MS: Infectious disease 27; Skills/procedures 22; Safety/infection ctrl 11 ; Basic care & comfort/pain mgt 7

A nurse in the emergency department is preparing to perform postmortem care on a client who died from a gunshot wound to the chest. An autopsy will be required. Which action is appropriate for the nurse to perform? 1. Delegate cleaning of blood from floor 2. Obtain consent from family for the autopsy 3. Remove all tubes and IV lines 4. Restrict family visitation of the deceased

1

An elderly client with staphylococcal pneumonia treated with intravenous antibiotic therapy for 3 days becomes extremely short of breath and restless and is difficult to arouse. Which additional assessment findings indicate to the nurse that the client can be developing sepsis? Select all that apply. 1. Absent bowel sounds 2. Capillary refill 5 seconds 3. Diminished breath sounds in bases 4. Serum glucose level 180 mg/dL (10.0 mmol/L) 5. Urine output 1 mL/kg/hr

1,2,4

The registered nurse (RN) is planning care to prevent venous thromboembolism in several clients. Which tasks can the RN delegate to the licensed practical nurse? Select all that apply. 1. Administering enoxaparin subcutaneously to a client in skeletal traction 2. Applying sequential compression devices to a client with limited mobility 3. Evaluating partial thromboplastin time in a client receiving heparin 4. Measuring a client with chronic heart failure for compression stockings 5. Teaching a client with a new prescription for warfarin about bleeding precautions

1,2,4

The nurse is changing the dressing, injection caps, and IV tubing of a client who is receiving total parenteral nutrition through a right peripherally inserted central venous catheter. The nurse should implement what actions to prevent complications during this procedure? Select all that apply. 1. Instruct the client to hold the breath when changing the injection caps and tubing 2. Instruct the client to keep the head to the right side during the dressing change 3. Perform hand hygiene before and after the procedure 4. Place the client in the Trendelenburg position before the procedure 5. Wear sterile gloves and a surgical mask when changing the dressing

1,3,5

The nurse is planning care for a client diagnosed with influenza who has had fever, muscle aches, headache, and sore throat for 36 hours. The health care provider prescribes ibuprofen and oseltamivir. Which of the following should the nurse include in the plan of care? Select all that apply. 1. Instruct client to be 3 ft (0.91 m) away from others when coughing or sneezing 2. Place client on contact precautions 3. Place mask on client when transporting 4. Question the oseltamivir prescription 5. Teach client about the importance of annual vaccination

1,3,5

An elderly client has a 17-mm induration after a tuberculin skin test (TST). Based on this result, which statement is most accurate? 1. The client has a false-positive reaction due to advanced age 2. The client has a tuberculosis (TB) infection 3. The client has active TB disease 4. The client must be isolated immediately

2

The nurse assessing a client notices pearly white plaque-like lesions on the mouth mucosa. The nurse understands that which client is at highest risk for oral candidiasis? 1. A client with asthma who uses an albuterol nebulizer once a day 2. A septic client receiving intravenous broad-spectrum antibiotics daily 3. A teenage client with braces who drinks several sugary drinks daily 4. An elderly client with poor oral hygiene and inadequate nutrition

2

The nurse administers IV vancomycin to a client with a methicillin-resistant Staphylococcus aureus infection. Which nursing actions are most appropriate? Select all that apply. 1. Assess client for lethargy and decreased deep tendon reflexes 2. Assess skin for flushing and red rash on face and torso 3. Infuse medication over at least 60 minutes 4. Monitor blood pressure during infusion 5. Observe IV site every 30 minutes for pain, redness, and swelling

2,3,4,5

A 59-year-old client comes to the clinic due to a blistering, linear rash on the left chest. The client reports itching and pain around the rash. What is the priority question for the nurse to ask the client? 1. "Did the rash start after taking a new medication?" 2. "Have you been keeping the rash covered?" 3. "Have you ever had chickenpox?" 4. "What have you tried to help the pain?"

3

The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy (PEG) tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications. While the nurse is preparing to administer the feeding, the tube becomes dislodged. What is the most appropriate intervention? 1. Insert a Foley catheter into the existing tract and inflate the balloon 2. Insert a small-bore nasointestinal tube to administer feedings and medications 3. Notify the health care provider who inserted the PEG tube 4. Reinsert the PEG tube into the existing tract immediately

3

The office nurse receives 4 telephone messages. Which client should the nurse call back first? 1. 32-year-old woman with a temperature of 100.4 F (38 C) who reports feeling achy following a flu shot yesterday 2. 50-year-old man who reports right shoulder pain and difficulty raising the arm above the head after playing baseball 2 days ago 3. 68-year-old woman with left-sided jaw pain, dizziness, and nausea who thinks it is an infection related to routine teeth cleaning yesterday 4. 72-year-old woman with urge incontinence who started taking solifenacin 2 days ago and reports constipation and very dry mouth

3

A female client comes to the clinic with a suspected lower urinary tract infection; urinalysis confirms a diagnosis of cystitis. Which symptoms reported by the client would bemost consistent with this condition? Select all that apply. 1. Chills and vomiting 2. Flank pain 3. Painful urination 4. Urinary frequency 5. Urinary urgency

3,4,5

The nurse is caring for a mechanically ventilated client with a tracheostomy tube in the intensive care unit. What client care tasks can be safely delegated to experienced unlicensed assistive personnel? Select all that apply. 1. Clean area around tracheostomy stoma with normal saline 2. Inform the family that the head of the bed must be elevated at least 30 degrees 3. Obtain and document respiratory rate and pulse oximetry readings 4. Perform oral care, using a tonsil tip suction device to suction the oropharynx 5. Perform passive and active range-of-motion exercises

3,4,5

The nurse is answering questions at a hospital-sponsored health fair. What actions should the nurse encourage to help prevent contracting the West Nile virus? Select all that apply. 1. Avoid raw, unpeeled fruits or vegetables 2. Limit contact with infected pets 3. Use insect (mosquito) repellent 4. Wash all bedding in hot water 5. Wear long-sleeved, light-colored clothes

3,5

The nurse is performing an initial assessment on a client diagnosed with Addison's disease. Which assessment findings should the nurse anticipate? Select all that apply. 1. Acanthosis nigricans 2. Hirsutism 3. Hyperpigmented skin 4. Truncal obesity 5. Weight loss

3,5

A charge nurse is monitoring a newly licensed registered nurse. What action by the new nurse would warrant intervention by the charge nurse? 1. Administers hydromorphone 1 mg to a client who rates pain at 7 on a 1 to 10 scale 2. Notifies physician of occasional premature ventricular beats in a client with myocardial infarction 3. Positions a postoperative pneumonectomy client on the affected side 4. Prepares to administer IVPB potassium chloride via gravity infusion for a client with hypokalemia

4

A client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the charge nurse choose as the best option for this client? 1. Room 1—client with Clostridium difficile 2. Room 2—client with fever of unknown origin 3. Room 3—client with bacterial pneumonia 4. Room 4—client with upper gastrointestinal bleed

4

The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to "reach the itch." What is the nurse's priority action? 1. Offer the client a straw to reach the itch instead of a lead pencil 2. Perform a peripheral neurovascular check of the casted extremity 3. Pour a generous amount of baby powder or corn starch in the cast to reach the itch 4. Review appropriate itch relief technique using the cool setting of a hair dryer

4

The nurse cares for a client with a colostomy. Which statement indicates that further teaching is required? 1. "I have lost 10 lb (4.5 kg) in the last month on my new, healthier diet." 2. "I include lots of fruits and vegetables as well as yogurt in my daily diet." 3. "I shower with my bag removed and use mild soap and water on the stoma." 4. "There is minimal bright red bleeding present when I change my stoma bag."

6

MS infectious etc 49 drag and drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348579

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The nurse receives report for 4 clients in the emergency department. Which client should be seen first? 1. 30-year-old with a spinal cord injury at L3 sustained in a motor cycle accident who reports lower abdominal pain and difficulty urinating 2. 33-year-old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait 3. 65-year-old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL 4. 70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL

4

The nurse teaches a group of homeless community clients preventive measures related to transmission of hepatitis A. Which of these measures would the nurse teach as thepriority precaution to prevent transmission? 1. Do not share needles when injecting drugs 2. Practice safe sex by using condoms 3. Receive the hepatitis A vaccine 4. Wash hands after bowel movements and before eating

4

A client with palpitations is admitted with supraventricular tachycardia. The client's heart rate is 210/min. Which is the most appropriate initial intervention? 1. Ask the client to bear down as if having a bowel movement 2. Grab the crash cart and apply hands-free defibrillation pads 3. Place ECG leads on client to further assess electrical activity 4. Place IV line distally from the heart for adenosine administration

1

A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering? 1. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours 2. IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy 3. IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmol/L) 4. IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure

1

After morning report, the nurse must perform which action first when caring for assigned clients? 1. Administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea 2. Hang the second unit of packed red blood cells for a client with a hemoglobin of 6 g/dL (60 g/L) 3. Replace the empty IV opioid medication syringe in a patient-controlled analgesia pump 4. Replace the heparin infusion bag that has 100 mL remaining and is infusing at 50 mL/hr

1

The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need forfurther teaching? 1. "I can leave right after the shot as I didn't have a reaction last time." 2. "I will be back in a week for my next allergy shot." 3. "I will let the doctor know if I get any itchy hives tonight." 4. "It is okay if I have some redness at the injection site tonight."

1

The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube? 1. Flush and aspirate the tube with warm water 2. Instill a digestive enzyme solution into the tube 3. Instill cola or cranberry juice into the tube 4. Use a small-barrel syringe to flush the tube

1

The nurse is caring for a client with scleroderma. Which assessment finding indicates the most serious complication of the disease and requires priority intervention? 1. Abrupt-onset hypertension and headache 2. Blue and cold fingertips 3. Dry cough and exertional dyspnea 4. Heartburn and difficulty swallowing

1

The nurse is teaching self-care management to a client experiencing an outbreak of genital herpes. Which statement by the client indicates a need for further teaching? 1. "I will be sure we use condoms during intercourse as long as I have lesions." 2. "I will not touch the lesions to prevent spreading the virus to other parts of my body." 3. "I will use a hair dryer on a cool setting to dry the lesions after taking a shower." 4. "I will use warm running water and mild soap without perfumes to wash the area."

1

The nurse notices a change in condition while caring for a client in septic shock who has an infected leg ulcer and positive blood cultures for methicillin-resistant Staphylococcus aureus (MRSA). Which assessment finding is most important for the nurse to report to the health care provider? 1. Cold and clammy skin 2. Oxygen saturation of 92% 3. Sinus tachycardia with a rate of 118 beats/min 4. Urine output of 0.5 mL/kg/hr

1

The nurse prepares to administer a prescribed dose of sodium polystyrene sulfonate to a client with hyperkalemia. Which action by the nurse is most important prior to administering the dose? 1. Assessing the client's abdomen and reviewing the medical record for frequency of stools 2. Assisting the client onto a bedside commode 3. Teaching the client the importance of frequent assessment of potassium and sodium levels 4. Verifying that the client had a daily weight assessment

1

The nurse receives a change-of-shift report on assigned clients. Which client is a priority for the nurse? 1. Client with pneumonia who has a temperature of 101 F (38.3 C), white blood cell count of 14,000/mm3 (14.0 x 109/L), and 12% (0.12) bands; IV antibiotic is now prescribed 2. Client who had an abdominal hysterectomy and reported an "8" on a 0-10 pain scale; hydromorphone IV push was prescribed 3. Client who has cirrhosis with an elevated ammonia level and is in a state of confusion, which was reported by the previous nurse 4. Client who was admitted yesterday due to diarrhea and was given IV fluids; hemoglobin level was 12 g/dL (120 g/L) but is 10 g/dL (100 g/L) today

1

The nurse receives hand-off report on assigned clients. Which client should the nurse assess first? 1. Client 1 day post femoral-popliteal bypass surgery who now has a nonpalpable pedal pulse present only with Doppler 2. Client with chronic venous insufficiency who has edema and brown discoloration of the lower extremities 3. Client with peripheral arterial disease and gangrene of the foot who has a cool-to-the-touch, hairless extremity 4. Client with peripheral arterial disease who reports severe cramping pain in the calf with activity such as walking Correct.

1

The nurse reviews prescriptions for assigned adult clients. Which prescription should the nurse question? 1. 0.45% sodium chloride (NaCl) solution prescribed for a client with syndrome of inappropriate antidiuretic hormone secretion who has a sodium level of 120 mEq/L (120 mmol/L) 2. 0.9% NaCl solution prescribed for a client with gastrointestinal bleeding who has a hemoglobin level of 8.9 g/dL (89 g/L) 3. 1,000 mL bolus of 0.9% NaCl solution prescribed for a client with septic shock who has a white blood cell count of 18,000/mm3 (18.0 × 109/L) 4. Lactated Ringer's solution prescribed for a male client with hypovolemic shock and a thermal burn who has a hematocrit level of 56% (0.56)

1

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first? 1. A client post cholecystectomy reporting increased nausea 2. A client post myomectomy with mild oozing of blood from the surgical site 3. A client post spinal surgery requesting additional pain medication 4. A client post transurethral resection of the prostate with reddish-pink drainage

1

The spouse of an immunocompromised client is diagnosed with influenza virus infection. The spouse asks the office nurse how long contact with the client should be avoided to prevent the infection from spreading. What is the nurse's most appropriate response? 1. "Avoid close contact for about a week." 2. "It's impossible to avoid contact with the client. Just wash your hands often." 3. "You are sick already, and so you are not contagious anymore." 4. "You don't have to worry as long as the client has received the influenza vaccination."

1

The nurse prepares to administer IV vancomycin to an 80-year-old client with a methicillin-resistant Staphylococcus aureus infection. The nurse should notify the health care provider about which serum laboratory results before administering the drug? Select all that apply. 1. Blood urea nitrogen is 60 mg/dL (21.4 mmol/L) 2. Creatinine is 2.1 mg/dL (185.6 µmol/L) 3. Glucose is 140 mg/dL (7.7 mmol/L) 4. Hemoglobin is 15 g/dL (150 g/L) 5. Magnesium is 1.5 mEq/L (0.75 mmol/L) 6. White blood cell count is 14,000/mm3 (14.0 × 109/L)

1,2

The hospice nurse is assisting a client's family in managing anorexia during end-of-life care. Which interventions would be most supportive? Select all that apply. 1. Administer nausea medication prior to meals 2. Involve the client in daily meal planning 3. Offer food items the client desires 4. Plan for loved ones to share meal time with the client 5. Prepare 3 highly nutritious meals a day on a schedule

1,2,3,4

Which statements would be appropriate for the nurse to make when discussing the possibility of hospice care with a client and the client's family? Select all that apply. 1. "Hospice care can be provided in the home, in a nursing home, or in the hospital." 2. "Hospice care is covered by Medicare." 3. "Hospice helps people die naturally in their own time." 4. "If your condition improves, you can be discharged from hospice." 5. "You can continue to receive curative, disease-directive treatment while you are on hospice."

1,2,3,4

The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming out of orientation? 1. Client diagnosed with chronic anemia receiving iron via IV route 2. Client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose >600 mg/dL (33.3 mmol/L) 3. Client undergoing ultrafiltration for congestive heart failure 4. Client with a prescription for routine hemodialysis who has chronic renal failure

4

The client with suspected active pulmonary tuberculosis (TB) has a positive tuberculin skin test (TST). Which prescription from the health care provider does the nurse anticipate will confirm the diagnosis in this client? 1. Collect 2 blood cultures from different intravenous sites after cleansing with a chlorhexidine swab 2. Collect 2 early morning nose specimens (swabs) from each nare using sterile culturettes 3. Collect an early morning sterile sputum specimen on 3 consecutive days 4. Collect blood for the QuantiFERON-TB test after cleansing the site with a chlorhexidine swab

3

The clinic nurse is completing a health history for a client with suspected rheumatic fever (RF). Which question is most important for the nurse to ask to establish a diagnosis? 1. "Do you typically take all your antibiotics when they are prescribed?" 2. "Has anyone in your family had rheumatic fever?" 3. "Have you recently had a streptococcal throat infection?" 4. "What has your temperature been over the past several days?"

3

The nurse assesses the site where a client received an intradermal purified protein derivative (ie, Mantoux) test 48 hours ago and notices a 16-mm area of induration. The client has no symptoms. Which action will the nurse take next? 1. Document the negative response in the client's medical record 2. Have the client return in a week to receive a second injection 3. Obtain a prescription for the client to have a chest x-ray 4. Place the client in an airborne-infection isolation room

3

The nurse in the student health center at a large university received student telephone messages. Which return telephone call is the priority? 1. Student who feels well but is concerned about possible exposure to viral meningitis at an off-campus party 2 weeks ago 2. Student who was in a baseball tournament yesterday and is now unable to lift the arm past the waist due to extreme shoulder pain 3. Student who woke from a deep sleep in an unfamiliar dormitory room and is panic-stricken with severe vaginal pain 4. Student with itchy, cottage-cheese-like vaginal discharge who is sexually active and worried about having a sexually transmitted infection

3

The nurse is caring for a 76-year-old client newly admitted with pneumonia and Clostridium difficile infection. Which of the following would be priority to report to the health care provider? 1. Blood gas results of PO2 80 mm Hg (10.6 kPa), pCO2 35 mm Hg (4.7 kPa), pH 7.38 2. Blood urea nitrogen of 29 mg/dL (10.4 mmol/L), potassium of 3.3 mEq/L (3.3 mmol/L), sodium of 132 mEq/L (132 mmol/L) 3. Coarse crackles in lung bases with moderate sputum production 4. Fever of 100.6 F (38.1 C) and reports of chills and fatigue

2

The nurse is giving a presentation at a community health event. The nurse should provide which instruction on how to prevent botulism? 1. Boil water if unsure of its source 2. Discard canned food with a bulging end 3. Keep milk cold 4. Wash hands

2

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone 2. Client admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently 3. Client admitted with intestinal obstruction who is reporting abdominal pain and distention and needs nasogastric tube placement 4. Client who had cardiac valve surgery 8 days ago but was readmitted with a sternal wound infection and needs antibiotics and a dressing change

2

The primary care provider's office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires an immediate call back? 1. 28-year-old woman is requesting antibiotic to be called to pharmacy due to another bladder infection 2. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration 3. 78-year-old man with sinusitis who takes pseudoephedrine is having difficulty voiding 4. 84-year-old man with prostate cancer and spine metastasis is requesting increased pain medication

2

The unlicensed assistive personnel (UAP) assists a client with cirrhosis who underwent paracentesis 4 hours ago. The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair. Which action should the nurse implement first? 1. Ask the UAP to take a set of vital signs 2. Assess the symptoms reported by the UAP 3. Hold the prescribed diuretic medications 4. Instruct the UAP to assist the client to bed

2

The nurse is preparing to administer a unit of packed red blood cells to a client whose hemoglobin is 7 g/dL (70 g/L). What tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1. Assist with checking identification of client and blood product 2. Measure vital signs at the end of the transfusion 3. Measure vital signs just after starting the transfusion 4. Measure vital signs prior to starting the transfusion 5. Obtain blood from the blood bank

2,4,5

The nurse is providing care for a client with Alzheimer disease who often becomes angry and agitated 20 minutes or more after eating. The client accuses the nurse of not providing food, saying, "I'm hungry. You didn't feed me." The nurse should take which action? 1. Give the client gentle reminders that the client has already eaten 2. Say that the client can have a snack in a couple of hours 3. Serve the client half of the meal initially and offer the other half later 4. Take a picture of the client having a meal and show it when the client becomes upset

3

The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia. The health care provider's prescription states: IV potassium chloride 10 mEq (10 mmol)/100 mL 5% dextrose in water now, infuse over 30 minutes. What is the nurse's priority action? 1. Assess the patency of the peripheral IV site 2. Check the most current serum potassium level 3. Contact the health care provider to verify the prescription 4. Set the electronic IV pump to 100 mL/hr

3

The nurse receives report on 4 clients. Which client conditions require priority assessment? 1. 34-year-old with acute pericarditis reporting left-sided chest pain that is worse with inspirations 2. 54-year-old post right femoropopliteal bypass surgery reporting sudden-onset severe right foot pain 3. 64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea 4. 70-year-old with pneumonia; rapid, irregular pulse of 140/min; and blood pressure of 130/86 mm Hg

3

The public health nurse provides care for a client on a directly observed therapy (DOT) program to treat tuberculosis (TB). Which option best describes the care the nurse provides on this program? 1. Follows the client until 3 sputum cultures are normal 2. Gives the client bus tokens or cab fare vouchers to attend scheduled clinic visits 3. Provides and watches the client swallow every prescribed medication 4. Screens all of the client's close contacts

3

A client with multidrug-resistant tuberculosis (MDR-TB) has a 1-month follow up visit after beginning medication therapy. The client states, "I've had really bad nausea and fatigue, but because my cough has already improved, I knew it would be alright to stop taking the medications." The nurse identifies which priority nursing diagnosis (ND) in this client's care plan? 1. Activity intolerance 2. Imbalanced nutrition, less than body requirements 3. Knowledge deficit of prescribed therapeutic regimen 4. Nausea

3

A nurse is discharging a client who has been hospitalized with streptococcal infective endocarditis (IE). Which statement by the client would indicate a need for further teaching? 1. "I may need prophylactic antibiotics before dental work from now on." 2. "I should call my health care provider (HCP) or 911 right away if I notice my speech is slurred." 3. "I shouldn't be concerned if I continue to have a fever at home." 4. "I will expect a home health nurse to give me IV antibiotics for several more weeks."

3

During a camping trip, a camp counselor falls and gets a small splinter of wood embedded in the right eye. What action should the volunteer camp nurse take first? 1. Gently flush the eye with cool water 2. Instill optic antibiotic ointment 3. Patch both eyes with eye shields 4. Remove the splinter using tweezers

3

The nurse plans discharge teaching for a client with active herpes lesions who has a new prescription for oral acyclovir and topical lidocaine. What information will the nurse include in the teaching plan? 1. Adhesive bandaging should remain on the lesions to prevent virus shedding 2. Blood tests will be drawn to ensure the virus is eradicated 3. Condoms should be used during intercourse until the lesions are healed 4. Gloves should be used to apply the medication to the lesions

4

The nurse prepares to administer intravenous albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL (15 g/L). Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing? 1. Altered mental status 2. Easy bruising 3. Loss of body hair 4. Pitting edema

4

The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention? 1. Assess pupillary response 2. Auscultate lung sounds 3. Inform anesthesia professional 4. Perform head tilt and chin lift

4

A client is admitted to the hospital for evaluation of suspected pulmonary tuberculosis (TB). The nurse assesses for which characteristic presenting signs and symptoms associated with TB disease? Select all that apply. 1. Dysuria 2. Jaundice 3. Low back pain 4. Night sweats 5. Purulent or blood-tinged sputum 6. Weight loss

4,5,6

The nurse evaluates morning laboratory results for several clients who were admitted 24 hours earlier. Which laboratory report requires priority follow-up? 1. Client with chronic obstructive pulmonary disease who has a PaCO2 of 52 mm Hg (6.9 kPa) 2. Client with heart failure who has a brain natriuretic peptide level of 800 pg/mL (800 ng/L) 3. Client with infected pressure ulcer who has a white blood cell count of 13,000/mm3 (13.0 x 109/L) 4. Client with pulmonary embolism who has a partial thromboplastin time of 127 seconds

4

The nurse is caring for 4 clients. Based on the assessment data, which client does the nurse anticipate the health care provider transferring to the intensive care unit? 1. 36-year-old with alcohol abuse who is prescribed IV lorazepam every 3 hours for agitation and has a blood pressure of 190/98 mm Hg and serum magnesium level of 1.5 mEq/L (0.75 mmol/L) 2. 56-year-old with stable angina who has chest and jaw pain relieved with nitroglycerin, blood pressure of 98/70 mm Hg, and dizziness when getting up 3. 60-year-old with chronic kidney disease who has a blood pressure of 168/88 mm Hg, serum creatinine level of 5.0 mg/dL (442 µmol/L), and reports nausea and itching 4. 82-year-old with pressure (decubitus) ulcer who has a change in mental status, temperature of 96.4 F (35.8 C), pulse of 110/min, and blood pressure of 96/72 mm Hg

4

A client in the critical care unit has a central venous catheter (CVC). The site around the CVC becomes red and inflamed. The client reports chills and nausea and has a temperature of 102 F (38.8 C). The nurse should prepare to implement which prescription first? 1. Administer broad-spectrum intravenous (IV) antibiotic through a new IV site 2. Document the occurrence and notify the hospital's infection control nurse 3. Give ondansetron (Zofran) 4 mg IV push to relieve client's nausea 4. Obtain blood cultures and send tip of the discontinued CVC to the lab for culture

4

A home health nurse is giving an infection control presentation on pulmonary tuberculosis (TB) disease to a group of home health aides. Which statement made by a home health aide indicates an understanding about the mode of transmission of pulmonary TB? 1. "It is spread by contact with the client's blood or urine." 2. "It is spread by contact with the client's soiled clothing and bed linens." 3. "It is spread by contact with the client's soiled eating utensils." 4. "It is spread by small droplets that the client coughs or sneezes into the air."

4

At 8 AM, medications are prescribed for assigned clients. Which medication should the nurse administer first? 1. Acetylsalicylic acid for a client with a history of coronary artery disease and ischemic stroke 2. Metformin for a client with serum glucose of 285 mg/dL (15.8 mmol/L) who is scheduled for a CT scan with contrast 3. Morphine sulfate for a client with terminal lung cancer who has chronic bone pain 4. Pyridostigmine for a client with myasthenia gravis exacerbation who reports difficulty swallowing

4

The nurse assesses and reviews the laboratory results for 4 clients. Which client's fever is of highest priority and should be reported to the health care provider immediately? 1. Client newly diagnosed with Hodgkin lymphoma scheduled for chemotherapy who has a fever of 100.9 F (38.3 C) and white blood cell count of 6,000/mm3 (6.0 × 109/L) 2. Client with acute cholecystitis scheduled for laparoscopic surgery who has a fever of 102 F (38.9 C) and white blood cell count of 13,000/mm3 (13.0 × 109/L) 3. Client with Clostridium difficile infection receiving metronidazole who has a fever of 101 F (38.3 C) and white blood cell count of 18,000/mm3 (18.0 × 109/L) 4. Client with colon cancer receiving chemotherapy who has a fever of 100.4 F (38 C) and white blood cell count of 1,500/mm3 (1.5 × 109/L)

4