movements daily B. Significant increase in appetite and food intake C. Absence of nausea and vomiting D. Absence of blood or mucus in stool

A. Two to three soft bowel movements daily

Following a recent history of dyspareunia and lower abdominal pain, a client has received a diagnosis of pelvic inflammatory disease (PID). When providing health education related to selfcare, the nurse should address what topics? Select all that apply. A. Use of condoms to prevent infecting others B. Appropriate use of antibiotics C. Taking measures to prevent pregnancy D. The need for a Pap smear every 3 months E. The importance of weight loss in preventing symptoms

A. Use of condoms to prevent infecting others B. Appropriate use of antibiotics

Match the nutrient in Column II with its associated rationale for use in Column I A. Vital for capillary formation ___ B. Increases inflammatory response in wounds _____ C. Necessary for DNA synthesis ____ D. Allows collagen deposition to occur _____ E. Essential for normal blood clotting_____ Vitamin A, Protein, Vitamin K, Zinc, Vitamin C

A. Vitamin C B. Vitamin A C. Zinc D. Protein E. Vitamin K

The nurse is caring for a client diagnosed with a cold. Which is an example of alternative therapy? A. Vitamin C, 2000mg daily B. Strict bedrest C. Humidification of the air D. Decongestant therapy

A. Vitamin C, 2000mg daily

While waiting to see the health care provider, a client shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the client is demonstrating: A. macules. B. papules. C. vesicles. D. pustules.

A. macules.

The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12. The nurse should question the client about a history of: A. total gastrectomy. B. bariatric surgery. C. diverticulitis. D. gastroesophageal reflux disease (GERD).

A. total gastrectomy.

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? A. Confusion B. Decreased blood pressure C. High fever D. Sudden agitation

B. Decreased blood pressure

The client comes into the emergency department in severe pain and reports that a pot of boiling water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin and both feet are edematous. Which depth of burn should the nurse document? A. Superficial partial thickness B. Deep partial thickness C. Full thickness D. First Degree

B. Deep partial thickness

A client with liver disease has developed ascites; the nurse is collaborating with the client to develop a nutritional plan. The nurse should prioritize which of the following in the client's plan? A. High-protein, low-fat diet B. Reduction in sodium intake C. Fluid restriction to 2 L per day D. Increased potassium intake

B. Reduction in sodium intake

A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer? A. The client has abdominal bloating that developed rapidly. B. The client has a rigid, "board-like" abdomen that is tender. C. The client is experiencing intense lower right quadrant pain. D. The client is experiencing dizziness and confusion with no apparent hemodynamic changes.

B. The client has a rigid, "board-like" abdomen that is tender.

The client has developed Iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis? A. The client has an autoimmune problem causing the destruction of the adrenal cortex B. The client has been taking steroid medications for an extended period for another disease process C. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol D. The client has developed an adrenal gland problem for which the HCP does not have an explanation

B. The client has been taking steroid medications for an extended period for another disease process

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse's assessment reveals a blood pressure (BP) of 98/52 mm Hg. The nurse should recognize that the client's kidneys will compensate by secreting what substance? A. Antidiuretic hormone (ADH) B. Aldosterone C. Renin D. Angiotensin

C. Renin

The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor? A. Serum Calcium B. Serum Phosphorus C. Serum Potassium D. Serum Sodium

C. Serum Potassium

While taking a health history on a 20-year-old female client, the nurse learns that the client is taking Miconazole. The nurse is justified in presuming that this client has what medical condition?

Candidiasis

An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this client be taught about this diagnosis? Select all that apply.

Cholesteatomas are often the result of chronic otitis media Cholesteatomas usually must be removed surgically

A nurse admits a client who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse should plan to care for what type of fracture?

Compound

Which intervention by the nurse is most effective for reducing hospital acquired infections? A. Administration of prophylactic antibiotics B. Aseptic wound care C. Control of upper respiratory tract infections D. Proper handwashing techniques

D. Proper handwashing techniques

A client is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the client's nutrition during treatment? A. A 1.5 L/day fluid restriction B. A high-potassium, low-sodium diet C. A high-protein diet D. A liquid or soft diet

D. A liquid or soft diet

A client with end stage renal disease (ESKD) is being treated for a right ankle fracture unrelated to a fall. The client's lab values show high phosphate levels, low calcium levels, and low vitamin D levels. What is the most likely reason for this client's fracture? A. A. Osteoporosis B. B. Codman triangle C. C. Hypertrophic osteoarthropathy D. D. Renal osteodystrophy

D. D. Renal osteodystrophy

A client has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies? A. Radiation therapy often results in secondary brain tumors. B. Surgical complications are exceedingly common. C. Diagnosis rarely occurs until the cancer is end stage. D. Metastases are common and respond poorly to treatment.

D. Metastases are common and respond poorly to treatment.

A nurse is caring for a client who has a diagnosis of GI bleed. During shift assessment, the nurse finds the client to be tachycardic and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client's vital signs and level of conscious, what would be a priority nursing action for this client? A. Place the client in a prone position. B. Provide the client with ice water to slow any GI bleeding. C. Prepare for the insertion of an NG tube. D. Notify the health care provider.

