MEDSURG MIDTERM

An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the client?

Duloxetine

A nurse is orienting a new client and family to the medical-surgical unit. What information does the nurse provide to best help the client promote his or her own safety?

Encourage the client and family to be active partners.

A client is in the hospital and has received two doses of an angiotensin-converting enzyme for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below:

Ensure a patent airway while calling the Rapid Response Team.

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

Ensure that informed consent is on the chart.

A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate?

Ensure that the radiology department is aware of the Isolation Precautions.

A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new nurse that which is the priority when working as a professional nurse?

Ensuring Client Safety

A client is having a catheter placed to deliver chemotherapy beads into a liver tumor via the femoral artery. What action by the nurse is most important?

Ensuring that informed consent is on the chart

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL (61 mmol/L). The client is symptomatic but refuses blood transfusions. What medication does the nurse prepare to administer?

Epoetin alfa

A nurse working with older adults in the community plans programming to improve morale and emotional health in his population. What activity would best meet this goal?

Exercise program to improve physical function

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

Explain that xerostomia may be a permanent side effect.

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

Measure and compare cuff pressures.

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

Applying suction while inserting the catheter

Which action by the nurse working with a client best demonstrates respect for autonomy?

Asks if the client has questions before signing a consent.

Emergency medical technicians arrive at the emergency department with an unresponsive client who has oxygen mask in place. Which action would the nurse take first?

Assess that the client is breathing adequately

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?

Potassium: 2.9 mEq/L (2.9 mmol/L)

A nurse works on an oncology unit and delegates personal hygiene to assistive personnel (AP). What action by the AP requires intervention from the nurse?

Allowing a very tired client to skip oral hygiene and sleep

A nurse is caring for four clients. Which client does the nurse assess first for impaired cognition?

An 88 year old client 3 days post-hemorrhagic stroke

The nurse is presenting information to a community group on safer sex practices. The nurse would teach that which sexual practice is the riskiest?

Anal intercourse

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

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

What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department?

Determine the acuity of the clients condition to determine priority of care.

The nurse in the outpatient surgery clinic is discussing an upcoming surgical procedure with a client. Which information provided by the nurse is most appropriate for the client's long-term outcome?

"Discuss acceptable pain control after your operation with the surgeon."

A nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? (Select all that apply.)

-Decreased immune response -Development of chronic pain -Possible immobility -Slower healing -Negative quality of life

The nurse learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? (Select all that apply.)

-Differentiated function -Nonmigratory -Specific morphology -Orderly and specific growth

A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. Which intervention for pain management does the nurse include in the client's care plan?

Round-the-clock analgesia with PRN analgesics

A nurse is learning about different surgical procedures and their classifications. Which examples below does this include? (Select all that apply.)

-Liver biopsy: diagnostic -Arthroscopy: preventative. Ileostomy: palliative. Total shoulder replacement: reconstructive -Body contouring: cosmetic

An emergency department nurse is preparing to transfer a client to the trauma intensive care unit. Which information would the nurse include in the nurse to nurse hand off report? (SATA)

-Mechanism of injury -Diagnostic Test Results -Isolation Precautions -Safety concerns

Nurses at a conference learn the process by which pain is perceived by the client. Which processes are included in the discussion? (Select all that apply.)

-Modulation -Sensory perception -Transduction -Transmission

A registered nurse (RN) is watching a new nurse change a dressing and perform care around a Penrose drain. What action by the new nurse warrants intervention?

Securing the drain's safety pin to the sheets

A nurse plans care for a client who is at risk for infection. Which interventions will the nurse implement to prevent infection? (Select all that apply.)

-Monitor white blood cell count and differential. -Screen all visitors for infections. -Promote sufficient nutritional intake.

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

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

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

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

A nursse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent"?

A 62 year old with a simple fracture of the left arm

A nurse is triaging clients in the emergency department. Which client would be considered "urgent"?

A 75 year old female with a cough and a temp of 102F

A client has been placed on Contact Precautions. The client's family is very afraid to visit for fear of being "contaminated" by the client. What action by the nurse is best?

Show the family how to avoid spreading the disease.

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

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

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate?

"Do not expose the radiation area to direct sunlight."

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

Anxious client who has tachypnea

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

Apply water-soluble ointment to nares and lips.

A client with HIV-III is hospitalized and has weeping Kaposi sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important for the nurse's safety?

Adhering to Standard Precautions

A primary health care provider notifies the nurse that a client has a "bandemia." What action does the nurse anticipate?

Administer antibiotics.

A client is to receive a fecal microbiota transplantation tomorrow (FMT). What action by the nurse is best?

Administer bowel cleansing as prescribed.

A nurse learns that which of the following is the single biggest risk factor for developing cancer?

Advancing age

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority?

Airway

A nurse is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which drug does the nurse plan health teaching?

Acetaminophen

A nurse is assessing pain in an older adult. Which action by the nurse is best?

Sit down, ask one question at a time, and allow the client to answer.

A client is put on twice-daily acetaminophen for osteoarthritis. Which finding in the client's health history would lead the nurse to consult with the primary health care provider over the choice of medication?

Drinking 3 to 5 beers a day

A nurse on the postsurgical inpatient unit is observing a client perform leg exercises. What action by the client indicates a need for further instruction?

Bends both knees, pushes against the bed until calf and thigh muscles contract.

A client is receiving rituximab. What assessment by the nurse takes priority?

Blood pressure

The nurse caring for oncology clients knows that which form of metastasis is the most common?

Bloodborne

The nurse learning about infection discovers that which factor is the best and most important barrier to infection?

Skin and mucous membranes

A nurse on the medical-surgical unit has received a hand-off report. Which client would the nurse see first?

Client with new-onset abdominal pain, rated as an 8 on a 0-10 scale

A new nurse asks the precepting nurse "What is the best way to assess a client's pain?" Which response by the nurse is best?

Client's self-report

A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best?

Call the client at home the next day to review teaching.

