Med Surg I HESI EAQ
Which finding is expected in a client diagnosed with early glomerulonephritis? a. anuria b. dysuria c. polyuria d. proteinuria
Proteinuria
The RN is teaching a nursing student about the process of medication reconciliation for a client who was admitted in a health care setting. Which statement made by the nursing student indicates the need for further teaching a. " i would check the new medication prescription against the current list of medicines" b. " I would avoid asking about the client's OTC meds" c. "I would obtain a comprehensive and current list of the client's meds" d> "I would avoid distractions and go slowly when reconciling the client's meds"
I would avoid asking about the client's OTC meds
Which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontinent of urine? a. restrict the client's fluid intake b. regularly offer the client a urinal c. apply incontinence pants d. insert an indwelling urinary catheter
Regularly offer the client a urinal
Which manifestations are seen in an older adult with the diagnosis of dementia? Select all that apply a. resistance to change b. inability to recognize familiar objects c. preoccupation with personal appearance d. inability to concentrate on new activities e. tendency to dwell on the past
Resistance to change Inability to recognize familiar objects Inability to concentrate on new activities Tendency to dwell on the past
Which change in arterial blood gases does the nurse expect in a client with hyperventilation due to anxiety a. respiratory acidosis b. respiratory alkalosis c. respiratory compensation d. respiratory decompensation
Respiratory alkalosis
Which initial action would the nurse take for a nursing home resident with moderate Alzheimer disease who begins to engage in numerous acting-out behaviors a. assess the client's LOC b. ID the stressors that precipitate the client's behavior c. observe the client's performance of activities of daily living d. monitor the s/e associated with the client's meds
ID the stressors that precipitate the client's behavior
The nurse is reviewing a list of current meds with a client who has developed GI bleeding. Which prescription would the nurse discuss with the primary health care provider? a. digoxin b. ibuprofen c. famotidine d. atorvastatin
Ibuprofen
Which urinary diversion surgery involves the transplantation of the ureters to a section of the colon, with one end attached to the abdominal wall as an ileostomy? a. cystostomy b. ileal conduit c. ureterosigmoidostomy d. cutaneous ureterostomy
Ileal conduit
The nurse is caring for a client diagnosed with a gastric ulcer. The nurse expects that which type of diet will be prescribed? a. soft diet b. low-fat, high-protein liquid diet c. hourly feedings of dairy products d. regular diet with foods that are well tolerated
Regular diet with foods that are well tolerated
A client with an intestinal obstruction is prescribed intestinal suction via a nasoenteric decompression tube. When caring for the client, the nurse would consider the loss of which constituents associated with this type of suctioning? a. protein enzymes b. energy carbohydrates c. vitamins and minerals d. water and electrolytes
Water and eletrolytes
Which modifiable risk factor would the nurse include in a community presentation on cardiovascular risk factors? Select all that apply a. weight b. inactivity c. cholesterol d. tobacco use e. homocysteine
Weight Inactivity Cholesterol Tobacco use Homocysteine
Which action would the nurse take for a client with invasive bladder carcinoma who is receiving radiation to the lower abdomen? a. observe the feces for the presence of blood b. monitor the BP for HTN c. administer enemas to remove sloughing tissue d. provide a high-bulk diet to prevent constipation
Obserce the feces for the presence of blood
Which response would the nurse make to a 30 yr old client diagnosed with hyperlipidemia and hypertension who asks the nurse to explain why treatment is important, stating " I feel find, so i don't really see the need to make any changes" a. "both high BP and high cholesterol contribute to development of heart disease" b. "lifestyle adaptations alone will be adequate as long as you continue to be asymptomatic" c. "usually someone with these diagnoses will have symptoms of heart disease already" d. "you should discuss your questions about medical problems with the health care provider"
"both high BP and high cholesterol contribute to development of heart disease"
Which problems would the nurse plan to address when dealing with ethical issues specifically related to end-of-life care? Select all that apply a. clients may be unable to communicate effectively b. all interventions for helping the clients seem futile c. clients are often unfamiliar with the concept of autonomy d. multiple meds affect the cognitive ability of the clients e. predictions regarding health outcomes are not always accurate
Clients may be unable to communicate effectively All interventions for helping the clients seem futile Predications regarding health outcomes are not always accurate
When an intestinal obstruction is suspected, a client has a nasogastric tube inserted and attached to suction. For what response should the nurse critically assess this client? a. edema b. belching c. fluid deficit d. excessive salivation
Fluid deficit
A client who is receiving radiation therapy for bone cancer lives alone and works full time. Which client action would the nurse encourage? a. begin to perform regularly scheduled aerobic activity daily b. take a leave of absence from work when receiving therapy c. include rest periods during the day while receiving radation d. continue the activities usually performed before becoming ill
Include rest periods during the day while receiving radiation
Which sign and symptom might the nurse identify when assessing a client with hyperthyroidism? Select all that apply a. menstrual irregularities b. hypotension c. facial edema d. flushed appearance e. short attention span
Menstrual irregularities Flushed appearance Short attention span
Which statement by a client is consistent with a diagnosis of heart failure a. "i see spots before my eyes" b. "I am tired at the end of the day" c. "i feel bloated when I eat a large meal" d. "i have trouble breathing when I climb a flight of stairs"