D. Notify the health care provider.

A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following? Select all 2 that apply. A. Producing antibodies B. Absorbing electrolytes C. Maintaining acid-base balance D. Physically repelling pathogens E. Preventing fluid loss

D. Physically repelling pathogens E. Preventing fluid loss

The client is admitted with a serum sodium level of 110 mEq/L. Which nursing interventions should be implemented? A. Encourage fluids orally B. Administer 10% Saline solution IVPB C. Administer ADH (Antidiuretic Hormone) IVPB D. Place on seizure precautions

D. Place on seizure precautions

A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the client's most recent laboratory tests, the nurse should prioritize what finding? A. White blood cell level B. Creatinine level C. Hemoglobin level D. Potassium level

D. Potassium level

Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism? A. Increase amount of fiber in the diet B. Encourage a low-calorie, low-protein diet C. Decrease the client's fluid intake to 1000 ml/day D. Provide six small, well balanced meals a day

D. Provide six small, well balanced meals a day

The client diagnosed with End-stage liver disease is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the the nurse to address this complication? A. Restrict sodium to 2g/day B. Limit oral fluids to 1500 ml/day C. Decrease daily fat intake D. Reduce protein intake to 60-80g/day

D. Reduce protein intake to 60-80g/day

_______ solutions cause cell dehydration and help increase fluid in the extracellular space. A. Hypotonic B. Osmosis C. Isotonic D. Hypertonic

D. Hypertonic

Magnesium is absorbed by what system in the body? A. Gastrointestinal B. Hepatic C. Lymphatic D. Renal

A. Gastrointestinal

The primary concentration of Phosphorus (85%) is located in the ______

Bones

With Malignant Hyperthermia, the core body temperature can increase 1 to 2 degrees Centigrade every 5 minutes, reaching or exceeding a body temperature of _______ degrees in a short amount of time.

42 C or 104 F

Which of the following is not a hypertonic fluid? A. 3% Saline B. D5W C. 10% Dextrose in Water (D10W) D. 5% Dextrose in Lactated Ringer's

B. D5W

A nurse is planning the care of a client with herpes zoster. What medication, if given within the first 24 hours of the initial eruption, can arrest herpes zoster? A. Acyclovir B. Azathioprine C. Prednisone D. Triamcinolone

A. Acyclovir

The nurse is creating a plan of care for a client with acute coronary syndrome. What nursing action should be included in the client's care plan? A. Facilitate daily arterial blood gas (ABG) sampling. B. Administer supplementary oxygen, as needed. C. Have client maintain supine positioning when in bed. D. Perform chest physiotherapy, as indicated.

B. Administer supplementary oxygen, as needed.

The nurse is caring for a client diagnosed with Stage IV pressure injury on left Trochanter and coccyx. Which collaborative problem has the highest priority? A. Impaired cognition B. Altered nutrition C. Self-care deficit D. Altered coping

B. Altered nutrition

The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications? A. Potassium-sparing diuretics B. Cholinergics C. Antibiotics D. Loop diuretics

B. Cholinergics

A nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing action(s) relevant to what potential complications? Select all 4 that apply. A. Dumping Syndrome B. Clotted or displaced catheter C. Pneumothorax D. Hyperglycemia E. Line Sepsis

B. Clotted or displaced catheter C. Pneumothorax D. Hyperglycemia E. Line Sepsis

A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects? A. Nervousness or paresthesia B. Throbbing headache or dizziness C. Drowsiness or blurred vision D. Tinnitus or diplopia

B. Throbbing headache or dizziness

The client diagnosed with cancer of the head of the pancreas is 2 days post pancreatoduodenectomy (Whipple) procedure. Which nursing problem has the highest priority? A. Anticipatory grieving B. Fluid volume imbalance C. Alteration in comfort D. Altered nutrition

B. Fluid volume imbalance

A client is having the second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the client's chest. The nurse should ask what priority question regarding the presence of a reddened rash? A. "Is the rash worse at a particular time or season?" B. "Are you having any loss of sensation in that area?" C. "Are you allergic to any foods or medication?" D. "Is your rash painful?"

C. "Are you allergic to any foods or medication?"

The emergency department nurse is caring for a client diagnosed with HHNS and a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of the acute complication? A. "When is the last time you took your Insulin?" B. "When did you have your last meal? C. "Have you had some type of infection recently?" D. "How long have you had Diabetes?"

C. "Have you had some type of infection recently?"

The nurse leading an educational session is describing self-examination of the breast. The nurse tells the women's group to raise their arms and inspect their breasts in a mirror. A member of the women's group asks the nurse why raising the arms is necessary. What is the nurse's best response? A. "It helps to spread out the fat that makes up your breast." B. "It allows you to simultaneously assess for pain." C. "It will help to observe for dimpling more closely." D. "This is what breast cancer experts recommend."

C. "It will help to observe for dimpling more closely."

A nurse is caring for a client who has been scheduled for a bone scan. Which statement should the nurse include when educating the client about this diagnostic test? A. "The test is brief and requires that you drink a calcium solution 2 hours before the test." B. "You will not be allowed fluid for 2 hours before and 3 hours after the test." C. "You will be encouraged to drink water after the administration of the radioisotope injection." D. "This is a common test that can be safely performed on anyone."

C. "You will be encouraged to drink water after the administration of the radioisotope injection."

The client diagnosed with Diabetes Insipidus weighed 180 pounds when the daily weight was recorded yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid in milliliters, has the client lost? A. 1000 ml B. 1500 ml C. 2000 ml D. 2500 ml

C. 2000 ml

A medical nurse has admitted four clients over the course of a 12-hour shift. For which client would assessment of ankle-brachial index (ABI) be most clearly warranted? A. A client who has peripheral edema secondary to chronic heart failure B. An older adult client who has a diagnosis of unstable angina C. A client with poorly controlled type 1 diabetes who is a smoker D. A client who has community-acquired pneumonia and a history of COPD

C. A client with poorly controlled type 1 diabetes who is a smoker

A client has been diagnosed with stage II breast cancer. The client tells the nurse that the health care provider has recommended breast conservation surgery followed by radiation. The client's husband has done some online research and is asking why his wife does not have a modified radical mastectomy "to be sure all the cancer is gone." The nurse knows that breast conservation surgery was recommended for which reason? A. "Modified radical mastectomies are very hard on a client, both physically and emotionally, and they really aren't necessary anymore." B. "According to current guidelines, having a modified radical mastectomy is no longer seen as beneficial." C. "Modified radical mastectomies have a poor survival rate because of the risk of cancer recurrence." D. "According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy."

D. "According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy."

A client with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the client should prioritize what question when addressing potential complications? A. "Are you experiencing any dizziness or light-headedness?" B. "Do you feel flushed or sweaty?" C. "Are you having any pain that seems to be radiating from your bones?" D. "Do you feel any muscle twitches or spasms?"