A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mmHg. What action would the nurse take first?

Call the rapid response team

A nurse is caring for a client with HIV-III who was admitted with HAND. What sign or symptom would be most important for the nurse to report to the primary health care provider?

Change in pupil size

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

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

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

Client is able to swallow own secretions without drooling.

A nurse is caring for four clients receiving pain medication. After the hand-off report, which client would the nurse see first?

Client with a Pasero Scale score of 4

A nurse assesses a group of clients who have rheumatoid arthritis (RA). Which client would the nurse see first?

Client with a red, hot, swollen right wrist

An emergency department charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event?

Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What action by the nurse is best?

Discuss concerns with the health care team

The nurse working with oncology clients understands that which age-related change increases the older client's susceptibility to infection during chemotherapy?

Decreased immune function

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

Decreased orthostatic changes when standing

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?

Demonstrate how to splint the incision

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

Depth of respirations

A nurse admits an older adult from a home environment. The client lives with an adult son and daughter-in-law. The client has urine burns on the skin, no dentures, and several pressure injuries. What action by the nurse is most appropriate?

Report the findings as per agency policy

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

Grilled chicken breast with glazed carrots

A nurse is learning the difference between normal cells and benign tumor cells. What information does this include?

Growing in the wrong place or time is typical of benign tumors.

A client with HIV-III and wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem?

Has a weight gain of 2 lb (1 kg)/1 mo.

A client is getting out of bed into the chair for the first time after an uncemented total hip arthroplasty. What action by the nurse is appropriate?

Have adequate help to transfer the patient.

A client with cancer has anorexia and mucositis, and is losing weight. The client's family members continually bring favorite foods to the client and are distressed when the client won't eat them. What action by the nurse is best?

Help the family show other ways to demonstrate love and caring.

A client with long-standing heart failure being treated for cancer has received a dose of ondansetron for nausea. What action by the nurse is most important?

Request a prescription for cardiac monitoring

A nurse is caring for a client admitted for Non-Hodgkin's lymphoma and chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nurse is most important?

Request an order for serum electrolytes and uric acid.

A client has urinary incontinence. Which assessment finding indicates that outcomes for a priority nursing diagnosis have been met?

Skin in perineal area is intact without redness on inspection

An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication would he or she suggest in place of the morphine?

Hydromorphone Hydrochloride

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

Hypertension Stroke Weight gain Diabetes Cognitive deficits Pulmonary disease

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic intervention does the nurse recommend?

Ice packs

An older adult recently retired and reports "being depressed and lonely." What information would the nurse assess as a priority?

Role of work in the adults life

The nurse assesses the client using the device pictured below to deliver 50% O2: The nurse finds that the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best?

Immediately increase the flow rate.

A client with HIV-III is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate?

Initiate Protective Precautions

A client has a platelet count of 9800/mm3 (9800 109/L). What action by the nurse is most appropriate?

Instruct the client to call for help to get out of bed.

A nurse is caring for a client who received intraspinal analgesia. Which action by the nurse is most important to ensure client safety?

Instruct the client to report any unrelieved pain.

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

Intact skin behind the ears

An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client?

Keep the light on in the bathroom

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?

Level II - Located within community hospitals and provides care to most injured clients.

An emergency department nurse is caring for a client who is homeless. Which action would the nurse take in gain the clients trust?

Listen to the clients concerns and needs

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

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

The nurse caring for clients admitted for infectious diseases understands what information about emerging global diseases and bioterrorism?

Many infections are or could be spread by international travel.

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. Which pain assessment tool would the nurse choose for this assessment?

FACES Pain Scale-Revised

A nurse talking with a co-worker who is moving to a new state and needs to find new employment there. What advice by the nurse is best?

Find a hospital that has achieved magnet status.

An emergency department nurse assesses a client who has been raped. With which health care team member would the nurse collaborate when planning this clients care?

Forensic Nurse Examiner

The postoperative nurse is caring for a client who reports feeling "something popped" after vomiting. What action by the nurse is best?

Gather sterile nonadherent dressings

A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate?

Gently inquire about advance directives.

A client had a recent thromboembolism and must resume work which requires frequent care and plane travel. What self-care measure does the nurse teach to reduce the risk of impaired clotting in this client?

Get up and walk around at least every 2 hours while traveling.

. A client who has rheumatoid arthritis is prescribed etanercept. What health teaching by the nurse about this drug is appropriate?

Giving subcutaneous injections

The nurse interviews an older client with moderate osteoarthritis and her husband. What psychosocial assessment question would the nurse include?

"Do you experience discomfort during sex?"

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

"Do you have any chronic breathing problems?"

A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem?

Assisting the client to pre-plan for this event

A nurse is planning primary prevention measures for community-dwelling adults to prevent visual impairment. What action by the nurse will best mee the objective?

Offer a healthy lifestyle class

A newly graduated nurse in the hospital states that because of being so new, participation in quality improvement (QI) projects is not wise. What response by the precepting nurse is best?

"Even being new, you can implement activities designed to improve care."

The nurse tells the staff development nurse he/she is very uncomfortable discussing sexuality with clients, especially those who are older. What suggestion by the staff development nurse is most appropriate?

"Find a trusted friend and role play."

A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue?

"Have something to drink every 1 to 2 hours."

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How would the nurse respond?

"You seem upset. I have time to talk if you'd like."

The nurse assesses a client with diabetes and osteoarthritis (OA) during a checkup. The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate?

"Have you been taking glucosamine supplements?"

A client has long-term rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is appropriate?

"Try a paraffin wax dip 20 minutes before you quilt."

A nurse is giving a client instructions for showering the night before surgery. What instruction is most appropriate?

"Use the prescribed solution and wash the area where you will have surgery very thoroughly."

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

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

A nurse is caring for a client whose spouse died in a recent mass casualty accident. The client says, "I can't believe that my spouse is gone and I am left to raise my children all by myself." How would the nurse respond?

"You so und anxious about being a single parent"

A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.)

