MS ATI B

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? The chest tube is draining serosanguineous fluid at 65 mL/hr. The client tolerates gentle milking of the tubing. Bubbling in the water seal chamber has ceased. There is tidaling in the water seal chamber.

Bubbling in the water seal chamber has ceased. Bubbling in the water seal chamber ceases when the lung re-expands.

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? Creatine kinase (CK-MB) 85 units/L High-density lipoprotein (HDL) 65 mg/dL Alanine aminotransferase (ALT) 28 units/L Troponin I 8 ng/mL

Troponin I 8 ng/mL ALT is an enzyme that is found primarily in the liver, although it can also be detected in the kidneys, heart, and skeletal muscle. Increases in this enzyme are associated with injury or disease. However, because the enzyme is not specific to the heart, its use as a diagnostic tool for MI is limited. An ALT value of 28 units/L is within the expected reference range.

The nurse has completed the assessment and is reviewing the findings in the EMR. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

- 12 % weight loss over 2 months - muscle guarding and tenderness in right lower quadrant of abdomen, - abdominal firmness and rigidity, - abdominal pain rate of 8, - hypoactive bowel sounds, - report of anorexia - temperature of 38.5 C (101.4 F)

A nurse is prioritizing client care. Complete the following sentence by using the lists of options. The nurse should first address the client's (1) , followed by the client's (2) ....

1. O2 stat 2. Temperature

After reviewing the findings in the client's medical record, the nurse should first address the client's (1) followed by the client's (2)

1. infection 2. pain rating

A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? Document the client's intake and output. Scan the bladder with a portable ultrasound. Pour warm water over the client's perineum. Perform a straight catheterization.

Scan the bladder with a portable ultrasound. Scan the bladder with a portable ultrasound.

For each assessment finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process.

Temperature - pneumonia Breath sounds - emphysema, asthma, & pneumonia Respiratory rate - emphysema, asthma, & pneumonia Cough - emphysema, asthma, & pneumonia Heart rate - emphysema and pneumonia ABG results - emphysema and pneumonia

A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia?

This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.

The nurse is reviewing the client's diagnostic results. Which of the following findings requires follow-up by the nurse? Select all that apply. WBC count Calcium level HCO3- level Oxygen saturation level Chest x-ray PCO2 level BUN level

WBC count - The client has an elevated WBC count, which indicates an infection. Oxygen saturation level - The client's oxygen saturation is decreased, which is a manifestation of pneumonia. Chest x-ray - The client's chest x-ray indicates increased opacity in the bilateral posterior lobes, which is a manifestation of pneumonia. PCO2 level - The client has an elevated PCO2 level, which indicates the retention of carbon dioxide BUN level - The client's BUN is elevated, which is a manifestation of dehydration or kidney disease

A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? Decreased T cells Increased creatinine clearance Increased eosinophils Decreased viral load

Decreased viral load Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment.

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? INR 1 INR 2.5 aPTT 45 seconds aPTT 90 seconds

INR 2.5 Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be monitored to ensure the anticoagulation is within the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.8° F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? Heart rate 110/min Blood pressure 160/70 mm Hg Respiratory rate 14/min Temperature 38.4° C (101.1° F)

Heart rate 110/min One of the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which occurs to compensate for blood loss.

A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? A client who is receiving preoperative teaching for a right knee arthroplasty. A client who states they will have difficulty obtaining a walker for home use. A client who reports an increase in pain following a left hip arthroplasty. A client who is having emotional difficulty accepting that they have a prosthetic leg.

A client who is receiving preoperative teaching for a right knee arthroplasty. The nurse should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions.

A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? Electrically generated feelings of heat Cryotherapy for painful areas Realignment of energy flow through meridians A tingling sensation replacing the pain

A tingling sensation replacing the pain A TENS unit applies small electric currents to the painful area, with the client increasing the current until the "pins and needles" sensation overrides the pain.

A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include in the teaching? Take an antacid before meals and at bedtime. Increase fiber intake to at least 30 g per day. Drink ginger tea daily. Consume no more than 1 L of water per day.

Increase fiber intake to at least 30 g per day. Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.

A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse take? Defibrillate the client's heart. Perform synchronized cardioversion. Begin cardiopulmonary resuscitation. Administer lidocaine IV bolus.