D. "Do you feel any muscle twitches or spasms?"

The nurse is discharging a client home after mastoid surgery. What should the nurse include in discharge teaching? A. "Try to induce a sneeze every 4 hours to equalize pressure." B. "Be sure to exercise to reduce fatigue." C. "Avoid sleeping in a side-lying position." D. "Don't blow your nose for 2 to 3 weeks."

D. "Don't blow your nose for 2 to 3 weeks."

A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by the parents for an outbreak of urticaria. What would be the most appropriate question to ask this client's parents? A. "Has your child bathed in the past 24 hours?" B. "Did your child go to a friend's house today?" C. "Was your child digging in the dirt today?" D. "Has your child eaten any new foods today?"

D. "Has your child eaten any new foods today?"

A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis? A. Teaching focuses on safe and effective use of antibiotics. B. The client should be preliminarily screened for surgery. C. The focus of care is resting the voice to prevent chronic hoarseness. D. Symptom management is the main focus of medical and nursing care.

D. Symptom management is the main focus of medical and nursing care.

The client diagnosed with chronic alcoholism has chronic pancreatitis and hypomagnesemia. Which data should the nurse assess when administering Magnesium Sulfate to the client? A. Deep tendon reflexes B. Arterial blood gases C. Skin turgor D. Capillary refill time

A. Deep tendon reflexes

An older adult has encouraged the spouse husband to visit their primary provider, stating that concern that spouse may have Parkinson disease. Which description of the spouse's health and function is most suggestive of Parkinson disease? A. "Lately he seems to move far more slowly than he ever has in the past." B. "He often complains that his joints are terribly stiff when he wakes up in the morning." C. "He's forgotten the names of some people that we've known for years." D. "He's losing weight even though he has a ravenous appetite."

A. "Lately he seems to move far more slowly than he ever has in the past."

A client is undergoing diagnostic testing to determine the etiology of recent joint pain. The client asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? A. "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." B. "OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees." C. "OA originates with an infection. RA is a result of your body's cells attacking one another." D. "OA is associated with impaired immune function; RA is a consequence of physical damage."

A. "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."

The client diagnosed with Type I Diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? A. Administer 50% Dextrose IVP B. Notify the HCP C. Move the client to the ICU D. Check the serum Glucose level

A. Administer 50% Dextrose IVP

A female client with DM2 and Heart Failure is taking an antibiotic, loop diuretic, corticosteroid and an antipyretic medication. What medications and conditions would likely increase the client's risk of developing the infection Candida Albicans? Select all 3 that apply: A. Antibiotics B. Antipyretics C. Corticosteroids D. Diabetes E. Diuretics F. Heart Failure

A. Antibiotics C. Corticosteroids D. Diabetes

A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A. Applying a protective eye shield at night B. Chewing on the affected side to prevent unilateral neglect C. Avoiding the use of analgesics whenever possible D. Avoiding brushing the teeth

A. Applying a protective eye shield at night

The client diagnosed with end-stage liver disease has Vitamin K deficiency. Which interventions should the nurse implement? Select all that apply: A. Avoid rectal temperatures B. Use only a soft bristle toothbrush C. Monitor the platelet count D. Use only small gauge needles E. Assess for Asterixis

A. Avoid rectal temperatures B. Use only a soft bristle toothbrush C. Monitor the platelet count D. Use only small gauge needles

Nursing education and consideration for Bell's Palsy include which of the following? Select all 3 that apply: A. Bell's Palsy is commonly seen between the ages of 15-45 years of age B. Bell's Palsy commonly affects women more often than men C. Bell's Palsy is more likely to occur in Diabetic individuals D. Bell's Palsy is three times more likely to affect pregnant women E. Bell's Palsy occurs frequently in individuals younger than 15 years of age and then again in adults older than 60 years of age

A. Bell's Palsy is commonly seen between the ages of 15-45 years of age C. Bell's Palsy is more likely to occur in Diabetic individuals D. Bell's Palsy is three times more likely to affect pregnant women

The nurse is caring for a client whose acute kidney injury (AKI) resulted from a prerenal cause. Which condition most likely caused this client's health problem? A. Burns B. Glomerulonephritis C. Ureterolithiasis D. Pregnancy

A. Burns

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? A. Checking the client's capillary blood glucose levels regularly B. Having the client frequently rate his or her hunger on a 10-point scale C. Measuring the client's heart rhythm at least every 6 hours D. Monitoring the client's level of consciousness each shift

A. Checking the client's capillary blood glucose levels regularly

A client has just returned to the floor following a transurethral resection of the prostate. A triple lumen indwelling urinary catheter has been inserted for continuous bladder irrigation. What, in addition to balloon inflation, are the functions of the three lumens? A. Continuous inflow and outflow of irrigation solution B. Intermittent inflow and continuous outflow of irrigation solution C. Continuous inflow and intermittent outflow of irrigation solution D. Intermittent flow of irrigation solution and prevention of hemorrhage

A. Continuous inflow and outflow of irrigation solution

A client with end-stage kidney disease is scheduled to begin hemodialysis. The nurse is working with the client to adapt the client's diet to maximize the therapeutic effect and minimize the risks of complications. The client's diet should include which of the following modifications? Select all that apply. A. Decreased protein intake B. Decreased sodium intake C. Increased potassium intake D. Fluid restriction E. Vitamin D supplementation

A. Decreased protein intake B. Decreased sodium intake D. Fluid restriction

A nurse educator is conducting an inservice for nursing students about how tobacco use impacts coronary artery disease (CAD)? What are the primary ways that tobacco use impacts CAD? Select all 4 that apply. A. Decreases the supply of oxygen to the myocardium B. Increases platelet adhesion C. Raises the heart rate and blood pressure D. Causes the coronary arteries to dilate E. Increases the blood carbon monoxide level