- A 35-year-old female with severe chest pain: red tag - A 60-year-old male with an open fracture with distal pulses: yellow tag

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

- A 76 year old who is cognitively impaired

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

- Assess client further for fall risk

A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.)

-A sore that does not heal -Changes in menstrual patterns -Indigestion or trouble swallowing -Obvious change in a mole -Frequent indigestion

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

-Stridor -Ecchymosis behind the ear

The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is "on the light constantly" asking for more pain medication. When assessing this client's pain, which statement or question by the nurse is most appropriate?

"Help me understand how pain is affecting you right now."

A nurse has educated a client on an epinephrine autoinjector. What statement by the client indicates additional instruction is needed?

"I don't need to go to the hospital after using it."

A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping?

"I have had the same best friend for decades."

The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information?

"I will be careful if I need enemas for constipation."

The nurse is assessing a client's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. Which question by the nurse would be best to ask the client for completing a comprehensive pain assessment?

"What pain rating would be acceptable to you?"

The older client's adult child questions the nurse as to why the client is at higher risk for infection when the client's white cell count is within the normal range. What response by the nurse is best?

"White blood cells are less active in older people so they are not as efficient."

A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?

"Antihistamines do not help poison ivy."

A client has been newly diagnosed with systemic lupus erythematosus and is reviewing self-care measures with the nurse. Which statement by the client indicates a need to review the material?

"Baby powder is good for the constant sweating."

A new nurse reports to the nurse preceptor that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. Which response by the experienced nurse is best?

"Being able to sleep doesn't mean pain doesn't exist."

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

"Call your primary health care provider for diarrhea"

A nurse wants to become part of a Disaster Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns?

"Deployed DMAT providers are federal employees, so their licenses are good in all 50 states"

After a hospitals emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. Which question should the nursing supervisor ask at this time?

"Do all areas of the hospital have the supplies and personnel they need?"

The nurse is teaching a client who is planning to have a total hip arthroplasty. What statement by the client indicates a need for further teaching?

"I will receive IV heparin before surgery to decrease the risk of clots."

The nurse is teaching a client who is prescribed acetaminophen for control of osteoarthritic joint pain. What statement by the client indicates a need for further teaching?

"I won't take more than 5000 mg of this drug each day."

A client is prescribed celecoxib for joint pain. What statement by the client indicates a need for further teaching?

"I'll be sure to take this drug three times a day only on an empty stomach."

A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching?

"I'm so glad I don't have to give up my juicy steaks."

A nurse has presented an educational program to a community group on Lyme disease. What statement by a participant indicates the need to review the material?

"If Lyme disease is not treated successfully, it is usually fatal."

A nurse manager is preparing an educational session for floor nurses on drug-resistant organisms. Which statement below indicates the need to review this information?

"If you leave work wearing your scrubs, go directly home and wash them right away."

A nurse cares for victims during a community wide disaster drill. One of the victims asks "why are the individuals with black tags not receiving any care?" How does the nurse respond?

"In a disaster, extensive resources are not used for one person at the expense of many others."

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate?

"It is normal to be fatigued even for months afterward."

An assistive personnel asks why brushing client s' teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best?

"It mechanically removes biofilm on teeth."

A client is receiving rituximab and asks how it works. What response by the nurse is best?

"It prevents the start of cell division in the cancer cells."

The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed?

"It's alright for me to keep my pets and change the litter box."

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

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

A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer risk. What response by the nurse is best?

"Maybe; preservatives, dyes, and preparation methods may be risk factors."

A client has a left knee arthrocentesis to remove excess joint fluid. What postprocedure health teaching will the nurse include?

"Monitor the site for bleeding or clear fluid leakage when you are home."

. A nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. Which response by the charge nurse is best?

"Pain is so complex it takes different approaches to control it."

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

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

The primary health care provider prescribes methotrexate (MTX) for a client with a new diagnosis of rheumatoid arthritis. The nurse provides health teaching about the drug. What statement by the nurse is appropriate to include about methotrexate?

"The drug can increase your risk for infection, so you should avoid crowds."

A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication?

"This client has allergies to morphine and codeine."

A client with HIV-III asks the nurse why gabapentin is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best?

"This drug helps treat the pain from nerve irritation."

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

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

A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.)

- Client who had open reduction and internal fixation of a femur fracture 3 days ago - Client on the medical unit for wound care

A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.)

- Hospital incident commander - Assumes overall leadership for implementing the emergency plan - Triage officer - Rapidly evaluates each client to determine priorities for treatment

A new graduate nurse has started working on a medical-surgical unit. What actions would the nurse take to be prepared for a disaster? (SATA)

- Know the institutions Emergency Response Plan - Participate in the institutions disaster drill -Develop a personal preparedness plan -Understand that nurses play a role in every phase of a disaster -Be willing to be flexible working during a crisis situation

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.)

-"Chemo" gloves -Face mask -Impervious gown -Eye protection

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

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

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

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

A client who had a recent total knee arthroplasty will be using a continuous passive motion (CPM) machine after discharge at home. What health teaching about the CPM machine will the nurse include? (Select all that apply.)

-"Keep the machine padded well to prevent skin breakdown." -"Ensure that your leg is placed properly on the machine." -"Use the machine as prescribed but not at mealtime." -"When the machine is not being used, do not store it on the floor." -"Check that the cycle and range of motion is kept at the level prescribed."

The nurse is teaching assistive personnel about postoperative care for an older adult who had a posterolateral total hip arthroplasty. What teaching will the nurse include? (Select all that apply.)

-"Move the client slowly to prevent dizziness and a possible fall." -"Encourage the client to deep breathe and cough at least every 2 hours." -"Help the client use the incentive spirometer at least every 2 hours." -"Keep the abduction pillow in place at all times while the client is in bed." -"Let me know if the client has an elevated temperature or pulse." -"Keep in mind that the client may be a little confused after surgery."