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

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? Elevated blood pressure Dehydration Stress ulcers Hypernatremia

Stress ulcers Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment.

A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside? Suction machine Wire cutters Padded clamp Communication board

Suction machine The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client's airway as needed and reduce the risk for aspiration.

A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? Anorexia Abdominal pain radiating to the right shoulder Rebound abdominal tenderness Tachycardia

Tachycardia When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately to the provider.

A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching? Avoid foods that are high in ascorbic acid. Add oatmeal to the water when taking a tub bath. Urinate every 6 hr. Take daily cranberry supplements.

Take daily cranberry supplements. The client should take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI.

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider? Hydrocodone Bupropion Lactulose Warfarin

Warfarin Warfarin is an anticoagulant, which increases the client's risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery.

A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? Document that depolarization has occurred. Increase the pacemaker's voltage. Decrease the pacemaker's sensitivity. Check the placement of the ECG leads.

Document that depolarization has occurred. When a pacing stimulus is delivered to the ventricle, a pacemaker artifact appears as a spike on the ECG rhythm strip. The spike should be followed by a QRS complex, which indicates pacemaker capture or depolarization.

A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching? Drink 240 mL (8 oz) of water after administration. Expect results in 4 to 6 hr. Take this medication before meals to increase appetite. Reduce dietary fiber intake to improve medication absorption.

Drink 240 mL (8 oz) of water after administration. The client should follow each dose of psyllium with an additional 240 mL (8 oz) of liquid.

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? Painless ulcerations on the ankles Hair loss on the lower legs No extremity pain when resting Rubor with elevation of the extremity

Hair loss on the lower legs The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth.

A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Potassium 4.1 mEq/L Heart rate 55/min SaO2 92% Weight 67.1 kg (148 lb)

Heart rate 55/min The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider.

The nurse is reviewing the client's medical record from Day 5. Click to highlight the findings below that indicate the client is improving. To deselect a finding, click on the finding again. Nurse's Notes Day 5 0800: Heart rate 72/min Respiratory rate 20/min Blood pressure 128/56 mm Hg Oxygen saturation 95% on room air Lung sounds are diminished in the bilateral posterior bases with occasional crackles heard upon auscultation. Cough is productive with yellow mucus.

Heart rate 72/min Respiratory rate 20/min Blood pressure 128/56 mm Hg Oxygen saturation 95% on room air

A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment? History of asthma Appendectomy 1 year ago Penicillin allergy Total knee arthroplasty 6 months ago

History of asthma A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate.

A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take? Monitor the client's INR daily. Expel air bubbles when using a prefilled syringe. Inject the medication into the anterolateral abdominal wall. Massage the injection site after administration.

Inject the medication into the anterolateral abdominal wall. The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation.

A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take? Administer a placebo to the client without their knowledge. Instruct the client on alternative therapies for pain reduction. Tell the client not to worry about addiction to prescribed narcotics. Suggest the client receive a different opioid for pain reduction.

Instruct the client on alternative therapies for pain reduction. The nurse should respect the client's concerns and offer nonpharmacologic alternatives to pain management, such as relaxing activities and distraction.

A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. Assist the client to start arm exercises 48 hr after surgery. Maintain the right arm in an extended position at the client's side when in bed. Place the client in a supine position for the first 24 hr after surgery.

Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period.

A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? Obtain ABGs. Administer propofol to the client. Instruct the client to allow the machine to breathe for them. Disconnect the machine and manually ventilate the client.

Instruct the client to allow the machine to breathe for them. When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator."

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? Remove the client's indwelling urinary catheter. Irrigate the indwelling urinary catheter. Clamp the indwelling urinary catheter. Apply traction to the indwelling urinary catheter.

Irrigate the indwelling urinary catheter. The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow.

A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? Keep a lead-lined container in the client's room. Limit each visitor to 1 hr per day. Place a dosimeter badge on the client. Remove soiled linens from the client's room each day.

Keep a lead-lined container in the client's room. The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant.

A nurse is caring for an client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client? Check on the client every 2 hr. Provide a quiet environment with no distractions. Turn on the television in the client's room. Keep the client occupied with a manual activity.