A. Decreases the supply of oxygen to the myocardium B. Increases platelet adhesion C. Raises the heart rate and blood pressure E. Increases the blood carbon monoxide level

During an assessment of a newly admitted client, the nurse notes that the client's HR is 110 bpm, the BP shows orthostatic changes when he stands up and this tongue is sticky with a paste like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects which of the following conditions? A. Dehydration B. Hypokalemia C. Fluid Volume Excess D. Hypernatremia

A. Dehydration

The nurse is leading a workshop on sexual health for men. The nurse should describe what organic causes of erectile dysfunction? Select all 3 that apply. A. Diabetes B. Testosterone deficiency C. Anxiety D. Depression E. Parkinsonism

A. Diabetes B. Testosterone deficiency E. Parkinsonism

A 29-year-old client has just been told that they have testicular cancer and needs to have surgery. During a presurgical appointment, the client admits to feeling devastated that they require surgery, stating that it will leave them "emasculated" and "a shell of a man." The nurse should identify what nursing diagnosis when planning the client's subsequent care? A. Disturbed body image related to effects of surgery B. Spiritual distress related to effects of cancer surgery C. Social isolation related to effects of surgery D. Risk for loneliness related to change in self-concept

A. Disturbed body image related to effects of surgery

The nurse is assessing a client with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all 3 that apply. A. Dyspnea B. Unusual fatigue C. Hypotension D. Syncope E. Peripheral cyanosis

A. Dyspnea B. Unusual fatigue D. Syncope

The client 1 day postoperative develops an elevated temperature. Which nursing intervention would have priority for this patient? A. Encourage the client to deep breathe and cough every hour B. Encourage the client to drink 200 ml of water every shift C. Monitor the client's wound for drainage every 8 hours D. Assess the urine output for color and clarity every 4 hours

A. Encourage the client to deep breathe and cough every hour

A nurse is taking a health history on a client with musculoskeletal dysfunction. What should the nurse prioritize during this phase of the assessment? A. Evaluating the effects of the musculoskeletal disorder on the client's function B. Evaluating the client's adherence to the existing treatment regimen C. Evaluating the presence of genetic risk factors for further musculoskeletal disorders D. Evaluating the client's active and passive range of motion

A. Evaluating the effects of the musculoskeletal disorder on the client's function

An older adult client with type 2 diabetes is brought to the emergency department by the client's daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A. Fluid and electrolyte replacement B. Reversing acidosis by administering insulin C. Administering sodium bicarbonate intravenously D. Administration of antihypertensive medications

A. Fluid and electrolyte replacement

Indicate which of the following factors contribute to Hypernatremia. Select all that apply: A. Heatstroke B. Diuretics C. Burns over a large surface area D. Diabetes Insipidus with water restriction E. Adrenal insufficiency

A. Heatstroke C. Burns over a large surface area D. Diabetes Insipidus with water restriction

The ICU nurse is developing a nursing care plan for a client diagnosed with severe full thickness and deep partial thickness burns over half of the body. Which client problem is the priority? A. High risk for infection B. Impaired physical mobility C. Ineffective coping D. Knowledge deficit

A. High risk for infection

A nurse is caring for a client with liver failure and is performing an assessment of the client's increased risk of bleeding. The nurse recognizes that this risk is related to the client's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Inability of the liver to use vitamin K B. Alterations in glucose metabolism C. Retention of bile salts D. Inadequate production of albumin by hepatocytes

A. Inability of the liver to use vitamin K

A medical nurse who is caring for a client being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this client. What is a priority psychosocial outcome for this client? A. Indicates acceptance of altered appearance and demonstrates positive self-image B. Freely expresses needs and concerns related to postoperative pain management C. Compensates effectively for alteration in ability to communicate related to dysarthria D. Demonstrates effective stress management techniques to promote muscle relaxation

A. Indicates acceptance of altered appearance and demonstrates positive self-image

A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? A. Ineffective tissue perfusion related to bowel ischemia B. Imbalanced nutrition: Less than body requirements related to impaired absorption C. Anxiety related to bowel obstruction and subsequent hospitalization D. Impaired skin integrity related to bowel obstruction

A. Ineffective tissue perfusion related to bowel ischemia

The nurse is planning care for a patient with acute hypernatremia. What should the nurse include in this patient's plan of care? Select all that apply: A. Maintain IV access B. Limit length of visits C. Restrict fluids to 1500 ml/day D. Conduct frequent neurologic checks E. Orient to time, place and person every 2 hours

A. Maintain IV access D. Conduct frequent neurologic checks E. Orient to time, place and person every 2 hours

Indicate which of the following factors contribute to Hypercalcemia. Select all that apply: A. Malignant tumors B. Immobilization because of multiple fractures C. Pancreatitis D. Kidney Failure E. Thiazide Diuretics

A. Malignant tumors B. Immobilization because of multiple fractures E. Thiazide Diuretics

A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the client may be prescribed what drug? A. Metoclopramide B. Omeprazole C. Lansoprazole D. Calcium carbonate

A. Metoclopramide

Match the term in Column II with its definition in Column I A. Pain receptors sensitive to noxious stimuli B. Non-steroidal agents that decrease inflammation C. Significantly increases a person's response to pain D. Chemicals known to inhibit the transmission or perception of pain E. This substance is released in response to painful stimuli, causes vasodilation F. Medication administered directly into the subarachnoid space and cerebral spinal fluid Histamine, Nociceptors, NSAIDS, Epidural, Anxiety, Endorphins

A. Nociceptors B. NSAIDS C. Anxiety D. Endorphins E. Histamine F. Epidural

Which patient below would NOT be a candidate for a hypotonic solution? A. Patient with increased intracranial pressure B. Patient with Diabetic Ketoacidosis C. Patient experiencing Hyperosmolar Hyperglycemia D. All of the options are correct

A. Patient with increased intracranial pressure

A nurse is caring for a client in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristic(s) of this stage of the disease? Select all 3 that apply. A. Perforation into the mediastinum B. Development of an esophageal lesion C. Erosion into the great vessels D. Painful swallowing E. Obstruction of the esophagus