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

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

The nurse is teaching a client with mild rheumatoid arthritis (RA) about how to protect synovial joints. Which health teaching will the nurse include? (Select all that apply

-"Use both hands instead of one with holding objects." -"When getting out of bed or a chair, use the palms of your hands." -"Bend your knees instead of your waist and keep your back straight." -"Do not use multiple pillows under your head to prevent neck flexion." -"Use a device or rubber grip to open jars or bottle tops." -"Use long-handled devices such as a hairbrush with an extended handle."

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

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

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

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

A nurse is planning postoperative care for a client following a total hip arthroplasty. What nursing interventions would help prevent venous thromboembolism for this client? (Select all that apply.)

-. Early ambulation -Quadriceps-setting exercises -Compression stockings/devices -Anticoagulant drug therapy

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered to be at high risk? (Select all that apply.)

-. Morbidly obese client -Client who smokes -Client with severe heart failure -Wheelchair-bound client

A home health care nurse assesses an older adult for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adult's kitchen might indicate an adequate intake of these nutrients? (SATA)

-1% milk -Carrots -Oranges -Vitamin D supplements

A nurse is caring for clients on an inclient surgical unit. Which clients does the nurses identify as having risk for impaired immunity? (SATA)

-86 years old -Has type 2 diabetes -Taking prednisone -Low socioeconomic status

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

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

The nurse is teaching a client about medications for HIV-II treatment. What drugs are paired with the correct information? (Select all that apply.)

-Abacavir: avoid fatty and fried foods. -Efavirenz: take 1 hour before or 2 hours after antacids. -All drugs: you must adhere to the drug schedule at least 90% of the time for effectiveness.

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

-Absorptive atelectasis -Combustion -Dried mucous membranes -Toxicity

A nurse learns the concepts of addiction, tolerance, and dependence. Which information is accurate? (Select all that apply.)

-Addiction is a chronic physiologic disease process. -Tolerance is a normal response to regular opioid use. -Tolerance is said to occur when opioid effects decrease. -Physical dependence occurs after repeated doses of an opioid

A client has received several doses of midazolam. The nurse assesses the client to be difficult to arouse with respirations of 6 breaths/min. What actions by the nurse are most important? (Select all that apply.)

-Administer oxygen per protocol. -Ensure suction is working -Transfer the client to intensive care.

A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.)

-Admit the client to a negative-airflow room. -Obtain specialized respirators for caregiving.

The nurse learns that which risk factors can affect immunity? (Select all that apply.)

-Age -Environmental factors -Drugs -Nutritional status

A nurse asks the supervisor why older adults are more prone to infection than other adults. What reasons does the supervisor give? (Select all that apply.)

-Age-related decrease in immune function -Decreased cough and gag reflexes -Diminished acidity of gastric secretions -Thinning skin that is less protective -Higher rates of chronic illness

Which are steps in the process of making an antigen-specific antibody? (Select all that apply.)

-Antibody-antigen binding -Invasion -Recognition -Sensitization -Production

For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.)

-Antibody-mediated immunity -Cell-mediated immunity -Inflammation

A client receiving radiation therapy reports severe skin itching and irritation. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.)

-Apply approved moisturizers to dry skin. -Bathe the client using mild soap. -Help the client pat skin dry after a bath. -Make sure no clothing is rubbing the site.

A client has thrombocytopenia. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.)

-Apply the client's shoes before getting the client out of bed. -Assist the client with ambulation. -Use a lift sheet to move the client up in bed.

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

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

The nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.)

-Appropriate drug -Proper route of administration -Sufficient dose -Sufficient length of treatment

A client's family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.)

-Ask the family to describe their concerns more fully. -Consult with a social worker, chaplain, or ethics committee. -Explain the client's right to know and ask for their assistance.

A client with HIV-III is hospitalized with P. jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values would be most important for the nurse report to the primary health care provider? (Select all that apply.)

-Aspartate transaminase, alanine transaminase: elevated -Platelet count: 80,000/mm3 (80 109/L) -Serum sodium: 120 mEq/L (120 mmol/L)

A client receiving chemotherapy has a white blood cell count of 1000/mm3 (1 109/L). What actions by the nurse are most appropriate? (Select all that apply.)

-Assess all mucous membranes every 4 to 8 hours. -Listen to lung sounds and monitor for cough. -Monitor the venous access device appearance hourly. -Take and record vital signs every 4 to 8 hours.

A visiting nurse is in the home of an older adult and notes a 7lb weight loss since last months visit. What actions would the nurse perform first? (SATA)

-Assess the clients ability to drive or transportation alternatives -Determine if the client has dentures that fit appropriately -Have the client complete a 3 day diet recall diary`

A client with HIV-III has oral thrush and difficulty eating. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.)

-Assist the client with oral care every 2 hours. -Offer the client frequent sips of cool drinks. -Remind the client to use only a soft toothbrush. -Offer the client soft foods like gelatin or pudding.

A client has mucositis. What actions by the nurse will improve the client's nutrition? (Select all that apply.)

-Assist with rinsing the mouth with saline frequently. -Encourage the client to eat room-temperature foods. -Provide local anesthetic medications to swish and spit. -Offer the client fluids to drink each hour.

A client with HIV-III is in the hospital with severe diarrhea. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.)

-Assisting the client to get out of bed to prevent falls -Obtaining a bedside commode if the client is weak -Providing gentle perianal cleansing after stools -Reporting any perianal abnormalities

A nurse manager wants to improve hand-off communication among the staff which actions by the manager would best help achieve this goal? (SATA)

-Attend hand-off rounds to couch and mentor -Create a template of suggested topics to include in report -Encourage staff to ask questions during hand-off -Provide education on the SBAR method of communication

A nurse on the postoperative unit administers many opioid analgesics. Which actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.)

-Avoid using other medications that cause sedation. -Give the lowest dose that produces good control. -Identify clients at high risk for unwanted sedation. -Use an oximeter to monitor clients receiving analgesia

A nurse is visiting a client discharged home after a total hip arthroplasty. What safety precautions would the nurse recommend to the client and family? (Select all that apply.)

-Buy and install an elevated toilet seat -Install grab bars in the shower and by the toilet. -Remove all throw rugs throughout the house. -Use a shower chair while taking a shower.

Which findings are AIDS-defining characteristics? (Select all that apply.)

-CD4+ cell count less than 200/mm3 (0.2 109 /L) or less than 14% -Infection with P. jiroveci -Presence of HIV wasting syndrome -Confusion, dementia, or memory loss

A nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.)

-CD4+ cells begin to create new HIV virus particles. -Antibodies produced are incomplete and do not function well. -Macrophages stop functioning properly. -Opportunistic infections and cancer are leading causes of death.

A nurse caring for clients with systemic lupus erythematosus (SLE) plans care understanding the most common causes of death for these clients is which of the following? (Select all that apply.)

-Cardiovascular impairment -Chronic kidney disease

The nurse is caring for an older client who had a total knee arthroplasty. Prior to surgery, the client lived alone independently. With which interprofessional health care team members will the nurse collaborate to ensure positive client outcomes? (Select all that apply.)

-Case manager -Physical therapist

A client with an infection has a fever. What actions by the nurse help increase the client's comfort? (Select all that apply.)

-Change the client's gown and linens when damp. -Offer cool fluids to the client frequently. -Sponging the client with tepid water.

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.)

-Check that consent is on the chart. -Ensure that the client has an armband on -Have the client help mark the surgical site. -Allow the client to use the toilet before giving sedation. -Assess the client for fall risks.

A client has impaired tissue integrity and a nonhealing wound. The nurse has taught the client about diet changes to improve wound healing. What diet selections does the nurse evaluate as good understanding by the client? (SATA)

-Chicken breast -Orange Juice -Boost supplement -Spinach salad

The nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.)

-Clotting abnormalities from thrombocythemia -Increased risk of infection from white blood cell deficits -Nutritional deficits such as early satiety and cachexia -Potential for reduced gas exchange -Various motor and sensory deficits -Increased risk of bone fractures

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

-Cognition -Dexterity -Range of motion -Vision -Upper arm range of motion

A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas would the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (SATA)

-Collaborating with an interprofessional team -Implementing evidence-based care -Routinely using informatics in practice -Using quality improvement in client care

What statements about the complement system are correct? (Select all that apply.)

-Comprised of 20 types of inactive plasma proteins. -Act as enzymes when activated to enhance innate immunity. -Sticks to the antigen and forms a membrane attack complex. -Is part of the innate immune system.

A nurse manager institutes the Fulmer SPICES framework as part of the routine assessment of older adults in the hospital. The nursing staff assesses for which factors? (SATA)

-Confusion -Incontinence -Sleep disorders

A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (SATA)

-Constipation -Dehydration -Weakness -Anorexia

A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. Which actions by the nurse are most appropriate? (Select all that apply.)

-Consult with the surgeon and voice objections. -Notify the nurse manager of the placebo prescription.

A Nurse is interested in making interprofessional work a high priority. Which actions by the nurse best demonstrate this skill? (SATA)

-Consults with other disciplines on client care -Coordinates discharge planning for home safety -Participates in comprehensive client rounding -Routinely asks other disciplines about client progress -Delegate tasks to unlicensed personnel appropriately.

A nurse is providing education about HIV risks at a health fair. What groups would the nurse include as needing to be tested for HIV on an annual basis? (Select all that apply.)

-Couples planning on getting married -Those who are sexually active with multiple partners -Injection drugs users -Sex workers and their customers

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

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

A nurse learns older adults are at higher risk for complications after surgery. What reasons for this does the nurse understand? (Select all that apply.)

-Decreased cardiac output -Decreased oxygenation -Frequent nocturia -Mobility alterations -Slower reaction times

The nurse is assessing a client for signs and symptoms of systemic lupus erythematosus (SLE). Which of the following would be consistent with this disorder? (Select all that apply.)

-Discoid rash on skin exposed to sunlight -Urinalysis positive for casts and protein -Pain on inspiration -Serum positive for antinuclear antibodies (ANA)

. A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.)

-Disposing of dressings properly -Performing proper hand hygiene -Removing and replacing wet dressings

The nurse is educating a client with HIV-II and the partner on self-care measures to prevent infection when blood counts are low. What information does the nurse provide? (Select all that apply.)

-Do not work in the garden or with houseplants. -Do not empty the kitty litter boxes. -Bathe daily using antimicrobial soap. -Avoid people who are sick and large crowds. -Make sure meat, fish, and eggs are cooked well.

The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.)

-Edema -Redness -Warmth -Decreased function

A client with a broken arm had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. Which actions by the nurse are most appropriate? (Select all that apply.)

-Educate the client on cold therapy. -Repeat the ice application. -Teach the client relaxation techniques.

A nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the nurse learn? (Select all that apply.)

-Eosinophils increase during allergic reactions and parasitic invasion. -Macrophages can participate in many episodes of phagocytosis. -Monocytes turn into macrophages after they enter body tissues. -Neutrophils can only take part in one episode of phagocytosis.

A nurse working in an acute care of the elderly unit learns that frailty in the older population includes which components? (SATA)

-Exhaustion -Slowed physical activity -Weakness

The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.)

-Exposure to carcinogens -Genetic predisposition -Immune function

. The nurse assesses a client with long-term rheumatoid arthritis (RA) for late signs and symptoms. Which assessment findings will the nurse document as late signs and symptoms of RA? (Select all that apply.)

-Felty syndrome -. Joint deformity -Weight loss

A client asks the nurse about what medications may be included for nonopioid multimodal analgesia following a total knee arthroplasty. What medications may be given to the client? (Select all that apply.)

-Gabapentin -Ketorolac -Ketamine -Bupivacaine

A client has rheumatoid arthritis (RA) and the nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.)

-Grab bars to reach high items -Long-handled bath scrub brush -Toothbrush with built-up handle

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.)