"i have trouble breathing when I climb a flight of stairs"
Which assessment in a female client suggests an abnormal endocrine finding? a. facial hair b. protruding eyes c. pulse of 90 beats per minute d. blood pressure of 120/80 mm Hg
Protruding eyes
Which assessment for findings would indicate a possible asthma exacerbation? Select all that apply a. fever b. stridor c. wheezing d. tachycardia e. hypotension
Wheezing Tachycardia
Which early sign of respiratory acidosis would the nurse expect the client with a restrictive airway disease to exhibit? Select all that apply a. headache b. irritability c. restlessness d. hypertension e. lightheadedness
Headache Irritability Restlessness
When a client is newly diagnosed with COPD, which action by the nurse has the highest priority? a. teach the client how to use the prescribed inhalers b. discuss the normal progression of the disease process c. ask whether the client is interested in quitting smoking d. explain the purpose of a pulmonary rehabilitation program
Ask whether the client is interested in quitting smoking
Which medication increaes the risk for upper GI bleeding? Select all that apply a. aspirin b. ibuprofen c. ciprofloxacin d. acetaminophen e. methylprednisolone
Aspirin Ibuprofen Methylprednisolone
Which statement indicates understanding after teaching a post-radiation therapy client about proper skin care to the treatment area? Select all that apply a. "i will wear loose-fitting clothing over the area" b. "i will avoid using adhesive bandages" c. "i will avoid exposing the area to cold temps" d. "i will avoid rinsing the area with a saline soluation" e. "i will use lotions to moisten the area when wearing makeup"
"i will wear loose-fitting clothing over the area" "i will avoid using adhesive bandages" "i will avoid exposing the area to cold temps"
The nurse is preparing an intraoperative care plan for a client. Which intervention would be excluded from the care plan? a. ensuring the client's skin integrity b. reviewing the preoperative instructions c. administering a general anesthetic to the client d. placing the client in the correct position on the operating table
Administering a general anesthetic to the client
How would the nurse describe heart failure to a client? a. a cardiac condition caused by inadequate circulating blood volume b. an acute state in which the pulmonary circulation pressure decreases c. an inability of the heart to pump blood in proportion to metabolic needs d. a chronic state in which the systolic BP drops below 90 mm Hg
An inability of the heart to pump blood in proportion to metabolic needs
Which action is the priority when the preoperative nurse learns that a client is taking several herbal supplements? a. provide the client with information about the usefulness of herbal therapies b. inform the client about taking supplemental vitamins rather than herbs c. teach the client about herbal supplements d. ask the client which herbs have been taken
Ask the client which herbs have been taken
Which manifestation would the nurse expect to find when assessing a client with hyperthyroidism? Select all that apply a. dry skin b. weight loss c. tachycardia d. restlessness e. constipation f. exophthalmos
Weight loss Tachycardia Restlessness Exophthalmos
Which condition would the nurse suspect in a client who complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination with a digital rectal examination report indicating smooth, firm, and enlarged prostate tissue surrounding the urethra? a. prostatitis b. paraphimosis c. prostate cancer d. BPH
BPH (benign prostatic hyperplasia)
While obtaining a client's health hx, which factor would the nurse identify as predisposing the client to type 2 diabetes? a. having diabetes insipidus b. eating low-cholesterol foods c. being 20 lbs overweight d. drinking a daily alcoholic beverage
Being 20 lbs overweight
The nurse applies a cold pack to relieve musculoskeletal pain. What rationale explains the analgesic properties of cold therapy? a. promotes analgesia and circulation b. numbs the nerves and dilates the blood vessels c. promotes circulation and reduces muscle spasms d. causes local vasoconstriction, preventing edema and muscle spasms
Causes local vasoconstriction, preventing edema and muscle spasms
A client who had been receiving palliative care for cancer has deteriorated and now needs end of life care. The nurse identifies that which type of care will now be removed from the treatment plan? Select all that apply a. chemotherapy b. repositioning c. regular oral care d. blood transfusion e. radiation therapy
Chemotherapy Blood transfusion Radiation therapy
Which symptom requires the most rapid action by the nurse when caring for a client with known peripheral arterial disease who calls the clinic and tells the nurse about experiencing several symptoms? a. anxiety b. chest pain c. weak pulse quality d. cool and pale lower legs
Chest pain
The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia and lives alone, with adult children living nearby. According to the prescribed medication regimen, the client is to take meds 6 times throughout the day. Which nursing intervention is correct to assist with client with taking the medication a. contact the client's children and ask them to hire a private-duty who will provide round-the-clock care b. develop a chart for the client, listening the times the medication should be taken c. Contact the primary health care provider and discuss the possibility of simplifying the medication regimen d. instruct the client and client's children to put meds in a weekly pill organizer
Contact the primary health care provider and discuss the possibility of simplifying the medication regimen
When receiving hemodialysis, the client may develop hyponatremia. Which clinical findings related to the potential development of hyponatremia would the nurse monitor? Select all that apply a. diarrhea b. seizures c. Chvostek sign d. cardiac dysrthythmias e. increased temperature
Diarrhea Seizures
A client is scheduled for a barium swallow. How would the nurse prepare the client for the test? Select all that apply a. ask about allergies to iodine before the test b. administer cleansing enemas before the test c. suggest a light breakfast on the day of the test d. ensure that a laxative is prescribed after the test e. instruct to withhold prescribed opiods for 1 day before the test