A. Perforation into the mediastinum C. Erosion into the great vessels E. Obstruction of the esophagus

The nurse is preparing to collect an ordered urine sample for urinalysis. The nurse should be aware that this test will include what assessment parameters? Select all that apply. A. Specific gravity of the client's urine B. Testing for the presence of glucose in the client's urine C. Microscopic examination of urine sediment for RBCs D. Microscopic examination of urine sediment for casts E. Testing for BUN and creatinine in the client's urine

A. Specific gravity of the client's urine B. Testing for the presence of glucose in the client's urine D. Microscopic examination of urine sediment for casts

The nurse obtains consent forms for the scheduled surgery. Which clients are able to consent legally to surgery? Select all that apply A. The 65 year old non-English speaking client who cannot read or write B. The 30 year old non-English speaking client C. The 16 year old client with a fractured ankle D. The 80 year old client not oriented to the day E. The 45 year old client who is blind and cannot read Braille

A. The 65 year old non-English speaking client who cannot read or write B. The 30 year old non-English speaking client D. The 80 year old client not oriented to the day E. The 45 year old client who is blind and cannot read Braille

Which client would the nurse identify as having the highest risk for developing postoperative complications? A. The 67 year old client who is obese, has diabetes and takes insulin B. The 50 year old client diagnosed with arthritis and taking non-steroidal anti-inflammatory drugs C. The 45 year old client having abdominal surgery to remove the gallbladder D. The 60 year client diagnosed with anemia who smokes one pack of cigarettes per day

A. The 67 year old client who is obese, has diabetes and takes insulin

The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the Anesthesiologist? Select All that Apply A. The client has loose, decayed teeth B. The client is experiencing anxiety C. The client smokes two packs of cigarettes a day D. The client has an x-ray that shows no infiltrates E. The client reports using Herbs

A. The client has loose, decayed teeth C. The client smokes two packs of cigarettes a day E. The client reports using Herbs

A client's neck dissection surgery resulted in damage to the client's superior laryngeal nerve. What area of assessment should the nurse consequently prioritize? A. The client's swallowing ability B. The client's ability to speak C. The client's management of secretions D. The client's airway patency

A. The client's swallowing ability

The client is admitted to the out patient surgery center for the removal of a Malignant Melanoma. Which assessment data indicates that the lesion is Malignant Melanoma? A. The lesion is asymmetrical and has irregular borders B. The lesion has a waxy appearance with pearl like borders C. The lesion has a thickened and scaly appearance D. The lesion appeared as a thickened area after an injury

A. The lesion is asymmetrical and has irregular borders

A client's serum potassium level is 2.2 mEq/L. Which nursing action is the highest priority for this patient? (SATA) A. Start O2 at 2L/min B. Initiate cardiac monitoring C. Initiate seizure precautions D. Keep the patient on bed rest

B. Initiate cardiac monitoring C. Initiate seizure precautions

The physical environment of a surgical suite is designed primarily to promote: A. Electrical safety B. Medical and surgical asepsis C. Comfort and privacy of the patient D. Communication among the surgical team

B. Medical and surgical asepsis

A nurse is providing care for a client whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis? A. Encourage the client to conduct online research into colostomies. B. Engage the client in dialogue about the implications of having the colostomy. C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem. D. Emphasize the fact that the colostomy is temporary measure and is not permanent.

B. Engage the client in dialogue about the implications of having the colostomy.

A client has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the client's subsequent care? A. Teaching the client to safely and effectively administer immunosuppressants B. Helping the client identify and avoid the offending agent C. Teaching the client how to maintain meticulous skin hygiene D. Helping the client perform wound care in the home environment

B. Helping the client identify and avoid the offending agent

A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what event? A. Gastrointestinal hypermotility B. Hemodynamic instability C. Hypokalemia D. Respiratory arrest

B. Hemodynamic instability

When teaching clients about the risk factors of cervical cancer, what would the nurse identify as the most important risk factor? A. Late childbearing B. Human papillomavirus (HPV) C. Postmenopausal bleeding D. Tobacco use

B. Human papillomavirus (HPV)

A postsurgical client has illuminated the call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the client's left leg is visibly swollen and reddened. Which action by the nurse would be most appropriate? A. Administer a PRN dose of subcutaneous heparin. B. Inform the health care provider that the client has signs and symptoms of venous thromboembolism (VTE). C. Mobilize the client promptly to dislodge any thrombi in the client's lower leg. D. Massage the client's lower leg to temporarily restore venous return.

B. Inform the health care provider that the client has signs and symptoms of venous thromboembolism (VTE).

A client with diabetes is attending a class on the prevention of associated diseases. What action should the nurse teach the client to reduce the risk of osteomyelitis? A. Increase calcium and vitamin intake. B. Monitor and control blood glucose levels. C. Exercise 3 to 4 times weekly for at least 30 minutes. D. Take corticosteroids as prescribed.

B. Monitor and control blood glucose levels.

A 20-year-old client with no medical history arrives at a walk-in/urgent care clinic reporting swelling on the left side of the neck. On palpation, the lymph nodes on the neck are painless, firm but not hard. What is the next appropriate intervention for this client? A. Recommend immediate and urgent transfer to the nearest trauma center. B. Perform diagnostic studies to rule out any infectious origin at a hospital. C. Refer the client to a primary health care provider for a nonurgent appointment. D. Complete a computed tomography scan because the client has Hodgkin lymphoma.