-Hemoglobin: 7.8 mg/dL (78 mmol/L) -pH: 7.68 -Potassium: 2.9 mEq/L (2.9 mmol/L)

The nurse is teaching an elderly client the risks of infection for older adults. Which of the following factors would the nurse include in the education? (Select all that apply.)

-Higher risk for respiratory tract and genitourinary infections. -May not have a fever with severe infection. -Should receive influenza, pneumococcal, and shingles vaccinations. -Skin tests for tuberculosis may be falsely negative.

The nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.)

-Host -Mode of transmission -Portal of entry -Reservoir

The nurse is learning about immunoglobulins. . Which principles does the nurse learn? (Select all that apply.)

-IgA is found in high concentrations in secretions from mucous membranes. -IgE is associated with antibody-mediated hypersensitivity reactions. -IgG comprises the majority of the circulating antibody population. -IgM is the first antibody formed by a newly sensitized B-cell.

A nurse is studying the function of immunoglobulins. Which immunoglobulins are correctly matched to their function? (Select all that apply.)

-IgA: most responsible for preventing infection in the respiratory tracts, the GI tract, and the genitourinary tract. -IgE: associated with antibody-mediated immediate hypersensitivity reactions. -IgG: activates classic complement pathway and enhances neutrophil and macrophage actions. -IgM: first antibody formed by a newly sensitized B-lymphocyte plasma cell.

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on? (Select all that apply.)

-Infection prevention -Thromboembolism prevention -Correct hair removal

A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.)

-Instructing people on the use of chemoprevention -Providing vaccinations against certain cancers -Teaching teens the dangers of tanning booths -Educating adults about healthy eating habits

A nurse is caring for several clients in the morning prior to surgery. Which medications taken by the clients require the nurse to consult with the primary health care provider about their administration? (Select all that apply.)

-Insulin -Phenytoin -Metoprolol -Warfarin -Prednisone

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

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

A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

-Keep the clients skin dry -Obtain a pressure relieving mattress -Turn the client every 2 hours

A nurse is studying the functions of specific leukocytes. Which leukocytes are matched correctly with their function? (Select all that apply.)

-Monocyte: matures into a macrophage. -Plasma cell: secretes immunoglobulins in response to the presence of a specific antigen. -Natural killer cell: nonselectively attacks non-self cells.

An emergency department nurse is caring for a trauma patient. Which interventions does the nurse perform during the primary survey (SATA)

-Needle decompression -Initiating IV fluids -Endotracheal intubation -Removing wet clothing

A nurse is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.)

-Neuropathic pain sometimes accompanies amputation -Deep somatic pain is pain arising from bone and connective tissues. -Somatic pain originates from skin and subcutaneous tissues. -Visceral pain is often diffuse and poorly localized.

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

-New-onset cough -Tachypnea -Pain with respirations

The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (SATA)

-Nurses expertise -Client preferences -Research findings -Values of the client

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

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

A client is being administered the first dose of belimumab for a systemic lupus erythematosus flare. What actions by the nurse are most appropriate? (Select all that apply.)

-Observe the client for at least 2 hours afterward. -Ensure emergency equipment is working and nearby.

A nurse learns that the fastest growing subset of the older population is which group?

-Old Old

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

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

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

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

The nurse is assessing a client with long-term rheumatoid arthritis (RA) who has been taking prednisone for 10 years. For which complications of chronic drug therapy would the nurse assess? (Select all that apply.)

-Osteoporosis -Diabetes mellitus -Glaucoma -Hypertension -Hypokalemia -Decreased immunity

Emergency medical services brings a large number of clients to the emergency department following a mass casualty incident, The nurse identifies the clients with which injuries with yellow tags? (SATA)

-Partial-thickness burns covering both legs -Neck injury and numbness of both legs -Small pieces of shrapnel embedded in both eyes -Bruising and pain in the right lower abdomen

A postoperative client has an epidural infusion of morphine and bupivacaine. Which actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.)

-Perform a bladder scan if the client is unable to void after 4 hours. -Remind the client to use the incentive spirometer every hour. -Take and record the client's vital signs per agency protocol.

The nurse is caring for a client with severely impaired mobility. What actions does the nurse place on the care plan to address potential complications? (SATA)

-Perform a depression screen once a day -Consult physical therapy for range of motion -Increase fiber in the client diet

A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment would the nurse perform first?

-Perform an oral assessment

A nurse admits an older adult to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? (SATA)

-Perform and document results of a Braden Scale assessment -Request a dietary consultation from the health care provider -Suggest a high-protein oral supplement between meals -Assess the clients own teeth or the dentures for proper fit

. A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.)

-Phase I requires intensive care unit monitoring. -Phase II ends when the client is stable and awake -Vital signs may be taken only once a day in phase III.

The complex care provided during an emergency requires interprofessional collaboration. Which team members are paired with the correct responsibilities? (SATA)

-Psychiatric Crisis nurse - interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis -Paramedic-Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

A nurse prepares to discharge an older adult client home from the emergency department. What actions does the nurse take to prevent future ED visits? (SATA)

-Screen for depression and suicide -Complete a functional assessment

The nurse caring for clients assesses their daily laboratory profiles. Which lab results are considered to be in the normal range? (Select all that apply.)

-Segmented neutrophils: 68% -Lymphocytes: 38% -Eosinophils: 2% -Basophils: 1%

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

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

The nurse is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.)

-Type I—examples include hay fever and anaphylaxis. -Type III—immune complex deposits in blood vessel walls. -Type IV—examples are poison ivy and transplant rejection.

Which statements are true regarding Standard Precautions? (Select all that apply.)

-Use personal protective equipment as needed for client care. -Wear gloves when touching clients' excretions or secretions.

A nurse is caring for clients in a busy emergency department. What actions would the nurse take to ensure client and staff safety? (SATA)

-Use two identifiers before each intervention and before mediation administration -Attempt de-escalation strategies for clients who demonstrate aggressive behaviors -Search the belongings of clients with altered mental status to gain essential medical information -Use facility policy identification procedures for "Jane/John Doe" clients. -Check clients for a medical alert bracelets or necklaces.