Keep the client occupied with a manual activity. The nurse should provide the client with a manual activity such as a puzzle or an art project. This can help to distract the client from the IV catheter.

A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew? Metoprolol Bupropion Atorvastatin Naproxen

Naproxen Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding.

A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? Nonrebreather mask Venturi mask Simple face mask Partial rebreather mask

Nonrebreather mask The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask.

Click to highlight the findings the nurse should report to the provider immediately. Client sleeping, arouses to verbal stimuli Respiratory rate 14/min Oxygen saturation 95% on room air, breath sounds clear Reports pain as 2 on scale of 0 to 10 Perineal pad saturated with blood, large clots present Change of blood pressure, heart rate of 102/min

Perineal pad saturated with blood, large clots present Change of blood pressure, heart rate of 102/min The client has manifestations of vaginal hemorrhage, including vaginal bleeding, blood clots, reduced blood pressure, and tachycardia. The nurse should report these findings to the provider.

A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? Use pillows to support the client's head and neck. Offer opioid medication. Place a tracheostomy tray at the bedside. Place the client in semi-Fowler's position.

Place a tracheostomy tray at the bedside. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to place a tracheostomy tray at the client's bedside in case of airway obstruction.

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care? Explain procedures as they occur to the client. Place personal items, such as pictures, at the client's bedside. Orient the client to their location once a shift. Encourage the family members to remain home until the client has adjusted.

Place personal items, such as pictures, at the client's bedside. The nurse should plan to have the family bring personal items such as pictures to place at the client's bedside for cognitive support.

The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention. Potassium level WBC count Temperature Oxygen saturation Heart rate

Potassium level WBC count Temperature Oxygen saturation

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? 240 mL (8 oz) of orange juice 1 ampule of 50% dextrose IV bolus NPH insulin 60 units subcutaneous Regular insulin 20 units IV bolus

Regular insulin 20 units IV bolus DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be effective within 10 min when administered intravenously.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? Remain with the client for the first 15 min of the infusion. Prime the blood administration IV tubing with lactated Ringer's solution. Verify the client's identity by using the client's room number prior to starting the transfusion. Infuse the unit of packed RBCs within 8 hr.

Remain with the client for the first 15 min of the infusion. The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood.

A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? Keep the client's personal care items in the bathroom. Keep the overhead lights on in the client's bedroom while the client is sleeping. Remind the client to scan their complete range of vision during ambulation. Secure the client's extension cords under carpeting.

Remind the client to scan their complete range of vision during ambulation. The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls.

A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? Report of sore throat Report of memory loss Alopecia Mucositis

Report of sore throat When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis.

A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor? Hyperreflexia Increased blood pressure Respiratory paralysis Tachycardia

Respiratory paralysis The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate.

A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching? Try to walk at least three times per week for exercise. To increase stamina, walk for 5 min after fatigue begins. Take over-the-counter cough medicine for persistent cough. Use a salt substitute to reduce sodium intake.

Try to walk at least three times per week for exercise. The development of a regular exercise routine can improve outcomes in clients who have heart failure.

A nurse is caring for a client who has a stage 3 pressure injury. Which of the following findings contributes to delayed wound healing? WBC count 6,000/mm3 BMI 24 Urine output 25 mL/hr Albumin 4 g/dL

Urine output 25 mL/hr Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? Serum sodium level 145 mEq/L Forearm skin tents when pinched Respiratory rate decreased Urine specific gravity 1.045

Urine specific gravity 1.045 A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration.

A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? "I should take calcium supplements so the medication will work better in my system." "I am taking this medication to increase my energy level." "This medication can cause my blood pressure to drop." "I will not need to restrict protein in my diet while taking this medication."

"I am taking this medication to increase my energy level." The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance.

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? Secure the straps firmly around the boot. Remove the device before showering. Use crutches with rubber tips. Adjust the screws to maintain alignment.

Use crutches with rubber tips. Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls.

A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.) Expressive aphasia Visual spatial deficits Left hemianopsia Right hemiplegia One-sided neglect

Visual spatial deficits - Visual spatial deficits and loss of depth perception occur secondary to a right-hemispheric stroke. Left hemianopsia - Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right-hemispheric stroke. One-sided neglect - One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke.