B. Perform diagnostic studies to rule out any infectious origin at a hospital.

A nurse is providing care for a client who has a rheumatic disorder. The nurse's focused assessment includes the client's mood, behavior, level of consciousness, and neurologic status. Which diagnosis is most likely for this client? A. Osteoarthritis (OA) B. Systemic lupus erythematosus (SLE) C. Rheumatoid arthritis (RA) D. Gout

B. Systemic lupus erythematosus (SLE)

Which action by the client indicates that the nurse's pre-operative teaching plan has been successful? A. The client demonstrates how to use the (IS) Incentive Spirometer B. The client demonstrates the use of the PCA pump (Patient Controlled Anesthesia) C. The client can name two anesthesia agents used during surgery D. The client ambulates down the hall to the nurse's station each hour

B. The client demonstrates the use of the PCA pump (Patient Controlled Anesthesia)

The long term care nurse has received the morning shift report. Which client should the nurse assess first? A. The client with no bowel movement today B. The client diagnosed with periorbital skin lesions C. The client diagnosed with stage I pressure injury D. The client recently diagnosed with Telangiectasis

B. The client diagnosed with periorbital skin lesions

The nurse is caring for the client diagnosed with Hepatic Encephalopathy. Which clinical manifestation indicates the disease is progressing? A. The client has a decrease in serum ammonia level B. The client is not able to circle choices on the menu C. The client is able to take deep breaths as directed D. The client is able to eat previously restricted food items

B. The client is not able to circle choices on the menu

The older client is admitted to the hospital for severe back pain. Which data should the nurse assess first during the admission assessment? A. The client's use of herbs B. The client's current pain level C. The client's sexual orientation D. The client's ability to care for self

B. The client's current pain level

The pain management nurse is assessing a trauma patient's readiness for discharge, by determining the level of comfort the patient prefers. The nurse completes this portion of the pain assessment by asking about the patient's: A. aggravating and alleviating factors. B. functional pain goal. C. intensity of pain. D. onset of pain.

B. functional pain goal.

A patient is demonstrating confusing, hallucinations, and a positive Chvostek's sign. Which medication should the nurse prepare to provide to this patient? A. calcium chloride B. magnesium sulfate C. insulin and glucose D. sodium bicarbonate

B. magnesium sulfate

Goals for patient safety in the operating room (OR) include the Universal Protocol, in which: A. All surgical centers of any type must submit reports on patient safety infractions to the accreditation agencies B. The members of the surgical team stop whatever they are doing to check that all sterile items have been properly prepared C. A surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure and surgical site D. All members of the surgical team pause right before surgery to meditate for one minute to decrease stress and possible errors

C. A surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure and surgical site

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? A. Administration of prophylactic antibiotics B. Administration of antiretroviral medications to clients over age 65 C. Administration of pneumococcal vaccine to vulnerable individuals D. Obtaining culture and sensitivity swabs from all newly admitted clients

C. Administration of pneumococcal vaccine to vulnerable individuals

The nurse is assessing a client who has a chronic pain disorder and who also has class II obesity. What principle should guide the care team's choice of pain treatments for this client? A. The client may require higher doses of opioids than clients without obesity. B. The client is more likely to experience relief with NSAIDs than with opioids. C. Adverse effects of opioids may be more difficult to assess than in clients without obesity. D. The client's renal function must be monitored more closely during pain treatment than in clients without obesity.

C. Adverse effects of opioids may be more difficult to assess than in clients without obesity.

A client aged 48 years comes to the clinic because they have discovered a lump in the breast. After diagnostic testing, the client receives a diagnosis of breast cancer. The client asks the nurse when the teenage daughters should begin mammography. What is the nurse's best advice? A. Age 28 B. Age 35 C. Age 38 D. Age 48

C. Age 38

The triage nurse in the emergency department is assessing a client who reports pain and swelling in the right lower leg. The client's pain became much worse last night and appeared along with fever, chills, and sweating. The client states, "I hit my leg on the car door 4 or 5 days ago, and it has been sore ever since." The client has a history of chronic venous insufficiency. Which intervention should the nurse anticipate for this client? A. Platelet transfusion to treat thrombocytopenia B. Warfarin to treat arterial insufficiency C. Antibiotics to treat cellulitis D. Intravenous heparin to treat venous thromboembolism (VTE)

C. Antibiotics to treat cellulitis

The telemetry nurse is reviewing the laboratory results for a client. Which further assessment data should the nurse determine before notifying the Health Care provider? A. Obtain the client's 24 hour urine output B. Ask the nurse's aide/Patient Care tech to obtain a blood glucose level C. Assess the client's telemetry reading D. Call an RRT (Rapid response team)

C. Assess the client's telemetry reading

The postoperative client reports hearing a "popping sound" and feeling "something opening" when ambulating in the room. Which intervention should the nurse implement first? A. Notify the physician that the client has had an evisceration B. Contact the surgery department to prepare for emergency surgery C. Assess the operative site and cover the site with a moistened sterile dressing D. Explain that this is a common feeling and tell the client to continue with the activity

C. Assess the operative site and cover the site with a moistened sterile dressing

A client with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the client's treatment? A. Decisional conflict B. Deficient knowledge C. Death anxiety D. Disturbed thought processes

C. Death anxiety

The nurse is caring for a client in the emergency department who was admitted for a hypertensive emergency. The nurse knows the goal of intravenous vasodilator therapy for a hypertensive emergency would be which outcome? Select all 2 that apply: A. Lower the blood pressure to reduce the onset of neurological changes B. Decrease the blood pressure to a normal level based on the client's age C. Decrease the systolic blood pressure by no more than 25% within the first hour D. Decrease the blood pressure to less than or equal to 120/80 as quickly as possible

C. Decrease the systolic blood pressure by no more than 25% within the first hour D. Decrease the blood pressure to less than or equal to 120/80 as quickly as possible

The client is being admitted to the outpatient department before an Endoscopic-Retrograde-Cholangiopancreatogram (ECRP) to rule out cancer of the pancreas. Which instructions should the nurse teach? Select all that apply: A. Prepare to be admitted to the hospital after the procedure for observation B. If something happens during the procedure, then emergency surgery will be done C. Do not eat or drink anything after midnight the night before the test D. If done correctly, this procedure will correct the blockage of the stomach E. Expect a sore throat after the procedure that can last 1 to 2 days