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

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

A nurse begins a job at a Veterans Administration Hospital and asks why so much emphasis is on HIV testing for the veterans. What reasons is this nurse given? (Select all that apply.)

-Veterans have a high prevalence of substance abuse. -Many veterans may engage in high risk behaviors. -Many older veterans may not know their risks. -Everyone should know their HIV status. -Belief that the VA has tested them and would notify them if positive.

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

-Visual hallucinations -Manic behavior

A nurse is planning a community education event-related to impaired cellular regulation. What teaching topics would the nurse include in this event? (SATA)

-Ways to minimize exposure to sunlight -Resources available for smoking cessation -Creative cooking techniques to increase dietary fiber

A nurse cares for several clients on an inpatient unit. Which infection control measures will the nurse implement? (Select all that apply.)

-Wear a gown when contact of clothing with body fluids is anticipated. -Teach clients and visitors respiratory hygiene techniques. -Disinfect frequently touched surfaces in client-care areas.

A hospitalized client has a history of depression for which sertraline is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose?

. Hydromorphone

A client has arrived in the inpatient postoperative unit. What action by the inpatient nurse takes priority?

. Participating in hand-off report

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

21%

A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept?

Assesses for the cultural influences affecting health care.

A client with HIV-III has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most important with this condition?

Assessing mucous membranes

An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first?

A 26 year old male who has pale, cool, clammy skin

A nurse is triaging clients in the emergency department. Which client would the nurse prioritize to receive care first?

A 45 year old reporting chest pain and diaphoresis

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?

Assessing the IV site and blood return every hour

A clinic nurse is working with an older client. What action is most important for preventing infections in this client?

Assessing vaccination records for booster shot needs

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

Assist the client to choose a communication method.

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

Assistance with activities of daily living

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

Airway patency

Anticoagulant drug therapy

Anticoagulant drug therapy

An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. What action would the nurse take?

Arrange for post incident crisis support

The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives. Which action would the nurse take first?

Ask the spouse if he or she wishes to be present during the resuscitation

A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below:

Assess blood pressure and pulse.

The nurse assesses a client after a total hip arthroplasty. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is appropriate?

Assess neurovascular status in both legs.

A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia but no other medical history except well-controlled hypertension and high cholesterol. The client scores a zero. Which action by the nurse is best?

Assess physiologic indicators and vital signs

A client with HIV-II has had a sudden decline in status with a large increase in viral load. What action would the nurse take first?

Assess the client for adherence to the drug regimen.

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?

Assess the client for anxiety.

A nurse is assessing an older client for the presence of infection. The client's temperature is 97.6° F (36.4° C). What response by the nurse is best?

Assess the client for more specific signs.

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

Assess the client for obstructive sleep apnea.

The assistive personal (AP) reports to the registered nurse that a postoperative client has a pulse of 132 BPM and a blood pressure of 168/90 mm Hg. What response by the nurse is most appropriate?

Assess the client for pain

A client has just been informed of a positive HIV test. The client is distraught and does not know what to do. What intervention by the nurse is best?

Assess the client for support systems.

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

Assess the client's airway.

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

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

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important?

Assess the client's gait and balance.

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

Assess the client's lung sounds.

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

Assess the client's oxygen saturation.

A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV). The test is negative and the client states "Whew! I was really worried about that result." What action by the nurse is most important?

Assess the client's sexual activity and patterns.

A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The client's oxygen saturation is 87%. Which action would the nurse perform first?

Attempt to arouse the client.

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?

Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met.

A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections?

Auditing staff members' hand hygiene practices

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important?

Auscultate lung sounds

The postanesthesia care unit (PACU) nurse is caring for an older client following a lengthy surgery. The client's pulse is 48 beats/min which is 20 beats/min lower than the preoperative baseline. What assessment does the nurse make next?

Temperature

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for postdischarge care?

Older adult who lives alone at home despite some memory loss.

A nurse learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ?

Bone marrow

A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors?

Bring a list of all medications and what they are for.

The nurse in the emergency department (ED) is caring for four clients. Which client does the nurse assess for gas exchange abnormalities first?

Brought in unconscious by roommate after opioid overdose.

A home health care nurse is planning an exercise program with an older adult who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult?

Building strength and flexibility

A nurse is observing as an assistive personnel (AP) performs hygiene and provides comfort measures to a client with an infection. What action by the AP requires intervention by the nurse?

Ordering an oscillating fan for the client

A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort?

Pace activities, allowing for adequate rest.

. The nurse is caring for a client who has severe osteoarthritis. What primary joint problems will the nurse expect the client to report?

Pain

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first?

Client with a respiratory rate of 6 breaths/min

A nurse on the postoperative inpatient unit receives hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client would the nurse see first?

Client with a respiratory rate of 8 breaths/min.

A nurse is volunteering in a temporary shelter for survivors of a hurricane. Which client does the nurse anticipate has the highest need for further assessment and referral?

Client with a score of 48 on the Impact of Event Scale Revised (IES-R)

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

Collect the nasal drainage on a piece of filter paper.

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action does the nurse take?

Communicate the clients death to the family in a simple and concrete manner.

The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective?

Consistent use of Standard Precautions

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best?

Consult the primary health care provider about a dietitian referral.

A client with HIV-II is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important?

Consult with the pharmacy about drug interactions.

A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important?

Consult with the primary health care provider about obtaining stool cultures.

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

Contact the primary health care provider and prepare for intubation.

A client has been hospitalized with an opportunistic infection secondary to HIV-III. The client's partner is listed as the emergency contact, but the client's mother insists that she should be listed instead. What action by the nurse is best?

Contact the social worker to assist the client with advance directives.

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?