A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? Wear a mask. Wear a gown. Keep the client's room well-lit. Maintain the head of the bed at a 45° elevation.

Wear a mask. Bacterial meningitis requires droplet precautions. Therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy.

A nurse is reviewing the client's electronic medical record (EMR) and the provider's prescriptions. Which of the following actions should the nurse take? Select the 3 actions that the nurse should take.

provided informed consent, administer gentamicin 100 mg IV, and the client's prescribed PO phenytoin

A nurse is providing discharge teaching about infection prevention to a client who is receiving chemotherapy. Which of the following statements by the client indicates understanding of the teaching? "I will avoid eating raw fruits and vegetables." "I can ask a friend to change my cats litter box." "I will use a mild soap when washing my genital area." "I can sip on a glass of juice for at least 2 hours before I should discard it."

"I can ask a friend to change my cats litter box." Changing a pet's litter box increases the client's risk of being exposed to toxoplasmosis. Therefore, the client should wear gloves or avoid changing the pet's litter box.

A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change? "It is just easier to let my partner administer my insulin." "I used to never worry about my feet. Now, I inspect my feet every day with a mirror." "I'm concerned I won't be able to read my blood sugar level because the screen is so small." "I know a lot of people who have diabetes and do not take insulin. I wish I didn't have to."

"I used to never worry about my feet. Now, I inspect my feet every day with a mirror." This statement indicates that the client is successfully coping with the change because the client is performing preventive foot care to reduce the risk for complications.

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? "I will take my iron with a glass of milk." "I will take an antacid with my iron." "I will limit my intake of red meat." "I will eat more high-fiber foods."

"I will eat more high-fiber foods." The client should eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements.

A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? "I should clean my toothbrush in the dishwasher once a month." "I should eat more fresh fruit and vegetables." "I will avoid drinking a glass of cold liquid that has been standing for 30 minutes." "I will take my temperature once a day."

"I will take my temperature once a day." A client who has AIDS is immunocompromised and is at risk for infection. The client should check their temperature daily to identify a temperature greater than 37.8° C (100° F), which is an early manifestation of an infection.

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "I will wash the ink markings off the radiation area after each treatment." "I will use my hands rather than a washcloth to clean the radiation area." "I will be able to be out in the sun 1 month after my radiation treatments are over." "I will use a heating pad on my neck if it becomes sore during the radiation therapy."

"I will use my hands rather than a washcloth to clean the radiation area." The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation.

A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "I should avoid walking as much as possible." "I should sit down and read for several hours a day." "I will wear clean graduated compression stockings every day." "I will keep my legs level with my body when I sleep at night."

"I will wear clean graduated compression stockings every day." The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand.

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? "I will need to take antibiotics for 1 year." "My partner will need to take an antiviral medication." "My joints ache because I have Lyme disease." "I bruise easily because I have Lyme disease."

"My joints ache because I have Lyme disease." Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage II and, by stage III, become chronic. Other chronic complications include memory problems and fatigue.

A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? "This measures how much blood my heart is pumping." "This identifies if I have a defective heart valve." "This identifies if the pacemaker cells of my heart are working properly." "This measures the blood circulating to my heart muscle."

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

A nurse is caring for a client who was just admitted from the emergency department (ED). The client is most likely experiencing (__1__) and (__2__)

1. Acute chest syndrome 2. pneumonia

A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1. Administer oxygen via a nonrebreather mask 2. Initiate IV therapy with a large bore catheter 3. Insert an NG tube 4. Administer ranitidine Rationale: The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to administer oxygen. The nurse should then initiate IV therapy to support circulation by expanding intravascular fluid volume. Next the nurse should insert an NG tube to monitor the rate of bleeding and prevent gastric dilatation. The nurse may administer ranitidine when the client is not longer bleeding to prevent a stress ulcer.

A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in their diet? 12 almonds One small banana 1 tbsp peanut butter 1/2 cup tomato juice

12 almonds The nurse should determine that almonds are the best source of calcium to recommend because 12 almonds contain 36 mg of calcium. Removal of the parathyroid glands, which regulate calcium in the body, can result in hypocalcemia.

A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

167

The nurse has completed their performing an assessment of the client and reviewing the client's EMR. (For each of the client's assessment finding, click to specify if the finding is consistent with appendicitis or Crohn's disease. Each finding may support more than one disease process.)