C. Do not eat or drink anything after midnight the night before the test E. Expect a sore throat after the procedure that can last 1 to 2 days

A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action should the nurse recommend as having the greatest potential to prevent esophageal cancer? A. Promotion of a nutrient-dense, low-fat diet B. Annual screening endoscopy for clients over 50 with a family history of esophageal cancer C. Early diagnosis and treatment of gastroesophageal reflux disease D. Adequate fluid intake and avoidance of spicy foods

C. Early diagnosis and treatment of gastroesophageal reflux disease

The client diagnosed with Type II DM is controlled well with Biguanide medication and has a history of liver disease. He is scheduled for Computated Tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? A. Provide a high fat diet 24 hours prior to the text B. Hold the Biguanide medication for 48 hours after the administration of the contrast dye to determine "contrast induced renal failure" C. Hold the Biguanide medication 48 hours prior to the administration of the contrast dye to determine "contrast induced renal failure" D. Administer pancreatic enzymes 24 hours after the test

C. Hold the Biguanide medication 48 hours prior to the administration of the contrast dye to determine "contrast induced renal failure"

A 35-year-old kidney transplant client comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposi sarcoma. The nurse caring for this client recognizes that this is what type of Kaposi sarcoma? A. Classic B. AIDS related C. Iatrogenic D. Endemic

C. Iatrogenic

When the cell presents with the same concentration on the inside and outside with no shifting of fluids this is called? A. Hypotonic B. Hypertonic C. Isotonic D. Osmosis

C. Isotonic

A nurse is providing client education for a client with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The client has recently been prescribed Misoprostol. What would the nurse be most accurate in informing the client about the drug? A. It reduces the stomach's volume of hydrochloric acid B. It increases the speed of gastric emptying C. It protects the stomach's lining D. It increases lower esophageal sphincter pressure

C. It protects the stomach's lining

A patient is admitted to the ER. The patient receives dialysis on Tuesdays and Thursdays of every week, and presents with a palpable AV shunt (thrill present) in the left upper arm. The patient is extremely lethargic and family members are present to help answer questions. While collecting the patient's medication history the daughter states her mother has been taking "a lot" of Maalox lately due to upset stomach. You note this to be a significant finding. Which of the following lab values correlates with this finding? A. Magnesium level of 1.0 B. Magnesium level of 2.4 C. Magnesium level of 3.6 D. Magnesium level of 1.4

C. Magnesium level of 3.6

During a recent visit to the clinic, a client presents with erythema of the nipple and areola on the right breast. The client states this started several weeks ago and they were fearful of what would be found. The nurse should promptly refer the client to the primary provider because the client's signs and symptoms are suggestive of what health problem? A. Peau d'orange B. Nipple inversion C. Paget disease D. Acute mastitis

C. Paget disease

A client diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care? A. Assess the drainage in the dressing. B. Slowly remove the soiled dressing. C. Perform hand hygiene. D. Don nonlatex gloves.

C. Perform hand hygiene.

The nurse is assessing a new adult client. What characteristic of this client's status should the nurse identify as increasing the client's risk for glaucoma? A. The client uses over-the-counter NSAIDs. B. The client has a history of stroke. C. The client has diabetes. D. The client has Asian ancestry.

C. The client has diabetes.

Which client is least likely to be at risk for developing Third Spacing? A. The client with Cirrhosis B. The client with Liver Failure C. The client with Diabetes D. The client with (CKD) Chronic Kidney Disease

C. The client with Diabetes

A diabetes nurse educator is presenting current recommendations for levels of caloric intake. What are the current recommendations that the nurse would describe? A. 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from protein B. 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from protein C. 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the remaining 10% to 20% from protein D. 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein

D. 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein

The client is admitted with a diagnosis of "Rule out Tuberculosis (TB)". Which type of Isolation Precautions will you implement as the nurse? A. Standard B. Contact C. Droplet D. Airborne

D. Airborne

The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange". Which is an expected outcome for this problem? A. Performs chest physiotherapy (CPT) three times a day B. Able to complete activities of daily living (ADLs) C. Ambulates in the hall several times during each shift D. Alert and oriented to person, place, time and events

D. Alert and oriented to person, place, time and events

The client is reporting a burning, stabbing pain that radiates around the left rib cage area. The nurse cannot find any type of skin abnormality. What action should the nurse implement? A. Transfer to client to the ED for cardiac monitoring B. Inform the client that the nurse can't see anything C. Administer non-narcotic analgesic to the client D. Ask if the client has ever had Chickenpox

D. Ask if the client has ever had Chickenpox

A client with a peptic ulcer disease has had metronidazole added to their current medication regimen. What health education related to this medication should the nurse provide? A. Take the medication on an empty stomach. B. Take up to one extra dose per day if stomach pain persists. C. Take at bedtime to mitigate the effects of drowsiness. D. Avoid drinking alcohol while taking the drug.

D. Avoid drinking alcohol while taking the drug.

The HCP has ordered an IM Antibiotic.After reconstituting the medication, the nurse must administer 5.5 ml of the medication. Which action should the nurse implement first when administering this medication?Infor A. Inform the HCP the amount of medication is too large B. Administer the medication in the dorsogluteal muscle C. Discard the medication in the sharps container D. Divide the medication and give 2.75 mL in each hip

D. Divide the medication and give 2.75 mL in each hip

The nurse caring for a client diagnosed with cancer of the pancreas writes the nursing diagnosis of "Risk for altered skin integrity related to Pruritus". A. Assess the skin turgor B. Apply anti-fungal creams as needed C. Monitor bony prominences for skin breakdown D. Have the client keep the fingernails short

D. Have the client keep the fingernails short

A client has presented at the clinic with symptoms of benign prostatic hyperplasia. What diagnostic findings would suggest that this client has chronic urinary retention? A. Hypertension B. Peripheral edema C. Tachycardia and other dysrhythmias D. Increased blood urea nitrogen (BUN)

D. Increased blood urea nitrogen (BUN)

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? A. 0.45% NaCl with 20 mEq/L KCl B. 0.45% NaCl with 40 mEq/L KCl C. Normal saline D. Lactated Ringer

D. Lactated Ringer

A patient is admitted to the Emergency department with hypovolemia. Which IV solution should the nurse anticipate administering? A. 3% Sodium Chloride B. 10% Dextrose C. 0.45% Na Cl D. Lactated Ringers solution

D. Lactated Ringers solution

A 45-year-old patient who reports pain in the foot that moves up along the calf says: "My right foot feels like it is on fire." The patient reports that the pain started yesterday, and he or she has no prior history of injury or falls. Which components of pain assessment has the patient reported? A. Aggravating and alleviating factors. B. Exacerbation, with associated signs and symptoms. C. Intensity, temporal characteristics, and functional impact. D. Location, quality, and onset.

D. Location, quality, and onset.

A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes? A. Preventing infection B. Maintaining skin and tissue integrity C. Preventing nausea and vomiting D. Maintaining fluid and electrolyte balance

D. Maintaining fluid and electrolyte balance

A dark-skinned client is admitted to the medical unit with liver disease. To correctly assess this client for jaundice, on what body area should the nurse look for yellow discoloration? A. Elbows B. Lips C. Nail beds D. Sclerae

D. Sclerae

A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A. Decreased hematocrit B. Decreased prothrombin time (PT) C. Potassium deficit D. Sodium deficit

D. Sodium deficit

A critical care nurse is caring for a client with immune hemolytic anemia. The client is not responding to conservative treatments, and the client's condition is now becoming life-threatening. The nurse is aware that a treatment option in this case may include which intervention? A. Hepatectomy B. Vitamin K administration C. Platelet transfusion D. Splenectomy

D. Splenectomy

A client with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this client's susceptibility to heat loss is related to atrophy of what skin component? A. Dermis B. Epidermis C. Merkel cells D. Subcutaneous tissue

D. Subcutaneous tissue

The nurse is providing preoperative education for a client diagnosed with endometriosis. A hysterectomy has been scheduled. What education topic should the nurse be sure to include for this client? A. Menstrual periods will continue to occur for several months, some of them heavy. B. Normal activity will be permitted within 48 hours following surgery. C. After a hysterectomy, hormone levels remain largely unaffected. D. The bladder must be emptied prior to surgery and a catheter may be placed during surgery.

D. The bladder must be emptied prior to surgery and a catheter may be placed during surgery.

A client newly diagnosed with breast cancer states that the health care provider suspects regional lymph node involvement and told the client that there are signs of metastatic disease. The nurse learns that the client has been diagnosed with stage IV breast cancer. What is an implication of this diagnosis? A. The client is not a surgical candidate. B. The client's breast cancer is considered highly treatable. C. There is a 10% chance that the client's cancer will self-resolve. D. The client has a 15% chance of 5-year survival.

D. The client has a 15% chance of 5-year survival.

The client diagnosed with viral skin lesions and experiencing pruritis. Which statement would be an appropriate long term goal? A. The client will refrain from scratching the skin B. The client will maintain intact skin integrity C. The client will have relief from itching D. The client will not develop a secondary bacterial infection

D. The client will not develop a secondary bacterial infection

Which client is at the greatest risk for developing skin cancer? A. The African American male living in the Northeast B. The older Hispanic female who immigrated from Mexico as a child C. The client with a family history of Basal Cell carcinoma D. The client with fair complexion and unable to tan

D. The client with fair complexion and unable to tan

The nurse is caring for a client diagnosed with deep partial thickness and full thickness burns to the chest area. which assessment data would alert the nurse to notify the HCP immediately? A. The client is reporting severe pain B. The client's pulse oximetry is 95% C. The client's vitals are: Temp 100.4, HR 100, Resp 24, BP 102/60 D. The client's urinary output has been 50ml in 2 hours

D. The client's urinary output has been 50ml in 2 hours

Which statement explains the nurse's responsibility when obtaining informed consent for the client undergoing a surgical procedure? A. The nurse should provide detailed information about the procedure B. The nurse should inform the client of any legal consultation needed C. The nurse should write a list of the risks for postoperative complications D. The nurse should ensure that the client is voluntarily giving consent

D. The nurse should ensure that the client is voluntarily giving consent

A client has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving the client's diet. When introducing the client to the use of laxatives, what teaching should the nurse emphasize? A. The effect of laxatives on electrolyte levels B. The underlying causes of constipation C. The risk of fecal incontinence D. The risk of becoming laxative-dependent

D. The risk of becoming laxative-dependent

An emergency department nurse is training a new nurse about burns. He asks the new nurse to identify what characteristic of a burn will determine whether or not the client experiences a systemic response to this burn injury? A. The length of time since the burn B. The location of burned skin surfaces C. The source of the burn D. The total body surface area (TBSA) affected by the burn

D. The total body surface area (TBSA) affected by the burn

A nurse is providing a class on osteoporosis at the local center for older adults. Which statement related to osteoporosis is most accurate? A. High levels of vitamin D can cause osteoporosis. B. A nonmodifiable risk factor for osteoporosis is a person's level of activity. C. Secondary osteoporosis occurs in women after menopause. D. The use of corticosteroids increases the risk of osteoporosis.

D. The use of corticosteroids increases the risk of osteoporosis.

A 73-year-old patient with cancer is in the hospital for pain control and rates pain as a "12" on the Numeric Rating Scale of 0 to 10. Thirty minutes after receiving IV pain medication, the patient reports no pain relief. The pain management nurse calls the physician for additional orders for pain medication. The nurse's actions demonstrate: A. analgesic titration. B. empathy. C. independence. D. patient advocacy.

D. patient advocacy.

An adult client's abnormal complete blood count (FBC) and physical assessment have prompted the primary care provider to order a diagnostic workup for Hodgkin lymphoma. The presence of what assessment finding is considered diagnostic of the disease?

Reed-Sternberg cells