Correctly identifying the client prior to a blood transfusion

The nurse is caring for a client diagnosed with HIV-II. The client's CD4+ cell count is 399/mm3 (0.399 109 /L). What action by the nurse is best?

Counsel the client on safer sex practices/abstinence.

An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important?

Determine if there are new medications

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best?

Do not have the client sign the consent and call the primary health care provider

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

Document the findings.

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving tenofovir/emtricitabine. What information is most important to teach the client about this drug?

Does not reduce the need for safe sex practices.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support?

Don personal protective equipment

A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is most accurate?

Don't make assumptions about his or her health needs

The nurse learning about cellular regulation understands that which process occurs during the S phase of the cell cycle?

Doubling of DNA

A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive personnel (AP). Four hours later, the nurse notes that the client's blood pressure taken by the AP was much higher than previous readings, and the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?

Providing more appropriate supervision of the AP

A client with known HIV-II is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action would the nurse take first?

Place the client under Airborne Precautions.

The nurse caring for a client with malnutrition assesses which laboratory value as the priority?

Prealbumin

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate?

Prepare to administer vancomycin.

A registered nurse is caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). Which action by the nurse indicates the need for further education on pain control with PCA?

Presses the button when the client cannot reach it

A nurse asks the staff development nurse what "apoptosis" means. What response best?

Programmed cell death

An emergency department case manager is consulted for a client who is homeless. Which intervention would the case manager provide?

Provide referrals to subsidized community-based health clinics.

A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during and after the event?

Provide water and healthy snacks for energy throughout the event

A nurse is field-triaging clients after an industrial accident. Which client conditions would the nurse triage with a red tag?

Multiple fractured ribs and shortness of breath

A postoperative client has respiratory depression after receiving morphine for pain. Which medication and dose does the nurse prepare to administer?

Naloxone 0.4 to 2 mg

The nurse understands that which type of immunity is the longest acting?

Natural active

A nurse is assessing a client with glioblastoma. What assessment is most important?

Neurologic examination

An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrive and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient?

Neurologic status

A nurse is teaching the client with systemic lupus erythematosus about prednisone. What information is the priority?

Never stop prednisone abruptly.

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

Notify the Rapid Response Team.

A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has "a shift to the left" on the white blood cell count. What action by the nurse is most important?

Notify the primary health care provider and request antibiotics.

A client had a surgical procedure with spinal anesthesia. The client's blood pressure was 122/78 mm Hg 30 minutes ago and is now 138/60 and the client reports nausea. What action by the nurse is best?

Notify the primary health care provider.

After a total knee arthroplasty, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the skin of both legs is pale pink, warm, and dry, but the client is unable to dorsiflex or plantarflex the surgical foot. What action would the nurse take next?

Notify the surgeon or anesthesia provider immediately.

A client asks the nurse about having a total knee arthroplasty to relieve joint pain. Which factor would place the client at the highest risk for impaired postoperative healing?

Obesity

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

Obtain pulse oximetry reading.

A client is admitted with possible sepsis. Which action will the nurse perform first?

Obtain specified cultures.

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

Occupation and hobbies.

A client has a leg wound that is in Stage II of the inflammatory response. For what sign or symptom does the nurse assess?

Purulent drainage

An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying "Those are for old people." What action by the nurse would be most helpful?

Put color-coted stickers on the bottle caps

A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action by the nurse is best?

Read the policy on handling radioactive excreta.

A nurse is assessing a female client who is taking hormone therapy for breast cancer. What assessment finding requires the nurse to notify the primary health care provider immediately?

Red, warm, swollen calf

The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem?

Regulator T-cells

A client is scheduled to have a total hip arthroplasty. What preoperative teaching by the nurse is most important?

Remind the client to have all dental procedures completed at least 2 weeks prior to surgery.

Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients would the nurse assess first?

Serum potassium of 2.8 mEq/L (2.8 mmol/L)

A postoperative nurse is caring for a client who received a neuromuscular blocking agent during surgery. On assessment the nurse notes the client has weak hand grasps. What assessment does the nurse conduct next?

Signs of oxygenation

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

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

A nurse is constructing a personal preparedness plan in case of a disaster. What does the nurse consider making this plan?

Store basic supplies to last for at least 3 days

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

Swallow twice while bearing down.

A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps?

Teach the client to hold the handrail when using the steps

A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?

Teaching measures to prevent scalp injury

A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the client is breathing rapidly. What response by the charge nurse is best?

The client is trying to get rid of excess body acids.

A nurse wants to become involved in community disaster preparedness and is interested in helping setup and staff first-aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for the nurses interests?

The medical Reserve Corps

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

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

A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client's chart that the cancer classification is TISN0M0. What does the nurse conclude about this client's cancer?

There are no distant metastases noted in the report.

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?

There is no redness, warmth, or drainage at the insertion site.

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action would the nurse take first?

Transfer the client to a negative pressure room

What does the nurse learn about the function of colony-stimulating factor?

Triggers the bone marrow to shorten the time needed to produce mature WBCs.

Which statement about carcinogenesis is accurate?

Tumor cells need to develop their own blood supply.

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

Tying a square knot at the back of the neck

A nurse is preparing to give a client ketorolac intravenously for pain. Which assessment findings would lead the nurse to consult with the primary health care provider?

Urine output of 20 mL/2 hr

An emergency department manager wants to mitigate the possible acute and chronic stress after mass casualty events in the staff. What action would the manager take?

Use available resources for broad education and training in disaster management.

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?

Use of multiple herbs and supplements

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

Validate that informed consent has been given by the client.

The nurse assesses a client with rheumatoid arthritis (RA) and Sjögren syndrome. What assessment would be most important for this client?

Visual acuity

A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate?

Wear personal protective equipment when handling the medications.

The registered nurse asks the nursing assistant why a cardiac client's morning weight has not yet been done. This nursing assistant says, "I'll get to it, what's the big deal?" When deciding how to respond, the nurse considers what information about weight?

Weight is the most accurate noninvasive indicator of fluid status

A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review?

White rice