???? Appendicitis: - pain - temperature - GI concerns Chron's Disease: - stool color - pain location - temperature - GI concerns

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Actions to Take: 1. Administer morphine IV. 2. Ensure the client is NPO. Potential Condition: 1. Cholecystitis Parameters to Monitor: 1. Monitor the color of the client's stools 2. Monitor the client for dark urine.

A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? Apply ice to the client's puncture wounds. Initiate corticosteroid therapy for the client. Keep the client's leg above heart level. Administer an opioid analgesic to the client.

Administer an opioid analgesic to the client. The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.

The nurse is planning care for the client. (For each potential provider's prescription, click to specify if each potential prescription is anticipated or contraindicated for the client.)

Anticipated: - Obtain blood cultures. - Obtain vital signs every hour. - Insert a nasogastric tube. Contraindicated: - Administer an intermittent IV bolus of fluid within 1 hour.

A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching? Position tabletop clocks with multi-colored backgrounds throughout the home. Explain how to complete a task while having the client do the task. Place a calendar on the wall with days and weeks included. Create complete outfits and allow the client to select one each day.

Create complete outfits and allow the client to select one each day. The family should place completed outfits on hangers and allow the client to select which one to wear each day.

A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Disease processes Laboratory findings Current medications Family history

Current medications The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing.

A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? Shellfish Peanuts Eggs Avocados

Avocados Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity.

A nurse is providing teaching for the client. Which of the following instructions should the nurse include? Select all that apply. (Select All that Apply.) Consume high-protein snacks. Avoid highly seasoned foods. Maintain a high carbohydrate intake. Eat several small meals per day. Eat five servings of fresh fruit per day. Avoid drinking fluids with meals.

Avoid drinking fluids with meals - Avoid drinking fluids with meals is correct. The nurse should instruct the client to drink fluids 30 min before or after meals Eat several small meals per day Consume high-protein snacks - Consume high-protein snacks is correct. The client should eat snacks that are high in protein and low in carbohydrates to prevent the gastric food boluses and reactive hypoglycemia in dumping syndrome. Avoid highly seasoned foods

A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? Potassium 4.8 mEq/L Magnesium 1.7 mEq/L BUN 34 mg/dL Hematocrit 45%

BUN 34 mg/dL Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal impairment. The nurse should notify the provider of this result.

A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? Obtain a sputum specimen to determine if there is colonization. Bathe the client using chlorhexidine solution. Place the client in droplet isolation. Restrict visits from the client's friends and family.

Bathe the client using chlorhexidine solution. The nurse should bathe the client using chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body.

A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider? Restlessness T3 level 215 ng/dL Blood pressure 170/80 mm Hg Decreased weight

Blood pressure 170/80 mm Hg Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm.

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? Hypotension Tachypnea Nuchal rigidity Bradycardia

Bradycardia A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? Ginkgo biloba Glucosamine Calcium Vitamin C

Calcium Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration.

A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take? Inspect the cast for drainage once every 24 hr. Check that one finger fits between the cast and the leg. Perform neurovascular checks every 2 to 3 hr. Make sure the client has a warm blanket covering the cast.

Check that one finger fits between the cast and the leg. To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application.

A nurse is caring for a client who is scheduled for a right knee arthroplasty. The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply.

"I will need to do the breathing exercises every 1 to 2 hours after the surgery" - Rationale: The client should cough and deep breathe and use the incentive spirometer every 1 to 2 hr to reduce the risk of postoperative complications, such as pneumonia. "I will be sure to ask for pain medication before my knee starts to hurt too bad" - Rationale: For optimal control of postoperative pain, the client should request analgesic medication before the pain becomes severe "I will probably be going home with a walker" - Rationale: It can take 6 weeks for complete recovery from knee arthroplasty. Clients are often discharged with the use of a walker and will advance to a cane or crutch 4 to 6 weeks following surgery.

The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply. "I will be sure to ask for pain medication before my knee starts to hurt too bad." "I will probably be going home with a walker." "Well, I guess there's no changing my mind about having surgery now." "My physical therapy will start after I leave the hospital." "I will need to do the breathing exercises every 1 to 2 hours after the surgery."