Ensure that a laxative is prescribed after the test Instruct to withhold prescribed opioids for 1 day before the test
Which manifestations of surgically induced hypothyroidism might the client exhibit after a thyroidectomy? Select all that apply a. fatigue b. dry skin c. insomnia d. excitability e. weight loss d. intolerance to heat
Fatigue Dry skin
The registered nurse delegates the care of a client in the immediate postoperative period to the UAP. Which tasks are in the scope of practice of the UAP? Select all that apply a. feeding the client b. ambulating the client for the first time c. monitoring the VS d. assisting the client with bathing e. teaching leg exercises to the client
Feeding the client Assisting the client with bathing
To prevent an adverse outcome while providing care for a client experiencing diarrhea, which client data would the nurse closely monitor a. skin condition b. fluid and electrolyte balance c. food intake d. fluid intake and output
Fluid and electrolyte balance
A client suffering from cancer is near the end of life. Which action(s) would be performed by the nurse support the client's family members? Select all that apply a. helping the family set up hospice b. taking time to make sure that the family understands care options c. staying with the client in the absence of family members d. giving the family information about the dying process e. making sure that the family knowns what to do at the time of death
Helping the family set up hospice Taking time to make sure that the family understands care options Staying with the client in the absence of family members Giving the family information about the dying process Making sure that the family knowns what to do at the time of death
A client with COPD exacerbation is receiving O2 at 2L/min per nasal cannula and has an O2 sat of 88%. Which action would the nurse anticipate taking next? a. increasing O2 flow rate to 3 L/min b. preparing for intubation and assisted ventilation c. administration of an inhaled rapid-acting bronchodilator d. continuing to monitor the client with no therapy change
Increasing oxygen flow rate to 3L/min
Which guidance would the nurse to provide to a sexually active 16 year old client when she inquires as to how she can protect herself from contracting HIV a. ask her partner to withdraw before ejaculating b. make certain their relationship is monogamous c. insist that her partner use a condom when having sex d. seek counseling about various contraceptive methods
Insist that her partner use a condom when having sex
Which agent is indicated for tx of mild anemia that has developed in a client with upper GI bleeding? a. dextran b. iron salts c. vit B12 d. erythroproitein
Iran salts
Which assessment finding would the nurse consider abnormal? Select all that apply a. joint crepitation b. muscular atrophy c. muscle strength of 5 d. tenderness of the spine e. full range of joint motion
Joint crepitation Muscular atrophy Tenderness of the spine
After an acute episode of upper FO bleedings, a client vomits undigested meds and reports severe epigastric and abdominal pain. The client has absent bowel sounds, rigid abdomen, a pulse rate of 134, and shallow respirations of 32 per min. The primary health care provider has been contacted. Which action would the nurse take next? a. keep the client NPO b. teach the client about coughing and deep-breathing exercises c. inquire whether any red or black stools have been noted d. place the client in the supine position with the legs elevated
Keep the pt NPO
The nurse is teaching pursed-lip breathing to a client with COPD. The client asks about the benefit of the exercise. Which explanation would the nurse give? a. prevents complications that are associated with COPD b. relieves shortness of breath by increasing the breath rate c. increases the amount of air that the client can inhale with each breath d. keeps the airway open longer to decrease the work that goes into breathing
Keeps the airway open longer to decrease the work that goes into breathing
Which risk factor increases a client's risk for infection int he community? Select all that apply a. lifestyle b. occupation c. chronic diseases d. frequent traveling e. diagnostic procedures
Lifestyle Occupation Frequent traveling
Which clinic manifestation would the nurse expect to find in a client who has acute HIV infection? Select all that apply a. malaise b. confusion c. constipation d. swollen lymph glands e. oropharyngeal candidiasis
Malaise Swollen lymph glands
Which finding in a client with asthma exacerbation requires the most rapid action by the nurse? a. report of chest tightness b. HR of 112 beats per minute c. expiratory wheezes in both lungs d. markedly decreased breath sounds
Markedly decreased breath sounds
An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mmHg, and HCO3 is 20 mEq/l. Which disturbance would the nurse identify based on these results? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis
Metabolic Acidosis
Which action would the nurse take to ID hyponatremia in an adolescent client with a perceived inability to ingest food? Select all that apply a. monitor VS b. monitor behavior c. monitor electrolyte status d. monitor for targeted daily calorie intake e. monitor activities for detrimental behaviors
Monitor VS Monitor electrolyte status
Which clinical manifestation would the nurse expect to ID when performing an admission hx and physical for a client with chronic peripheral arterial disease a. edema of the feet and ankles b. reddened and painful areas on the calves c. pain with exercising and thickening of the toenails d. ulcers around the ankles and reports of a dull ache in the legs
Pain when exercising and thickening of the toenails
The student nurse is describing palliative care to a client's family. Which statement made by the student nurse indicates a need for correction by the RN? a. "palliative care is the same as hospice care" b. "palliative care focuses on the care of the client" c. "palliative care includes symptom management in the client" d. "palliative care is an interprofessional approach to the delivery of care"
Palliative care is the same as hospice care
Which findings would the nurse expect when assessing a client with peripheral arterial disease? Select all that apply a. pallor of feet b. warm extremities c. ulcers on the toes d. thick, hardened skin e. delayed capillary refill
Pallor of feet Ulcers on the toes Delayed capullary refill
Which action by a clinet who requires an above-the-knee amputation for peripheral arterial disease best indicates readiness for the surgery? a. explains the goals of the procedure b. displays few signs of anticipatory greig c. participates in learning perioperative are d. verbalizes acceptance of permanent dependency needs
Participates in learning perioperative care
Which reason would an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium be prescribed for a client with a NG tube set to low intermittent suction? a. prevent constipation b. prevent dehydration c. prevent vomiting d. prevent electrolyte imbalance
Prevent electrolyte imbalance
Which intervention would the nurse include when developing a plan of care for an older client with dementia? a. explain to the client the details of the regimen b. demonstrate interest in the client's various likes and dislikes c. be firm when dealing with the client's attitudes and behaviors d. provide consistency in carrying out nursing activities for the client
Provide consistency in carrying out nursing activities for the client
How can the nurse best manage a common s/e of chemotherapy? a. restricting fluid intake b. instituting contact precautions c. keeping the hair closely cropped d. providing meticulous oral hygiene
Providing meticulous oral hygiene
Which factors are unique to delirium when distinguishing between dementia and delirium? Select all that apply a. slurred speech b. lability of mood c. long-term memory loss d. visual or tactile hallucinations e. insidious deterioration of cognition f. a fluctuating LOC
Slurred speech Visual or tactile hallucinations A fluctuating LOC
Which activities would the nurse include when teaching adults about activities that increase the risk of developing bladder cancer? Select all that apply a. jogging 3 miles a day b. drinking 3 cans of cola a day c. smoking 2 packs of cigarettes a day d. working with dyes used in rubber every day e. using a jackhammer and chainshaw every day
Smoking 2 packs of cigarettes a day Working with dyes used in rubber every day
Which stage of HIV disease is present in the client with 350 cells/mm3 of CD4+ T-cell count, according to the CDC a. stage 1 b. stage 2 c. stage 3 d. stage 4
Stage 2
Which priority intervention would the nurse expect to initiate for a postoperative care client with hypotension? a. start O2 therapy b. inspect the surgical incision c. administer IV fluid boluses d. administer vasoconstrictive agents
Start O2 therapy
Which instruction would the nurse include in a health practices teaching plan for a female client with a hx of recurrent UTIs? a. "wear cotton underwear or lingerie" b. "void at least every 6 hrs around the clock" c. "increase foods containing alkaline ash in the diet" d. "wipe the perineum from back to front after toileting"
Wear cotton underwear or lingerie
The primary health care provider instructs the nurse to manage fluid replacement therapy in a client with cancer. Which type of care is the client receiving? a. palliative care b. comfort care c. supportive care d. end of life care
Supportive care
Which description of symptoms is consistent with dementia of Alzheimer type? a. symptom onset is fairly rapid b. symptoms will subside periodically c. symptoms are triggered by personal crisis d. symptoms reflect progressive disintegration
Symptoms reflect progressive disintegration
Which clinical finding would the nurse expect when caring for a client with hyperthyroidism? Select all that apply a. lethargy b. tachycardia c. wt gain d. constipation e. exophthalmos
Tachycardia Exophthalmos
The RN is teaching a nursing about leadership skills for prioritizing the needs of the client. Which statement is an example of an intermediate-priority need? a. the teachings of home self-care b. a psychological episode of an anxiety attack c. a physiological episode of an obstructed airway d. the measures required to decrease postoperative complication
The measures required to decrease postoperative complications
Which statement would a nurse make when a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion during a sz? Select all that apply a. these sz are associated with amnesia b. these sz increase the risk for injuries from a fall c. these sz are most resistant to medication therapy d. these sz are preceded by perception of an offensive smell e. these sz cause one-sided movement of extremities in the client
These sz increase the risk for injuries from a fall These sz are most resistant to medication therapy
Which response would the nurse provide a client asked the purpose for using Buck Traction before surgery? a. to reduce the fracture b. to immobilize the fracture c. to maintain abduction of the leg d. to eliminate rotation of the femur
To immobilize the fracture
The nurse provides moist heat for a client with cartilage degeneration. Which rational explains the use of this nursing intervention? a. to slow bone loss b. to prevent skin breakdown c. to increase muscle strength d. to increase blood flow to the area
To increase blood flow to the area
Which purpose of metoclopramide administered intravenously 30 min before initiating chemo for cancer of the colon would the nurse explains to a client? a. to stimulate production of GI secretions b. to stimulate peristalsis of the upper GI tract c. to prolong excretion of the chemotherapeutic medication d. to increase absorption of the chemotherapeutic medication
To stimulate peristalsis of the upper GI tract
Which instruction will the home health nurse when teaching a client with peripheral artery disease? Select all that apply a. "avoid crossing your legs" b. "inspect your feet daily" c. "change positions slowly' d. "do not use compression stockings" "avoid green leafy vegetables in your diet"
a. "avoid crossing your legs" b. "inspect your feet daily" "do not use compression stockings"
The nurse is educating the client newly diagnosed with type 2 DM on oral antidiabetic meds. Which instruction would the nurse include in the teaching plan a. obtain a finger stick BG reading before each meal b. does not need to follow a specific diet until insulin is required c. teaching plan should include sxs of hypoglycemia d. teaching plan should include how to admin regular insulin e. teaching plan should include sick day rules
obtain a finger stick BG reading before each meal teaching plan should include sxs of hypoglycemia teaching plan should include sick day rules
An older client asks, " How do I know that the meds that I take are safe?" Which response by the nurse is correct? Select all that apply a. "ask your health care provider how and when you should be taking your meds" b. "stop taking a prescribed medication if you are not feeling better in a few days" c. "discard meds into the toilet that have exceeded the expiration date on the bottle" d. "check the name, dose, and instructions about administration of meds each time before leaving the pharmacy" e. "inform your health care provider of the OTC meds, recreational drugs, and amount of alcohol you ingest"
"ask your health care provider how and when you should be taking your meds" "check the name, dose, and instructions about administration of meds each time before leaving the pharmacy" "inform your health care provider of the OTC meds, recreational drugs, and amount of alcohol you ingest"
Which type of treatment is the Buck extension? a. skeletal traction b. cutaneous traction c. halter transfixation d. balanced suspension
Cutaneous traction
The nurse is caring for a client who had surgery for the formation of a continent urostomy. The nurse engages the client in early postoperative ambulation to prevent which complication? a. wound infection b. urinary retention c. abdominal distention d. incisional evisceration
Abdominal distention
Which clinical manifestations would the nurse expect a client with hypothyroidism to exhibit? Select all that apply a. cool skin b. photophobia c. constipation d. periorbital edema e. decreased appetite
Cool skin Constipation Periorbital edema Decreased appetite
When a client with COPD reports a 5;b wt gain in 1 wk, the nurse will assess for other signs and symptoms of which complications? a. polycythemia b. cor pulomonale c. compensated acidosis d. left ventricular failure
Cor pulmonale
Which type of lung sounds would the nurse expect to hear when caring for a client with heart failure a. stridor b. crackles c. wheezes d. rhonchi
Crackles
Which medication prescribed for a client with an acute episode of heart failure would the nurse question? a. diuretic b. beta blockers c. long-acting nitrate d. angiotensin receptor blocker
Beta Blocker
Which clinical manifestation would the nurse report immediately to the primary health care provider when providing care for a client with HIV infection a. blood in the urine b. new or productive cough c. vomiting accompanied by fever d. burning, itching, and discharge from the eyes
Blood in urine
Which nursing interventions require the nurse to wear gloves? Select all that apply a. giving a back rub b. cleaning a newborn immediately after delivery c. emptying a portable wound drainage system d. interviewing a client in the ED e. obtaining the BP of a client who is positive for HIV
Cleaning a newborn immediately after delivery Emptying a portable wound drainage system
Which clinical indicator would the nurse expect a client with hyperkalemia to exhibit? Select all that apply a. tetany b. seizures c. confusion d. weakness e. dysrhythmias
Confusion Weakness Dysrhythmias
Which event indicates a need to suggest testing of a client for HIV? Select all that apply a. diagnosed with TB in 1985 b. travelled to italy and greece in the late 1990s c. received blood transfusions in 1980 during total hip replacement surgery d. engaged in sexual relations with someone of the same sex for several years e. spent several nights in jail for a DUI charge
Diagnosed with TB in 1985 Received blood transfusions in 1980 during total hip replacement surgery Engaged in sexual relations with someone of the same sex for several years
A client with a disturbed state of mind is under observation . Which manifestation indicates that the client is suffering from dementia? Select all that apply a. displaying signs of depression b. difficulty making decisions c. continuously mentioning past failures d. inability to complete purposeful work e. disturbed sleep/wake cycle
Difficulty making decisions Inability to complete purposeful work
Which assessment finding is consistent with a client diagnosis of right-sided heart failure? Select all that apply a. collapsed neck veins b. distended abdomen c. dependent edema d. decreased appetite e. cool extremities
Distended abdomen Dependent edema Decreased appetite
Which condition would the nurse document to describe a client presenting with the loss of the ability to taste after cancer treatment has affected the client's ability to eat food? a. mucositis b. dysgeusia c. dysphagia d. xerostomia
Dysgeusia
A client with T1 DM for 25 yrs states, " I have been really bad for the past 15 yrs. I have not paid attention to my diet and have done little to control my DM." Which common complications of DM might the nurse expect to ID when assessing this client? Select all that apply a. leg ulcers b. loss of visual acuity c. thick, yellow toenails d. increased growth of body hair e. decrease sensation in the feet
Leg ulcers Loss of visual acuity Thick, yellow toenails Decreased sensation in the feet
Which finding would be of most concern when the nurse assesses a client with emphysema? a. barrel chest b. oral cyanosis c. pursed-lip expiration d. respirations 26 breaths per min
Oral cyanosis
While caring for a client in traction, which action would the nurse delegates to a LPN? Select all that apply a. padding traction connections b. determining correct body alignment c. assessing complication associated with immobility d. teaching the client about ROM exercises e. assisting the client with passive and active ROM exercises
Padding traction connections Assisting the client with passive and active ROM exercises
After an acute episode of upper GI bleeding, a client vomits undigested antacids and reports having severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, a pulse rate of 134, and shallow respirations of 32 per min. In addition to calling the health care provider, what action should the nurse take? a. prepare the client for surgery b. request a state chest XR (radiograph) c. place the client in the supine position, with legs elevated d. ask the client if there have any black stools
Prepare the client for surgery
Which action would the nurse take while a client is seizing on the hallway floor? a. hold the client's extremities firmly b. protect the client's head from injury c. insert an airway between the client's teeth d. have staff members move the client to a soft surface
Protect the client's head from injury
A client with COPD is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take? a. encourage the client to take slow, deep breaths and administer 5L/min oxygen per nasal cannula b. place the client in a side-lying position and perform chest physiotherapy using clapping and vibration c. raise the HOB to a high-fowler position and administer 2L/min oxygen per nasal cannula d. assist the client in assuming a position of comfort and perform postural drainage
Raise the HOB to a high-Fowler position and administer 2L/min oxygen per nasal cannula
The nurse is providing preoperative teaching to a client who is scheduled for abdominal surgery. The client is fidgeting, slightly diaphorectic, and asking simple questions about information that was already provided during the education session. Which initial step would the nurse take? a. repeat the information, speaking slowly and distinctly b. reduce the client's level of anxiety c. teach the client about measures to lessen preoperative anxiety d. ask the client to verbalize concerns and questions
Reduce the client's level of anxiety
Which physiological change of the musculoskeletal system would the nurse associate with aging? Select all that apply a. slowed movement b. cartilage degeneration c. increased bone density d. increased ROM e. increased bone prominence
Slowed movement Cartilage degeneration Increased bone prominence
Which topic will the nurse include in teaching for a client with Raynaud disease a. tobacco avoidance b. dietary salt reduction c. need for increased exercise d. low-fat, low-cholesterol diet
Tobacoo avoidance
Which client statements indicates the need for further teaching about the traction device after a major fracture? a. "traction must be applied continuously to be effective" b. "weights of 5-45 lbs are used to apply the counterweight" c. "the risks of skeletal traction include infection at the pin insertion site" d. "traction pushes the fractured ends together to prevent them from pulling apart"
Traction pushes the fractured ends together to prevent them from pulling apart
Which instruction would the nurse provide to the client who has been diagnosed with a urinary tract infection? a. void every 2 hrs b. record fluid intake and urinary output c. pour warm water over the vulva after voiding d. urinate after intercourse
Urinate after intercourse
Which topic would the nurse in teaching for a client with a new diagnosis of HTN? Select all that apply a. reason for daily low-dose aspirin use b. use of a home BP monitor c. adverse effects of tobacco on BP d. avoidance of any alcohol consumption e. benefits of moderate daily exercise
Use of a home BP monitor Adverse effects of tobacco on BP Benefits of moderate daily exercise
Which intervention would the public-health nurse prioritize to support secondary prevention efforts for cardiovascular disease a. offer routine BP screening at various community sites including worksites, schools, and faith institutions b. advocate for policy changes to support healthy environments that include opportunities for safe physical activity c. provide educational opportunities regarding prevention of CV disease through a variety of venues d. support access to healthy food options in the local community for all residents
offer routine BP screening at various community sites including worksites, schools, and faith institutions
Which blood gas report most likely reflects the acid-base balance of an infant with severe dehydration? a. pH of 7.50 and PCO2 of 34 mm Hg b. pH of 7.23 and PCO2 of 70 mm Hg c. pH of 7.20 and HCO3 of 20 mEq/L d. pH of 7.56 and HCO3 of 30 mEq/L
pH of 7.20 and HCO3 of 20 mEq/L
The nurse advises a client recovering from a musculoskeletal injury to increase intake of which nutrient? a. fat b. protein c. sodium d. Vit A
Protein
Which statement from a client who has received prescriptions for digoxin, furosemide, and a 2g sodium indicates that further teaching is needed a. "i must check my pulse every day" b. "i can gradually increased my exercise as long as I take rest periods" c. " i should call my health care provider if I have difficulty breathing when I am lying flat" d. "i can use a little table salt on my food as long as i do not use it when cooking food"
"i can use a little table salt on my food as long as i do not use it when cooking food"
A client's fasting plasma glucose are being evaluated. The nurse identifies that the client is considered to be diabetic if the results are within which range? a. 40-60 mg/dL (2.2-3.3 mmol/L) b. 80-99 mg/dL (4.5-5.5 mmol/L) c. 100-125 mg/dL (5.6-6.9 mmol/L) d. 126-140 mg/dL (7.0-7.8 mmol/L)
126-140 mg/dL (7.0-7.8 mmol/L)
For an older adult client with dementia who developed dehydration as a result of vomiting and diarrhea, which assessment information best reflects the client's fluid balance a. skin turgor b. intake and output results c. client's report about fluid intake d. blood lab results
Blood lab results
Which radiographic test would be used to view the entire skeleton? a. bone scan b. gallium and thallium scan c. CT d. MRI
Bone scan
Which response would the nurse provide to a client who develops a sz d/o as a result of a traumatic fall and states " I have not had a sz in 2 yrs. When can I stop taking my anti-sz meds?" a. " a gradual reduction in sz medication may be considered" b. " you will require medication for the rest of your life" c. " the medication probably will be d/c at this visit" d. "a minimum of 10 yrs w/o sz is necessary before d/c of meds is considered"
A gradual reduction in sz medication may be considered
Which factor is unique to vascular dementia when comparing assessment findings in clients with vascular dementia and dementia of the Alzheimer type a. memory impairment b. abrupt onset of symptoms c. difficulty making decisions d. inability to use words to communicate
Abrupt onset of symptoms
Which nursing intervention would be contraindicated for a client who has a fracture and has compartment syndrome? Select all that apply a. splitting the cast in half b. applying cold compresses c. reducing the traction weight d. loosening the client's bandage e. elevating the extremity above heart level
Applying cold compresses Elevating the extremity above the heart level
Which type of immunity will clients acquire through immunizations with live or killed vaccines? a. natural active immunity b. artificial active immunity c. natural passive immunity d. artificial passive immunity
Artifical active immunity
When determining the main difference between type 1 and type 2 diabetes, the nurse recognizes which clinical presentation about type 1? a. onset of disease is slow b. excessive weight is contributing factor c. complications are not present at the time of diagnosis d. treatment involves diet, exercise, and oral medications
Complications are not present at the time diagnosis
The nurse is providing preoperative education to a client scheduled for orthopedic surgery at 0800 the next day. Which instruction would the nurse include? a. "have your dinner completed by 6:00pm tonight and then no food or fluids after that" b. "drink whatever liquids you want tonight and then only clear liquids tomorrow morning" c. "consume a light evening meal tonight and then no food or liquids after midnight d. "eat lunch today and then don't drink or eat anything until after your surgery"
Consume a light evening meal tonight and then no food or fluids after midnight
A client arrives at a health clinic reporting a recent onset of hematuria, frequency, urgency, and pain on urination. Which diagnosis will the nurse observe in the client's medical record? a. chronic glomerulonephritis b. nephrotic syndrome c. pyelonephritis d. cystitis
Cystitis
Which factor contributes to a client's slow rate of healing? Select all that apply a. diabetes b. cataract c. smoking d. dermatitis e. alcohol abuse
Diabetes Smoking Alcohol abuse
Which intervention would the nurse recommend to decrease TB in the community? a. improving financial resources b. eliminating overcrowded housing c. initiating needle-sharing programs d. improving access for food pantries e. providing barrier contraceptive device
Improving financial resources Eliminating overcrowded housing Initiating needle-sharing programs Improving access for food pantries Providing barrier contraceptive device
After treatment for a bladder infection, a client ask whether there is anything she can do to prevent cystitis in the future. Which response would the nurse give? a. "avoid regular use of tampons" b. "decrease your intake of prune juice" c. "increase your daily fluid consumption" d. "cleanse the perineum from back to front"
Increase your daily fluid consumption
Which action would the nurse take after finding a child having a tonic-clonic sz a. applying restraints b. administering oxygen c. protecting the child from self-injury d. inserting a plastic airway in the child's mouth
Protecting the child from self-injury
The nurse notes a client's BP of 200/110 mm Hg and swelling of the operative leg after a femoropopliteal bypass graft. Which action would the nurse take next? a. evaluate the client's orientation b. check pedal pulses distal to the graft c. notify the client's health care provider d. monitor BP every 15 minutes
Notify the client's health care provider
Which food would the nurse mention is bladder irritant when educating a client with interstitial cystitis? Select all that apply a. milk b. nuts c. citrus fruit d. aged cheeses e. soy-containing foods f. green, leafy vegetables
Nuts Citrus fruit Aged cheeses
Which statement indicates a client understands transmission of the HIV? Select all that apply a. "i can contract HIV by participating in oral sex" b. "i can contract HIV by eating from used utensils" c. "i can contract HIV by using the bathroom of a person who is HIV +" d. "HIV is contracted by using contaminated needles" e. "babies can contract HIV because of contact with maternal blood during birth"
"i can contract HIV by participating in oral sex" "HIV is contracted by using contaminated needles" "babies can contract HIV because of contact with maternal blood during birth"
Which statement by a client with type 2 diabetes indicates to the nurse that additional dietary teaching in needed? a. "i can eat as much dietetic fruit as i want" b. "i can have a lettuce salad whenever i want it" c. "i know that half of my diet should be carbohydrates" d. "i need to reduce the amounts of saturated fats in my diet"
"i can eat as much dietetic fruit as i want"
Which statement by the client would the nurse expect when assessing a client with a diagnosis of left ventricular failure? a. "my ankles are swollen" b. "my appetite is not very good" c. "when i eat a large meal, i feel bloated" d. "i have trouble breathing when i walk rapidly"
"i have trouble breathing when i walk rapidly"
Which statement indicates that the teaching has been effective after the nurse has finished teaching a 50 yr old female client symptoms of coronary artery disease in women a. "i don't need to worry about symptoms like chest pain or pressure" b. "i will call my health care provider about any unusual fatigue" c. "women have less risk of death from heart disease than men" d. "bad cholesterol levels are usually higher in women than in men"
"i will call my health care provider about any unusual fatigue"
Which activity would the nurse expect to cause the most distress when assessing a client with heart failure for activity tolerance? a. getting up from bed in the morning b. walking to visit the next-door neighbor c. climbing a flight of stairs to the bedroom d. leaving the table immediately after a meal
Climbing a flight of stairs to the bedroom
A client presenting with an acute asthma attack is being assessed in the emergency department. Th client's spouse that the client currently is undergoing treatment for an upper respiratory infection. The nurse understand that the client most lilkey has which type of asthma? a. allergic b. emotional c. extrinsic d. intrinsic
Intrinsic
Which action would the nurse take if the weights attached to a 7 year old child in traction are touching the floor? a. raising the foot of the bed b. lengthening the traction rope c. notifying the health care provider d. moving the child toward the head of the bed
Moving the child toward the head of the bed
Diagnosed with COPD, a 50 year old client's clinical data after treatment is: HR of 100 beats/min, BP of 138/82 mm Hg, RR of 32 breaths/min, Temp of 98.2%, and an O2 sat of 80%. Which VS obtained by the nurse indicates a positive outcome? Select all that apply a. radial pulse: 70 beaths/min b. temp: 98.6 c. rr: 14 breaths/min d. bp: 110/70 mm Hg e. O2 sat: 92%
RR: 14 breaths/min BP: 110/70 mm Hg O2 sat: 92%
Which action would the nurse correct after observing the student nurse caring for the skin of a client who recently underwent radiation therapy? Select all that apply a. using a washcloth for cleaning the radiated site b. rinsing soap thoroughly from the skin of the client c. drying the irradiated area with rubbing motions d. telling the client to wear loose clothing over the skin at the radian site e. removing the ink marks that ID the location of the focused beam of radiation
Using a washcloth for cleaning the radiated site Drying the irradiated area with rubbing motions Removing the ink marks that ID the location of the focused beam of radiation
Which prescribed diagnostic test would the nurse expect to confirm a tentative urinary tract infection diagnosis in a client recovering from deep, partial-thickness burns who develops chills, fever, flank pain, and malaise? a. cystoscopy and bilirubin level b. specific gravity and pH of the urine c. urinalysis and urine culture and sensitivity d. creatinine clearance and albumin/globulin (A/G) ratio
urinalysis and urine culture and sensitivity
Which basic strategy would the nurse teach a health class to reduce the incidence of HIV transmission? Select all that apply a. using condoms b. using separate toilets c. practicing sexual abstinence d. preventing direct causal contacts e. sterilizing the household utensils
using condoms practicing sexual abstinence
Which steps listen by the nursing student are accurate regarding discharge planning? Select all that apply? a. "plan the client's discharge at the time of leaving the hospital" b. "teach the client the safe and effective use of medications and medical equipment" c. "remember that discharge planning is a centralized, coordination, interdisciplinary process" d. "coordinate with just the primary health care provider when preparing discharge planning" e. "develop a care plan that moves the client from the hospital to another level of care"
Teach the client the safe and effective use of medications and medical equipment Remember that discharge planning is a centralized, coordinated, interdisciplinary process Develop a care plan that moves the client from the hospital to another level of health care
Once a client admitted with shock secondary to severe GO bleeding is stabilized, which action would the nurse take? a. monitor the peripheral pulses b. check the level of consciousness c. take a blood sample for laboratory tests d. control the bleeding with a pressure dressing
Take a blood sample for laboratory tests
Which topic would be the most important to include in teaching when a obese client receives a diagnosis of high BP a. causes of HTN b. symptoms of HTN c. effect of weight loss in HTN d. effect of lowering alcohol intake in HTN
Effect of weight loss in HTN
Which perioperative actions would the nurse plan when caring for a client scheduled for a septoplasty? Select all that apply? a. teach the client how to use hot compresses b. encourage the client to quit smoking before surgery c. observe the surgical site for edema d. teach the client about postsurgery activities that are restricted e. assess the client's respiratory status f. encourage the client to take aspirin before the surgery
Encourage the client to quit smoking before surgery Observe the surgical site for edema Teach the client about postsurgery activities that are restricted Assess the client's respiratory status
Which condition would the nurse consider as the most likely cause of pain for a client who tells the nurse, "My legs begin to hurt after walking for several blocks. The pain goes away when I stop walking, but it comes again when I resume walking" a. spinal stenosis b. beurger disease c. rheumatoid arthritis d. intermittent claudication
Intermittent Claudication
Which metabolic manifestation are likely to be observed in a client with hypothyroidism? Select all that apply a. impaired memory b. intolerance to cold c. difficulty breathing d. decreased BP e. decreased body temperature
Intolerance to cold Decreased body temperature
Which finding in a client seen at the outpatient clinic supports a diagnosis of an arterial ulcer? Select all that apply a. lack of hair b. thickened toenails c. copious ulcer drainage d. diminished pedal pulses e. brown skin discoloration
Lack of hair Thickened toenails Diminished pedal pulses
In which scenario is the nurse providing tertiary prevention? a. educating a community about the proper use of environmental sanitation b. educating a family about how to protect themselves from carcinogens c. providing education to a family regarding the need to pay attention to personality development d. providing education to a community about the need to integrate individual's limb amputations into the professional sphere
Providing education to a community about the need to integrate individual's limb amputations into the professional sphere
Which eye problem is the leading cause of blindness in clients with diabetes a. cataracts b. glaucoma c. retinopathy d. astigmatism
Retinopathy
Which action by a client with peripheral arterial disease indicates that more teaching about how to manage the disease is needed a. applying a hot water bottle to the abdomen b. using a heating pad to warm the extremities c. drinking a warm cup of tea when feeling chilly d. turning the room thermostat above 72F
Using a heating pad to warm the extremities
Which nursing intervention helps prevent complications associated with a shortened urethra revealed by a recent intravenous pyelogram? a. providing thorough perineal care after each voiding b. encouraging the client to use the toilet or bedpan every 2 hrs c. responding quickly to the client's indication of the need to void d. applying voiding stimulants to the perineum
providing thorough perineal care after each voiding