"I will need to do the breathing exercises every 1 to 2 hours after the surgery" is correct. The client should cough and deep breathe and use the incentive spirometer every 1 to 2 hr to reduce the risk of postoperative complications, such as pneumonia. "I will be sure to ask for pain medication before my knee starts to hurt too bad" is correct. For optimal control of postoperative pain, the client should request analgesic medication before the pain becomes severe. "I will probably be going home with a walker" is correct. It can take 6 weeks for complete recovery from knee arthroplasty. Clients are often discharged with the use of a walker and will advance to a cane or crutch 4 to 6 weeks following surgery.

A nurse is providing discharge teaching with the client. Which of the following statements made by the client indicates an understanding of the teaching? (Select all that apply.) "I will pack my abdominal wound with gauze after cleaning it." "I should avoid taking vitamin supplements." "I should alternate taking acetaminophen with my prescribed pain medication." "I should schedule several rest periods throughout the day." "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit."

"I will schedule several rest periods throughout the day" "I will notify my provider if temperature is greater than 101 F.

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? "You will still have the urge to void." "You can apply an aspirin tablet to the pouch to reduce odor." "You should cut the opening of the skin barrier one-eighth inch wider than the stoma." "You should use a moisturizing soap when washing the skin around the stoma."

"You should cut the opening of the skin barrier one-eighth inch wider than the stoma." The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine.

Complete the following sentence by using the lists of options. After reviewing the findings in the client's medical record, the nurse should first address the client's (1) followed by the client's (2)

1. abdominal pain 2. pain rating

A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

24mL (600mg/125mg)*5mL = 24mL

Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again. Client is short of breath and has a productive cough with yellow mucus. "I could barely breathe when I got up this morning and I had a throbbing headache." Capillary refill less than 2 seconds. Client is diaphoretic. Crackles heard in posterior lungs. Pedal pulses +2 bilaterally

Client is short of breath and has a productive cough with yellow mucus. - Shortness of breath, along with a productive cough with yellow mucus, indicates a potential problem. "I could barely breathe when I got up this morning and I had a throbbing headache." - Difficulty breathing and a throbbing headache indicates a potential problem. Client is diaphoretic. - Diaphoresis is a manifestation of an elevated temperature or hypoglycemia and indicates a potential problem. Crackles heard in posterior lungs. - Crackles heard in the posterior lower lobes indicate a potential problem.

The nurse is planning care for the client. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Limit the client's fluid intake to 1,500 mL per day.: - contraindicated - The client has manifestations of dehydration. Therefore, fluid restriction is contraindicated. Obtain a sputum culture and sensitivity. - Anticipated - The nurse should anticipate a prescription for a sputum culture and sensitivity to determine the type of bacteria present and to identify antibiotics to be prescribed. Famotidine 40 mg PO daily - nonessential - Famotidine is a histamine2 antagonist that is used in short-term therapy for the treatment of peptic ulcers. Therefore, the nurse does not need to administer famotidine 40 mg PO daily. Perform neurological checks every 2 hr. - nonessential - The nurse should anticipate a prescription for a sputum culture and sensitivity to determine the type of bacteria present and to identify antibiotics to be prescribed. Acetaminophen 500 mg PO every 6 hr as needed. - anticipated - The nurse should anticipate a prescription for acetaminophen to reduce the client's temperature and promote comfort. Administer oxygen at 3 L/min via nasal cannula. - anticipated - The client's oxygen saturation level is 88% on room air, which indicates hypoxemia. Therefore, the nurse should administer oxygen at 3 L/min via nasal cannula. Cough and deep breathe every 2 hr. - anticipated - The nurse should anticipate a prescription for coughing and deep breathing to promote lung expansion and improve impaired gas exchange.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? Low urine specific gravity Hypertension Bounding peripheral pulses Hyperglycemia

Low urine specific gravity An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.

A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? Bounding pedal pulse Capillary refill less than 2 seconds Pain that increases with passive movement Areas of warmth on the cast

Pain that increases with passive movement The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight.

A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include? Change the dressing every 72 hr. Immobilize the hand with a pressure dressing. Take pain medication 30 min after changing the dressing. Wrap fingers with individual dressings.

Wrap fingers with individual dressings. The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand.