MS2 E3 CTE

A nurse is caring for a client undergoing screening for primary Cushing's disease. The nurse should expect an elevation in which of the following laboratory findings?

Glucose Blood glucose is elevated in a client who has Cushing's disease.

Peritonitis expected finding:

Board-like abdomen

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?

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 assessing a client who has acute hepatitis B. which of the following findings should the nurse except?

joint pain

Adverse affect of metoclopramide: GERD treatment

Ataxia

a nurse is assessing a male client for an inguinal hernia. which of the following areas should the nurse palpate to verify that the client has an inguinal hernia?

C

A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIB treatment?

Decreased viral load

A nurse is caring for a client who has colorectal cancer and is receiving chemo. The client asks the nurse why his blood is drawn for a carcinoembryonic antigen (CEA) level. Which of the following responses should the nurse make? A."The CEA determines the current stage of your colon cancer." B. "The CEA determines the efficacy of your chemotherapy." C. "The CEA determines if the neutrophil count is below the expected reference range." D. "The CEA determines if you are experiencing occult bleeding from the gastrointestinal tract."

B. "The CEA determines the efficacy of your chemotherapy." A provider uses the CEA level to determine the efficacy of the chemotherapy. The client's CEA levels will decrease if the chemotherapy is effective.

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?

BUN 32 mg/dL

A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client?

Take insulin even if you are unable to eat your regular diet.

A nurse is caring for a client who has had a cerebrovascular accident. Which of the following findings indicates that the client has homonymous hemianopsia?

The client has to turn her head to see the entire visual field.

Duodenal ulcer expected finding:

The client states the pain occurs 1.5 to 3 hours after meals and during the night

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?

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 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. The development of a regular exercise routine can improve outcomes in clients who have heart failure.

A nurse is providing discharge teaching for a client who has diabetes insipidus and has a new prescription for desmopressin nasal spray. Which of the following instructions should the nurse include in the teaching?

"Blow your nose gently prior to using the nasal spray." The nurse should instruct the client to blow his nose gently prior to use of the spray. This action prevents dilution of the medication with nasal secretions.

Client teaching for cirrhosis and a prescription for lactulose:

Expect to have two to three soft stools per day

a nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. which of the following statements by the client indicates an understanding of the teaching?

"I should take this medication with a meal." The client should take metformin with or immediately following meals to improve absorption and to minimize gastrointestinal distress.

a nurse is performing a dressing change for a client who is recovering from a hemicolectomy. when removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. which of the following actions should the nurse first take?

call for help. Evidence-based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock; therefore, the nurse should obtain immediate assistance.

a nurse is performing a cardiac assessment for a client who had a myocardial infraction 2 days ago. which of the following actions should the nurse take first after hearing the following sound?

listen with the client on their left side. When providing nursing care, the nurse should first use the least invasive intervention. Therefore, after auscultating a murmur, the first action the nurse should take is to place the client on their left side and listen to the heart again so that the murmur can be heard more clearly.

a nurse is caring for a client who is experiencing a tonic-clonic seizure. which of the following actions should the nurse take?

loosen restrictive clothing. The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.

A nurse is collecting data forma client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect Decreased heart rate Yellowing of the skin Increased blood pressure Board-like abdomen

Board-like abdomen

Discharge diet teaching for mild diverticulitis:

Eat foods that are low in fiber

a nurse is assessing a client who has Crohn's disease. which of the following findings should the nurse except?

fatty, diarrheal stools

A nurse is caring for a client who has active bleeding from peptic ulcer disease. Which of the following findings is an indication that the client is experiencing compensatory shock?

Increased heart rate

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority?

Increased respiratory secretions

A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?

It's like a curtain closed over my eye.

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 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 providing preoperative teaching for a client who is scheduled for an open cholecystectomy. which of the following actions should the nurse take?

demonstrate ways to deep breathe and cough. The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications.

Discharge teaching for ileostomy, the client should report finding:

Dark purple stoma *Indication of bowel ischemia

Acute hepatitis B expected finding:

Joint pain

A nurse is assessing a client who has Cushing's disease. Which of the following findings should the nurse expect?

Muscle atrophy

A nurse is reinforcing teaching with a group of community residents about hepatitis B. Which of the following statements should the nurse include in the teaching? "Hep B immunization is recommended for those who travel, especially military personnel" "Hep B immunization is given to infants and children" "Hep B is acquired by eating foods that are contaminated during handling" "Hep B can be prevented by using good personal hygiene habits and proper sanitation"

"Hep B immunization is given to infants and children"

A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. which of the following statements by the client indicates and understanding of the teaching?

"I am dieting to lose weight." Excess weight creates increased abdominal pressure that can result in stress incontinence.

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 and understanding of the teaching?

"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 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?

"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 in an outpatient clinic is teaching a client who has a diabetic foot ulcer about foot care. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"I will apply lotion to the dry areas of my feet, but not between my toes." Lotion can be used for dry areas of the feet, but the client should avoid applying lotion between the toes, as this area is prone to bacterial growth.

A nurse is teaching a client who has type 1 diabetes mellitus about how to prevent complications during illness. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"I will call my doctor if my blood sugar is more than 250 milligrams per deciliter." The client should call the provider if her blood glucose levels exceed 250 mg/dL during illness.

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 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 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.

To screen a client for pheochromocytoma, a nurse schedules a vanillylmandelic acid test. When teaching the client about this test, which of the following instructions should the nurse include?

"Restrict coffee intake 2 to 3 days prior to the test." The client should avoid coffee and tea (even if they are decaffeinated), bananas, chocolate, and vanilla for 2 to 3 days prior to the test.

A nurse is developing a teaching plan for a client who had a thyroidectomy and takes a thyroid hormone replacement. Which of the following instructions should the nurse plan to include?

"Take this medication on an empty stomach." To promote proper absorption, the client should take the medication on an empty stomach and not eat or drink anything for 30 to 60 min after taking it.

A nurse is reinforcing teaching with a client who has Barrett's esophagus and is schedules to undergo and esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? "This procedure is performed to measure the presence of acid in your esophagus" "This procedure can determine how well the lower part of your esophagus works" "This procedure is performed while you are under general anesthesia" "This procedure can determine if you have colon cancer"

"This procedure can determine how well the lower part of your esophagus works"

A nurse is teaching a client about glycosylated hemoglobin (HbA1c) testing. Which of the following statements should the nurse identify as an indication that the client understands the information about this test?

"This test's result is a good indicator of my average blood glucose levels." HbA1c reflects the client's glucose levels over a 120-day period, which is the life span of RBCs.

a nurse in an emergency department is assessing a client who has a detached retina. which of the following should the nurse expect the client to report?

"it's like a curtain closed over my eye." A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field.

a nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. which of the following statements should the nurse include when instructing the client?

"take insulin even if you are unable to eat your regular diet." The client should continue the prescribed medication regimen when ill to prevent hyperglycemia.

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 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.

a nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. which of the following information should the nurse include in the teaching?

"you should void every 4 hours to decrease the risk of urinary retention." The nurse should instruct the client to void at least every 4 hr to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics.

a nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. which of the following statements should the nurse take?

"you will not be able to use sildenafil if you are taking nitroglycerin." The client should not use sildenafil when taking nitroglycerin because both medications can cause vasodilation and lead to significant hypotension.

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 her diet?

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?

167 mL/hr

A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority?

Apply firm pressure to the insertion site

A nurse is assessing a client who has Crohn's disease. Which of the following findings should the nurse expect? A. Fatty diarrheal stools B. Hyperkalemia C. Weight gain D. Sharp epigastric pain

A Fatty diarrheal stools Steatorrhea, or fatty stool, is an expected finding in a client who has Crohn's disease.

A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse expect? (Select all that apply) A. Oral temperature 38.4° C (101.1° F) B. WBC 6,000/mm3 C. Bloody diarrhea D. Nausea and vomiting E. Right lower quadrant pain

A, D, E Oral temperature 38.4° C (101.1° F) is correct. A low-grade temperature is an expected finding in a client who has appendicitis. Nausea and vomiting is correct. Nausea and vomiting are expected findings in a client who has appendicitis. Right lower quadrant pain is correct. Right lower quadrant pain is an expected finding in a client who has appendicitis.

A nurse is caring for a client who has ulcerative colitis. The client has had several exacerbations over the past 3 yr. Which of the following instructions should the nurse include in the plan of care tom inimize risk of further exacerbations? (Select all that apply) A. Use progressive relaxation techniques. B. Increase dietary fiber intake. C. Drink two 240 mL (8 oz) glasses of milk per day. D. Arrange activities to allow for daily rest periods. E. Restrict intake of carbonated beverages.

A, D, E Use progressive relaxation techniques is correct. Progressive relaxation techniques, a form of biofeedback, are recommended to help the client minimize stress, which can precipitate an exacerbation. Arrange activities to allow for daily rest periods is correct. Daily rest periods decrease stress and reduce intestinal motility. Restrict intake of carbonated beverages is correct. The client should avoid gastrointestinal stimulants, such as carbonated beverages, nuts, peppers, and smoking.

A nurse is providing discharge teaching for a client who has peptic ulcer disease and a new famotidine. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take this medication at bedtime." B. "I should expect this medication to discolor my stools." C. "I will drink iced tea with my meals and snacks." D. "I will monitor my blood glucose level regularly while taking this medication."

A. "I should take this medication at bedtime." The nurse should instruct the client to take the medication at bedtime to inhibit the action of histamine at the H2-receptor site in the stomach.

A nurse is providing discharge teaching for a client who has GERD. Which of the following statements by the client indicates an understanding of the teaching? A. "I will decrease the amount of carbonated beverages I drink." B. "I will avoid drinking liquids for 30 minutes after taking a chewable antacid tablet." C. "I will eat a snack before going to bed." D. "I will lie down for at least 30 minutes after eating each meal."

A. "I will decrease the amount of carbonated beverages I drink." The nurse should instruct the client to limit or eliminate fatty foods, coffee, cola, tea, carbonated beverages, and chocolate from his diet because they irritate the lining of the stomach.

A nurse is assessing a client who has acute hepatitis B. Which of the following findings should the nurse expect? A. Joint pain B. Obstipation C. Abdominal distention D. Periumbilical discoloration

A. Joint pain Joint pain is an expected finding in a client who has acute hepatitis B.

A nurse is developing a plan of care for a client who has cirrhosis and ascites. Which of the following inteventions should the nurse include the plan? A. Measure the client's abdominal girth daily B. Check mental status once daily C. Provide a daily intake of 4g of sodium for the client D. Assess the client's breath sounds every 12 hr

A. Measure the client's abdominal girth daily The nurse should measure the client's abdominal girth and weigh the client daily to monitor the amount of fluid accumulation in the abdomen and the effectiveness of treatment measures.

A nurse is teaching a client about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should explain that the purpose of the test is to assess for which of the following disorders?

Addison's disease The nurse should instruct the client that the ACTH stimulation test is the standard test for Addison's disease. It measures the cortisol response to ACTH. The response is absent or very decreased in clients who have primary adrenal insufficiency.

A nurse is managing the care of a client who is postoperative and has acute adrenal insufficiency. Which of the following actions should the nurse take?

Administer IV hydrocortisone sodium. Hydrocortisone sodium is necessary to replace the cortisol deficiency that occurs with adrenal insufficiency.

A nurse in an emergency department is caring for a client who reports chest pain of 8 on a pain scale of 0 to 10. Which of the following actions should the nurse take first?

Administer morphine

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.

Administer oxygen via a nonrebreather mask Initiate IV therapy with a large bore catheter Insert NG tube Administer Ranitidine

A nurse is collecting data from a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the clients condition? High-calorie diet Prior gastrointestinal illness Tobacco use Alcohol use

Alcohol use

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following non pharmacological interventions should the nurse suggest to the client to reduce pain?

Alternate application of heat and cold to the affected joints

Laboratory results of hepatic cirrhosis, finding should be reported to the provider:

Ammonia 180 mcg/dL *increased serum ammonia can indicate portal-systemic encephalopathy

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range withing 712 hrs after treatment begins? Aldolase Lipase Amylase Lactic dehydrogenase

Amylase

A nurse is collecting data from a client who is in the early stages of Hep A. Which of the following manifestations should that nurse expect? Jaundice Anorexia Dark Urine Pale feces

Anorexia Rationale: Jaundice, dark urine, and pale feces are all late manifestations of Hep A

a nurse is admitting a client who has acute pancreatitis. which of the following actions should the nurse take first?

identify the client's level of pain

A nurse is providing discharge teaching for a client who has chronic hepatitis C. Which of the following statements indicates an understanding of the teaching? A. "I will avoid alcohol until I'm no longer contagious." B. "I will avoid medications that contain acetaminophen." C. "I will decrease my intake of calories." D. "I will need treatment for 3 months."

B. "I will avoid medications that contain acetaminophen." A client who has hepatitis C should avoid medications that contain acetaminophen, which can cause additional liver damage.

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect? A. Bloody diarrhea B. Board-like abdomen C. Periumbilical cyanosis D. Increased bowel sounds

B. Board-like abdomen A board-like, distended abdomen, accompanied by extreme pain and tenderness, is an expected finding in a client who has peritonitis.

A nurse is providing dietary teaching for a client who is postoperative following a gastrectomy. Which of the following foods should the nurse encourage the client to include in her diet to prevent dumping syndrome? A. Ice cream B. Eggs C. Grape juice D. Honey

B. Eggs The nurse should instruct the client to increase intake of protein-containing foods, such as eggs, to decrease the risk for manifestations of dumping syndrome. The client should eat some form of protein at each meal.

A nurse is providing teaching for a client who has cirrhosis and a new prescription for lactulose. THe nurse should include which of the following instructions in the teaching. A. Notify provider if bloating occurs B. Expect to have 2-3 soft stools per day C. Restrict carbohydrates in the diet D. Limit oral fluid intake to 1000 mL per day of clear fluids

B. Expect ot have 2-3 soft stools per day The purpose of administering lactulose is to promote excretion of ammonia in stool. the nurse should instruct the client to take he medication every day and inform the client that 2-3 bowel movements everyday is the treatment goal.

a nurse is providing discharge teaching for a client who has a new prescription for medications to treat peptic ulcer disease. The nurse should identify that which of the gollowing medications inhibits gastric acid secretion? A. Calcium carbonate B. Famotidine C. Aluminum hydroxide D. Sucralfate

B. Famotidine The nurse should inform the client that famotidine is an H2-receptor antagonist that is prescribed for the treatment of peptic ulcer disease to inhibit the secretion of gastric acid.

A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? A. Blood glucose 110 mg/dL B. Increased serum amylase C. WBC 9,000/mm3 D. Decreased bilirubin

B. Increased serum amylase Serum amylase levels are increased in a client who has acute pancreatitis due to pancreatic cell injury.

A nurse is reviewing the prescriptions for a client who has Campylobacter enteritis. Which of the following prescriptions should the nurse clarify with the provider? A. 0.45% sodium chloride IV B. Magnesium hydroxide C. Ciprofloxacin D. Potassium

B. Magnesium hydroxide Nausea, vomiting, and diarrhea are manifestations of enteritis. The nurse should clarify a prescription for magnesium hydroxide, also known as milk of magnesia, with the provider. This medication increases gastrointestinal motility, which can increase the client's risk for an electrolyte imbalance and contribute to dehydration.

A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires a revision of his IV therapy prescription?

BUN

a nurse is caring for a client who has DKA. which of the following laboratory findings should the nurse expect?

BUN 32 mg/dl DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine.

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?

BUN 34 mg/dL

Food selection for discharge teaching for chronic cholecystitis:

Bananas *Low fat food options are recommended

A nurse is teaching a client who has diabetes mellitus. Which of the following should the nurse include as an expected finding of diabetic ketoacidosis (DKA)?

Blood glucose levels above 300 mg/dL Blood glucose levels above 300 mg/dL are an expected finding with DKA. Levels above 600 mg/dL are an expected finding with hyperglycemic-hyperosmolar state.

Cirrhosis assessment, priority finding to report to the provider:

Bloody stools

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?

Bradycardia

A nurse is assessing an older adult client who has heart failure and takes digoxin. Which of the following findings should the nurse recognize as an indication of digoxin toxicity?

Bradycardia

A nurse is obtaining the health history of a client who has an abdominal aortic aneurysm. Which of the following findings should the nurse expect?

Bruit heard over the middle upper abdomen

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?

Bubbling in the water-seal chamber has ceased.

A nurse is providing discharge teaching for an older adult client who has mild diverticulitis. Which of the following statements by the client indicates an understanding of the teaching? A. "I may experience right lower quadrant pain." B. "I will remain active by working in my garden every day." C. "I should eat foods that are low in fiber." D. "I will use a mild laxative every day."

C. "I should eat foods that are low in fiber." The nurse should instruct the client who has diverticulitis to follow a low-fiber diet. When the inflammation subsides, the client should consume foods that are high in fiber.

A nurse is providing dietary teaching for a client who has a new diagnosis of celiac disease. Which of the following statements by the client indicates an understanding of the teaching? A. "I can return to my regular diet when I am free of symptoms." B. "I will need to avoid taking vitamin supplements while on this diet." C. "I will eat beans to ensure I get enough fiber in my diet." D. "I need to avoid drinking liquids with my meals while on this diet."

C. "I will eat beans to ensure I get enough fiber in my diet." Clients who have celiac disease must maintain a gluten-free diet which eliminates fiber-rich whole wheat products. Clients should eat beans, nuts, fruits, and vegetables to ensure an adequate intake of fiber.

A nurse is assessing a client who has cirrhosis. Which of the following findings is a priority for the nurse to report to the provider? A. Spider angiomas B. Peripheral edema C. Bloody stools D. Jaundice

C. Bloody stools The greatest risk to the client who has cirrhosis of the liver is hemorrhagic shock due to bleeding in the esophageal varices. Therefore, bloody stools is the priority finding to report to the provider.

A nurse is providing discharge teaching for a client following an ileostomy. The nurse should instruct the client to report which of the following findings to the provider? A. Intolerance to high-fiber foods B. Liquid ileostomy output C. Dark purple stoma D. Sensation of burning during bowel elimination

C. Dark purple stoma The nurse should instruct the client to contact the provider if the stoma is a dark purple color, which is an indication of bowel ischemia.

A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching?

Consume at least 30 g of fiber daily

A nurse is teaching a client how to prepare for a colonoscopy. Which of the following instructions should the nurse include in the teaching? A. Begin drinking the oral liquid preparation for bowel cleansing on the morning of the procedure. B. Drink full liquids for breakfast the day of the procedure, and then take nothing by mouth for 2 hr prior to the procedure. C. Drink clear liquids for 24 hr prior to the procedure, and then take nothing by mouth for 6 hr before the procedure. D. Drink the oral liquid preparation for bowel cleansing slowly.

C. Drink clear liquids for 24 hr prior to the procedure, and then take nothing by mouth for 6 hr before the procedure. The nurse should instruct the client to drink clear liquids for 24 hr prior to the colonoscopy to promote adequate bowel cleansing. Maintaining NPO status for 4 to 6 hr prior to the colonoscopy preserves the bowel's cleansed state.

A nurse is assessing a client who has upper GI bleeding. Which of the following findings should the nurse expect? A. Bradycardia B. Bounding peripheral pulses C. Hypotension D. Increased hematocrit levels

C. Hypotension A client who has upper gastrointestinal bleeding is at risk for hemorrhagic shock. Hypotension is a manifestation of hemorrhagic shock.

A nurse is admitting a client who has acute pancreatitis. Which of the following actions should the nurse take first? A. Insert a nasogastric tube for the client. B. Administer ceftazidime to the client. C. Identify the client's current level of pain. D. Instruct the client to remain NPO.

C. Identify the client's current level of pain. The first action the nurse should take when using the nursing process is to assess the client. Clients who have acute pancreatitis often have severe abdominal pain. By assessing the client's level of pain, the nurse can identify the need for and implement interventions to alleviate the client's pain.

A nurse is providing discharge teaching for a client who has a new colostomy and is concerned about flatus and odor. Which of the following foods should the nurse recommend to the client? A. Eggs B. Fish. C. Yogurt D. Broccoli

C. Yogurt The nurse should recommend yogurt, cracker and toast, which can prevent flatus and odor.

A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range?

Calcium

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothryoxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?

Calcium

A nurse is assessing a client who has adrenal insufficiency. Which of the following findings should the nurse expect?

Calcium 12.8 mg/dL A client who has adrenal insufficiency has a calcium level above the expected reference range.

A nurse is caring for a client who is undergoing renal dialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in his hands. Which of the following medications should the nurse plan to administer?

Calcium carbonate

A home health nurse is providing teaching to a client who has a stage I pressure ulcer on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching?

Change position every hour

A community health nurse is planning an educational program about Hep A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing Hep A. Children and young adults Older adults Women who are pregnant Middle-aged men

Children and young adults Rationale: The usual mode of transmission for Hep A is oral-fecal route. Children and young adults are the two groups most often affected by the Hep A virus. They usually acquire it at school through poor hand hygiene, hand to mouth contact, or another from of close contact

A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? Vanilla pudding Apple juice Diet ginger ale Clear liquids

Clear liquids

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take?

Contact the primary care provider to clarify the prescription.

A nurse is assessing a client who has diabetes mellitus and reports feeling anxious. Which of the following findings should the nurse expect if the client is hypoglycemic?

Cool, clammy skin Hypoglycemia causes cool, clammy skin, in addition to anxiety, nervousness, tachycardia, and confusion.

A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. The nurse should report which of the following adverse effects of this medication to the provider?

Crackles heard on auscultation

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?

Current medications

A nurse is providing dietary teaching for a client who has chronic pancreatitis. Which of the following food selections by the client indicates an understanding of the teaching? A. 8 oz whole milk B. One slice of beef bologna C. 1 oz cheddar cheese D. 1 cup sliced banana

D. 1 cup sliced banana Foods that are high in fat can cause diarrhea for clients who have pancreatitis. One cup of sliced banana, which contains 0.49 g of fat, is a low-fat food option. Clients who have pancreatitis should consume a high-protein and low-fat diet with an adequate amount of carbohydrates and calories.

A nurse is reviewing the laboratory results of a client who has hepatic cirrhosis. Which of the following laboratory findings should the nurse report to the provider? A. Albumin 4.0 g/dL B. INR 1.0 C. Direct bilirubin 0.5 mg/dL D. Ammonia 180 mcg/dL

D. Ammonia 180 mcg/dL An ammonia level of 180 mcg/dL is above the expected reference range of 10 to 80 mcg/dL. The nurse should report an increased ammonia level because it can indicate portal-systemic encephalopathy.

A nurse us caring for a client who has GERD and a new prescription for metoclopramide. The nurse should plan to monitor for which of the following adverse effects? A. Thrombocytopenia B. Hearing loss C. Hypersalivation D. Ataxia

D. Ataxia The nurse should plan to monitor the client for extrapyramidal symptoms, such as ataxia, and should report any of these findings to the provider.

A nurse is assessing a client immediately following a paracentesis for the treatment of ascites. Which of the following findings indicates the procedure was effective? A. Presence of a fluid wave B. Increased heart rate C. Equal pre and postprocedure weights D. Decreased SOB

D. Decreased SOB Increased abdominal fluid can limit the expansion of the diaphragm and prevent the client from taking a deep breath. Once excess peritoneal fluid is removed, the diaphragm will expand more freely. The nurse should identify this finding as an indicator the procedure was effective.

A nurse is reviewing the laboratory values of a client who has colorectal cancer. Which of the following findings should the nurse expect? A. Negative fecal occult blood test B. Decreased serum carcinoembryonic antigen (CEA) level C. Hematocrit 43% D. Hemoglobin 9.1 g/dL

D. Hemoglobin 9.1g/dL A hemoglobin level of 9.1 g/dL is below the expected reference range. Decreased hemoglobin is an expected finding in a client who has colorectal cancer due to occult intestinal bleeding.

A nurse is assessing a client who has a duodenal ulcer. Which of the following findings should the nurse expect? A. The client states that the pain is in the upper epigastrium. B. The client is malnourished. C. The client states that ingesting food intensifies the pain. D. The client reports that pain occurs during the night.

D. The client reports that pain occurs during the night. Pain associated with a duodenal ulcer occurs when the stomach is empty, which is typically 1.5 to 3 hr after meals and during the night.

Assessing a client following a paracentesis, what indicates the procedure was effective?

Decreased shortness of breath *Increased abdominal fluid can limit the expansion of the diaphragm and prevent the client from taking deep breath

A nurse is reviewing the laboratory report of a client who is receiving nonsurgical treatment for Cushing's disease. Which of the following laboratory findings should the nurse identify as a positive outcome of the treatment?

Decreased sodium

A nurse is assisting with the client receiving TPN therapy and has just returned to the room following physical therapy.the nurse notes that the infusion pump for the clients TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? Hypertension Excessive thirst Fever Diaphoresis

Diaphoresis Rationale: nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger

A nurse is preparing a client who has supra ventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion?

Digoxin

a nurse is preparing a client who has supra ventricular tachycardia for elective cardioversion. which of the following prescribed medications should the nurse instruct the client to withhold for 48hr prior to cardioversion?

Digoxin Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion.

A nurse is administering meperidine IM in the right deltoid of a client. The nurse aspirates the pulse back blood in the syringe. Which of the following actions should the nurse take?

Dispose of the medication

A nurse is assessing a client's hydration status. Which of the following findings indicate fluid volume overload?

Distended neck veins

A nurse in an ICU is planning care for a client who is in cariogenic shock. The nurse should prepare to administer which of the following medications to increase cardiac output?

Dopamine

Which medication inhibits gastric acid secretions:

Famotidine *An H2 receptor antagonist that is prescribed for the treatment of peptic ulcer disease

A nurse is teaching a client who has diabetes mellitus about insulin injections. The client's prescription includes evening doses of insulin glargine and regular insulin. Which of the following instructions should the nurse include?

Draw up the insulins into separate syringes. The nurse should instruct the client to draw up the insulins into separate syringes because insulin glargine is not compatible with other insulins.

Teaching a client how to prepare for a colonoscopy:

Drink clear liquids for 24 hours prior to the procedure, and then take nothing by mouth 6 hours before the procedure

A nurse is assessing a client who has a comminuted fracture of the femur. Which of the following findings should the nurse identify as an early manifestation of a fat embolism.

Dyspnea

A nurse is caring for a client who has a pheochromocytoma. Which of the following actions should the nurse take?

Elevate the head of the client's bed. The nurse should elevate the head of the client's bed to reduce blood pressure and abdominal pressure.

A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory plus should the nurse expect?

Elevated bilirubin level

A nurse is reviewing the laboratory results of a client who had a recent exposure to hepatitis C virus. Which of the following tests should the nurse identify as indicating the presence of hepatitis C antibodies?

Enzyme immunoassay (EIA)

A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?

Extremity cool upon palpation

A nurse is providing education to a client who has tuberculosis (TB) and his family. Which of the following information should the nurse include in the teaching?

Family members in the household should undergo TB testing

A nurse is monitoring the laboratory values of a client who has diabetes mellitus and is taking insulin. Which of the following results indicates a therapeutic outcome of insulin therapy?

Fasting blood glucose 96 mg/dL This is within the expected reference range for a fasting blood glucose level and indicates that insulin therapy is effective.

Chron disease expected finding:

Fatty diarrheal stools (Steatorrhea)

A nurse is caring for a client who has a peripherally inserted central catheter (PICC). Which of the following actions should the nurse take to manage the PICC?

Flush the PICC line with 10 mL NS before and after medication administration.

A nurse is assessing a client following the administration of IV penicillin G. Which of the following findings should indicate to the nurse that the client is experiencing an anaphylactic reaction?

Flushing

A nurse is reinforcing teaching with a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend? Foods high in Vitamin C Foods low in fat Foods high in fiber Foods low in calories

Foods high in fiber

A nurse is assisting with the care of a client who has a history of cirrhosis and is admitted with manifestation of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility or recent excessive alcohol use? Gamma-glutamyl tranferase (GGT) Alkaline phosphatase (ALP) Serum bilirubin Alanine aminotransferase (ALT)

Gamma-glutamyl tranferase (GGT)

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?

Ginkgo biloba can cause an increased risk for bleeding

A nurse is assessing a client who is at risk for development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? A.) depicts oral candidiasis/thrush B.) depicts dry oral mucous membrane C.) depicts glossitis D.) depicts a healthy tongue dull in color

Glossitis

A nurse is providing dietary teaching to a client who has celiac disease. Which of the following food choices should the nurse identify as an indication that the client understands the teaching?

Grilled chicken breast

A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)?

Heart rate 52/min

A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide?

Hemodialysis is sometimes needed after surgery.

Expected laboratory value of colorectal cancer:

Hemoglobin 9.1 g/dL

a nurse is caring for a client who is postoperative following a total hip arthroplasty. which of the following laboratory values should the nurse report to the provider?

Hgb 8 g/dL The nurse should report an Hgb level of 8 g/dL, which is below the expected reference range and is an indicator of postoperative hemorrhage or anemia.

Postoperative gastroectomy, indication of acute gastric dilation?

Hiccups

A nurse is assessing a client who is postoperative following a gastrectomy. The nurse should identify which of the following findings as an indication of abdominal distention? A. Hiccups B. Hypertension C. Bradycardia D. Chest pain

Hiccups Following surgery, hiccups can be caused by irritation of the phrenic nerve due to abdominal distension. If the hiccups are intractable, the nurse should anticipate a prescription for chlorpromazine because persistent hiccups are distressful to the client and can lead to complications, such as vomiting.

A nurse is assessing a client who has a new diagnosis of Cushing's disease. Which of the following findings should the nurse expect?

Hirsutism Increased hair growth, or hirsutism, is an expected finding of Cushing's disease due to increased androgen production.

A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?

Hypoactive bowel sounds

A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client experiencing excessive stools. Which of the following findings is an adverse effect of this medication?

Hypokalemia

A nurse is caring for a client who is experiencing an acute myocardial infarction. The nurse should identify which of the following findings as a manifestation of cardiogenic shock?

Hypotension

A home health nurse is assessing a client who requires lifelong hormone replacement therapy for the treatment of hypothyroidism. The client has not been taking his medication regularly. Which of the following findings should the nurse expect?

Hypotension Hypotension is an expected finding with hypothyroidism, along with bradypnea, dysrhythmias, cold intolerance, and cool, dry skin.

Expected finding in upper gastrointestinal bleeding:

Hypotension *the result of blood loss

Discharge teaching for gastritis and famotidine:

I should make sure the water I drink is filtered

Discharge teaching for chronic hepatitis C, statement indicates an understanding of the teaching:

I will avoid medications containing acetaminphen *Can cause additional liver damage

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following statements by the client indicates an understanding of the teaching?

I will count my heart beats before taking this medication.

Effective GERD discharge teaching:

I will decrease the amount of carbonated beverages I drink

a nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. which of the following client statements indicates an understanding of the teaching?

I will monitor my blood pressure while taking this medication

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?

I will monitor my blood pressure while taking this medication.

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 use my hands rather than a washcloth to clean the radiation area

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 2.5

a nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. after ensuring a patent airways and administering oxygen, which of the following items should the nurse prepare to administer first?

IV fluids After establishing that the client's airway is secure and administering oxygen, evidence-based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support.

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

Ibuprofen can cause gastrointestinal bleeding in older adult clients.

A nurse's first actions upon admitting a client with Acute pancreatitis?

Identify the client's current level of pain (Then NPO status follows)

Dumping syndrome diet teaching:

Include eggs *Increase dietary intake of protein

A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?

Increased fluid intake

A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings?

Increased hematocrit An increased hematocrit is an expected finding resulting from dehydration.

Expected finding for acute pacreatitis:

Increased serum amylase *Due to pancreatic cell injury

A nurse is planning teaching for a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include?

Ingest alcohol with food to reduce alcohol-induced hypoglycemia. Alcohol inhibits the liver from producing glucose. Consuming carbohydrates while drinking alcoholic beverages helps prevent hypoglycemia.

A nurse admits a client who has anorexia, low-grade fever, night sweats, and productive cough. Which of the following actions should the nurse take first?

Initiate airborne precautions

A client who has emphysema 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?

Instruct the client to allow the machine to breathe for him.

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

Irrigate the indwelling urinary catheter

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

A nurse is monitoring a client's status 24 hours after a total thyroidectomy. Which of the following findings should the nurse report to the provider?

Laryngeal stridor Laryngeal stridor is a harsh, high-pitched sound with inspiration that indicates respiratory obstruction. The nurse should take immediate action to preserve the client's airway.

A client who has a diagnosis of Clostridium difficile is placed on contact precautions. Which of the following actions should the nurse take?

Leave a stethoscope in the room for blood pressure monitoring.

Hepatic encephalopathy diet precaution:

Limit animal protein intake *Due to increased production of ammonia

A nurse is assisting with the admission of a client who has fulminant hepatic failure. Which of the following procedures should the nurse expect for this client? Endoscopic sclerotherapy Liver Lobectomy Liver transplant Transjugular intrahepatic portal-systemic shunt placement

Liver transplant Rationale: Fulminant hepatic failure, most often caused by viral hepatitis, is caused by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Loosen restrictive clothing

A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?

Low back pain and apprehension

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Low urine specific gravity

Developing a care plan for cirrhosis and ascites, which intervention should be included:

Measure abdominal girth daily

a nurse is reviewing the prescriptions for a client who has Campylobacter enteritis. which of the following prescriptions should the nurse clarify with the provider?

Milk of magnesia the nurse should clarify a prescription for milk of magnesia with the provider. this medication increases gastrointestinal motility, which can increase the client's risk for an electrolyte imbalance.

What medication is contra-indicated for a client who has Campulobacter enteritis?

Milk of magnesia *Increases gastrointestinal motility, which can increase the risk for electrolyte imbalance

A nurse is planning care for a client who has community-acquired pneumonia. Which of the following interventions should the nurse include in the plan of care?

Monitor the client for confusion

A nurse is caring for a client who has diabetes mellitus and has developed peripheral neuropathy. Which of the following measures should the nurse recommend to prevent injuries to the client's feet?

Monitor the temperature of bath water with a thermometer. Peripheral neuropathy makes it difficult to determine if bath water is too hot. Therefore, to prevent injury, the client should use a bath thermometer to ensure a water temperature below 43.3° C (110° F).

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?

My joints ache because I have Lyme Disease

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?

Non-rebreather mask

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

Obtain vital signs

Appendicitis expected findings:

Oral temp (101.1F) Nausea and vomiting Right lower quadrant pain

A nurse is teaching a client who has an autoimmune disease about the adverse effects of long-term corticosteroid therapy. Which of the following effects should the nurse include? (select all that apply)

Osteoporosis is correct. Osteoporosis is an adverse effect of long-term corticosteroid therapy due to the suppression of bone formation and the acceleration of bone resorption that corticosteroid therapy can cause. Moon-shaped face is correct. Long-term corticosteroid therapy causes characteristics of iatrogenic Cushing's syndrome, including a moon-shaped face, a potbelly, and a buffalo hump. Increased risk of infection is correct. Increased risk of infection is an adverse effect of long-term corticosteroid therapy due to suppression of the immune system. It reduces the phagocytic actions of macrophages and neutrophils, thus increasing the risk of infection. Hearing loss is incorrect. Long-term corticosteroid therapy can cause cataracts and glaucoma, but it does not cause hearing loss. Weight loss is incorrect. Long-term corticosteroid therapy is more likely to cause weight gain due to the fluid and sodium retention these medications cause.

A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to audio clip.

Pericardial friction rub

A nurse is caring for client who has percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? Flush the tube with water place the client in semi-Fowler's position cleanse the skin around the tube site aspirate the tube prior to each feeding

Place client in semi-Fowler's position

A nurse is providing teaching to a client who is at risk for developing type 1 diabetes mellitus. The nurse should inform the client that which of the following manifestations indicate diabetes?

Polyuria Polydipsia Neuropathy

A nurse is caring for a client who is schedule to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor to the procedure? Prothrombin time Serum lipase Bilirubin Calcium

Prothrombin time

A nurse has administered propranolol by IV bolus to a client who is having a thyroid storm. Which of the following findings indicates that the client is having a therapeutic response?

Reduction of the effects of thyroid hormone on the heart Propranolol is a beta2-adrenergic blocking agent that decreases the rapid heart rate that excessive thyroid stimulation causes.

A nurse is assessing a client who had extracorporeal shock wave lithotripsy(ESWL) 6 hr ago. Which of the following findings should the nurse expect?

Stone fragments in the urine

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer?

Regular insulin 20 units IV bolus

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 minutes of the infusion.

A nurse is preparing a teaching plan for a client who has diabetes insipidus and requires intranasal desmopressin. Which of the following information should the nurse include in the teaching plan?

Report nocturia because it requires a dosage adjustment. The client should receive the initial dose of desmopressin in the evening; the provider will increase the dosage until the client no longer has nocturia.

A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?

Report of a night cough

A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effects should the nurse monitor?

Respiratory Paralysis

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? Right shoulder pain Urine output 20 mL/hr Temperature 38.4C (101.1F) Oxygen saturation 92%

Right shoulder pain

A nurse is checking a client who was admitted with a bowel obstruction. the client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowl perforation has occurred. Elevated blood pressure Bowel sounds increased in frequency and pitch Rigid abdomen Emesis of undigested food

Rigid abdomen

A nurse is caring for a client who has type 2 diabetes melliltus and has hyperglycemic-hyperosmolar state (HHS). Which of the following laboratory findings should the nurse expect?

Serum pH of 7.45 A client who has HHS produces enough insulin to prevent ketosis, but not enough to prevent hyperglycemia. Therefore, the serum pH is within the expected reference range. Glucose levels will be above 600 mg/dL.

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 screening?

Shellfish allergy

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?

Slow the infusion rate

A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider?

Sodium 110 mEq/L A client who has SIADH retains fluids, which causes dilutional hyponatremia.

A nurse is providing teaching to a client who has angina and a new prescription for sublingual nitroglycerin. Which of the following instructions should the nurse include?

Store the medication in its original container

A nurse is caring for a client who has cirrhosis of the liver with esophageal varices. Which of the following activities should the nurse instruct the client to avoid?

Straining to have bowel movements

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus and is planning a trip. Which of the following instructions should the nurse include in the teaching?

Take additional pairs of shoes

Colorectal cancer and chemotherapy; Why is carcinoembryonic antigen (CEA) level tested?

The CEA determines the efficacy of chemotherapy

A nurse is caring for a client who is dehydrated and is receiving a continuous tube feeding through a pump at 75 mL/hr. When the nurse check the client at 0800, which of the following findings requires intervention by the nurse? A full pitcher of water sitting on the clients bedside table within the clients reach The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding The client is lying on the right side with a visible dependent loop in the feeding tube The head of the bed is elevated at 20 degrees.

The head of the bed is elevated at 20 degrees

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 identifies if the pacemaker cells of my heart are working properly.

A nurse is receiving report on a client who is postoperative following an open repair of Zenker's Diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations?

Throat

A nurse is caring for a client following a thyroidectomy. The nurse should assess for which of the following findings as an indication of hypocalcemia?

Tingling and numbness of the hands and feet Hypocalcemia causes paresthesias, which usually starts in the hands and feet.

A nurse is caring for a client who si scheduled to undergo an EGD. The nurse should identify that the purpose of the procedure is which of the following? To visualize colon polyps TO detect an ulceration in the stomach To identify an obstruction in the biliary duct To determine the presence of free air in the abdomen

To detect ulceration in the stomach

A nurse is admitting a client who has hyperthyroidism. When assessing the client, the nurse should expect which of the following findings?

Tremors Findings of hyperthyroidism include tremors, diaphoresis, and insomnia.

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)?

Troponin 8 ng/mL

A nurse is assessing a client who is receiving morphine via a PCA pump. Which of the following findings indicates an adverse effect of the medication?

Urinary retention

A nurse is caring for a client who has a stage III pressure ulcer. Which of the following findings contributes to delayed wound healing?

Urine output 25 mL/hr

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?

Urine specific gravity is 1.045

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?

Urine specific gravity of 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 planning to irrigate and dress a clean, granulating wound for a client who has a pressure ulcer. Which of the following actions should the nurse take?

Use a 30 mL syringe

Measures to minimize risk for exacerbations for a client with ulcerative colitis:

Use progressive relaxation techniques Arrange activities to allow daily rest periods Restrict intake of carbonated beverages

A nurse is assisting with the admission of a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medication> Famotidine Esomeprazole Vasopressin Omeprazole

Vasopressin

A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric cerebrovascular accident(CVA). Which of the following neurologic deficits should the nurse expect to find when assessing the client?

Visual spatial deficits Left hemianopsia One-sided neglect

A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching?

Void before and after intercourse

A nurse is caring for a client who is taking propylthiouracil. The nurse should identify that the client has met the treatment goals when she reports an increase in which of the following manifestations?

Weight Propylthiouracil suppresses the production of thyroid hormones and, therefore, allows for weight gain. However, excessive weight gain could indicate that the dose of propylthiouracil is too high

A nurse is assessing a client who is taking carvedilol for heart failure. which of the following findings is the priority for the nurse to report to the provider?

Weight gain

A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray? Wheat toast Tapioca pudding Hard-boiled egg Mashed potatoes

Wheat toast Rationale: Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. What toast contains gluten and should be removed form the client's tray.

A nurse is providing discharge instructions to a client who has a partial thickness burn of the hand. Which of the following instructions should the nurse include?

Wrap fingers with individual dressings

Discharge teaching for a new colostomy, recommended foods to help with flatus and odor?

Yogurt

a nurse is teaching a class about client rights. which of the following instructions should the nurse include?

a client should sign an informed consent before receiving a placebo during a research trial. A nurse should ensure a client has provided informed consent before administering a placebo. The nurse should not administer a placebo to a client who thinks it is an active medication, because this action is a violation of client rights.

a nurse has received change-of-shift report for a group of clients. which of the following clients should the nurse assess first?

a client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet. When using the stable vs. unstable approach to client care, the nurse should assess this client first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual nitroglycerin tablet could be unstable. This client might be experiencing angina or could be having another MI.

a nurse is assessing a group of clients for indications of role changes. the nurse should identify that which of the following clients is at risk for experiencing a role change?

a client who has multiple sclerosis and is experiencing progressive difficulty ambulating. The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change as the client becomes less independent.

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 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 who has a family history of colorectal cancer. to help mitigate this risk, which of the following dietary alterations should the nurse recommend?

add cabbage to the diet. To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.

a nurse in an emergency department is reviewing the providers prescriptions for a client who sustained a rattlesnake bite to the lower leg. which of the following prescriptions should the nurse expect?

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

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). a new bag is not available when the current infusion is nearly completed. which of the following actions should the nurse take?

administer dextrose 10% in water until the new bag arrives. TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid a precipitous drop in the client's blood glucose level.

a nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. to help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid?

aged cheese Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches.

a nurse is reviewing the laboratory results of a client who has hepatic cirrhosis. which of the following laboratory findings should the nurse report to the provider?

ammonia 180 mcg/dl the nurse should report an increased serum ammonia level because it can indicate portal-systemic encephalopathy

a nurse is caring for a client 1 hr following a cardiac catheterization. the nurse notes the formation of a hematoma at the insertion side and a decreased pulse rate in the affected extremity. which of the following interventions is the nurse's priority?

apply firm pressure to the insertion site. The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding.

a nurse is caring for a client who has GERD and a new prescription for metoclopramide. the nurse should plan to monitor for which of the following adverse effects?

ataxia the nurse should plan to monitor the client for extrapyramdial symtoms, such as ataxia, and should report any positive findings to the provider.

a nurse is planning care for a client who has extensive burn injuries and is immunocompromised. which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection.

avoid placing plants or flowers in the client's room. Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room.

a nurse is providing discharge teaching for a client who has chronic cholecystitis. which of the following food selections by the client indicates the teaching was effective?

bananas this food selection by the client indicates the teaching was effective. low-fat options, such as bananas, are recommended due to the decreased risk for causing manifestations of cholecystitis

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?

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 is assessing a client who has cirrhosis. which of the following findings is the priority for the nurse to report to the provider?

bloody stools the greatest risk to the client is hemorrhaging. bloody stools are indication of bleeding in the gastrointestinal tract. this finding is the priority to the report to the provider.

a nurse is assessing a client who has peritonitis. which of the following findings should the nurse expect?

board-like abdomen a board-like, distended abdomen is an expected finding in this client

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 Cushings triad?

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 caring for a client who has pancreatitis. the nurse should expect which of the following laboratory results to be below the expected reference range?

calcium A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis.

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?

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 caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). the client reports muscle cramps and a tingling sensation in their hands. which of the following medications should the nurse plan to administer?

calcium carbonate Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to administer a calcium supplement, such as calcium carbonate, as a calcium replacement.

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?

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 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 with if the following findings?

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 providing discharge teaching for a client who has chronic hepatitis C. which of the following statements by the client indicates an understanding of the teaching?

i will avoid medications containing acetaminophen

a nurse is providing discharge teaching for a client following an ileostomy. the nurse should instruct the client to report which of the following findings to the provider?

dark purple stoma

A nurse is assessing a client immediately following a paracentesis for the treatment of ascites. which of the following findings indicates the procedure was effective?

decreased shortnesss of breath increased abdominal fluid can limit the expansion of the diaphragm and prevent the client from taking a deep breath. once excess peritoneal fluid is removed, the diaphragm will expand more freely. the nurse should identify this finding as an indicator of the effectiveness of the paracentesis.

a nurse is assessing a client who has had a suspected stroke. the nurse should place the priority on which of the following findings?

dysphagia Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding.

a nurse is providing teaching about dietary management to prevent dumping syndrome for a client who is postoperative following a gastrectomy. the nurse should encourage the client to include which of the following food in his diet?

eggs

a nurse is providing discharge teaching for a client who has GERD. which of the following client statements indicates the teaching was effective?

i will decrease the amount of carbonated beverages i drink

a nurse is reviewing the laboratory results of a client who has cirrhosis. which of the following laboratory values should the nurse expect?

elevated bilirubin level Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice.

a nurse in an acute care facility is caring for a client who is at risk for seizures. which of the following precautions should the nurse implement?

ensure that the client has a patent IV. The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.

a nurse is providing teaching for a client who has cirrhosis and a new prescription for lactulose. the nurse should include which of the following instructions in the teaching?

expect 2-3 soft stools per day.

a nurse is providing discharge teaching for a client who has a new prescription for medication to treat peptic ulcer disease. the nurse should identify that which of the following medications inhibits gastric acid secretion?

famotidine

a nurse in an emergency department is caring for a client who is experiencing a thyroid storm. which of the following manifestations should the nurse expect?

fever hypertension tachycardia

a nurse in an emergency department is caring for a client who reports visiting and diarrhea for the past 3 days. which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

heart rate 110/min A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate.

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?

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.

a nurse is reviewing the laboratory values of a client who has colorectal cancer. which of the following findings should the nurse expect?

hemoglobin 9.1 g/dl decreased hemoglobin is an expected finding in a client who has colorectal cancer because of occult intestinal bleeding.

a nurse is assessing a client who is postoperative following a gastrectomy. the nurse should identify which of the following findings as an indication of acute gastric dilation?

hiccups

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 requires further assessment?

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 has chronic glomerulonephritis with oliguria. which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis?

hyperkalemia The nurse should identify that a client who has chronic glomerulonephritis can experience hyperkalemia as a result of kidney failure. Kidney failure results in decreased excretion of potassium.

a nurse is caring for a client who has a potassium level of 3 mEq/L. which of the following assessment findings should the nurse expect?

hypoactive bowel sounds Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to decreased peristalsis.

a nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. the client is experiencing excessive stools. which of the following findings is an adverse effect of the medication?

hypokalemia Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration.

a nurse is assessing a client who has upper gastrointestinal blooding. which of the following findings should the nurse except?

hypotension

a nurse is providing discharge teaching for an older adult client who has mild diverticulitis. which of the following client statements indicates an understanding of the teaching?

i should eat foods that are lower in fiber

a nurse if providing discharge teaching for a client who has gastritis and a new prescription for famotidine. which of the following client statements indicates the teaching was effective?

i should make sure the water I drink is filtered

a nurse is providing teaching to a client who has irritable bowel syndrome (IBS). which of the following instructions should the nurse include in teaching?

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

a nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contract. which of the following information should the nurse provide?

increase fluid intake. Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test.

a nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. which of the following assessment findings in the nurse's priority?

increased respiratory secretions Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. These secretions place the client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the ALS and the pneumonia.

a nurse is reviewing the laboratory results of a client who has acute pancreatitis. which of the following findings should the nurse expect?

increased serum amylase serum amylase levels are increased in a client who has acute pancreatitis because of the pancreatic cell injury.

a nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. which of the following actions should the nurse take first?

initiate airborne precautions. This client is exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions.

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?

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 developing a plan of care for a client who has cirrhosis and ascites. which of the following interventions should the nurse include?

measure abdominal girth daily

a nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. which of the following interventions should the nurse include in the plan?

monitor the client's temperature every 4 hrs. The nurse should monitor the temperature of a client who has neutropenia every 4 hr because the client's reduced amount of leukocytes greatly increases the client's risk for infection.

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 interact with feverfew

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 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.

a nurse is planning care to decreased psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. which of the following interventions should the nurse include in the plan?

tell the client that it is possible to return to similar previous levels of activity. The nurse should help the client develop realistic goals and activities to have a productive life.

a nurse is caring for a client who has portal hypertension. the client is vomiting blood mixed with food after a meal. which of the following actions should the nurse take first?

obtain vital signs. The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making.

a nurse is assessing a client who has appendicitis. which of the following findings should the nurse except?

oral temp 101.1 F nausea and vomiting right lower quadrant pain

a nurse is caring for a client who has a prescription for enalapril. the nurse should identify which of the following findings as an adverse effect of the medication?

orthostatic hypotension The nurse should identify that dilation of arteries and veins causes orthostatic hypotension, which is an adverse effect of enalapril.

A nurse is reviewing laboratory values for a client who has diabetic ketoacidosis (DKA). Which of the following results should the nurse expect?

pH 7.32, PaCO2 36 mm Hg, HCO3- 14 mEq/L Metabolic acidosis is a common manifestation of DKA, with pH characteristically low, carbon dioxide within the expected reference range, and bicarbonate low.

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?

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 12 hr postoperative following a total hip arthroplasty. which of the following actions should the nurse take?

place a pillow between the client's legs. The nurse should place a pillow between the client's legs to prevent hip dislocation.

a nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. the client has dyspnea with a productive cough and is using accessory muscles to breathe. which of the following actions should the nurse take first?

place the client in high-fowler's position. The greatest risk to this client is injury from airway obstruction. Therefore, the priority intervention the nurse should take is to move the client into high-Fowler's position. High-Fowler's position facilitates lung expansion and improves ventilation and gas exchange.

a nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. identify the sequence the client should follow when demonstrating crutch use.

places body weight on the crutches. advances the unaffected leg onto the stair. shifts weight from the crutches to the unaffected leg. brings the crutches and effected leg up to the stair.

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. 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?

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 in a provider's office assessing a client who has hypertension and takes propranolol. which of the following findings should indicate to the nurse that a client is experiencing an adverse reaction to this medication?

report of a night cough The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider.

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?

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 teaching a young adult client how to perform testicular self-examination. which of the following instructions should the nurse include?

roll each testicle between the thumb and fingers. The nurse should instruct the client to roll each testicle horizontally between the thumbs and fingers to feel for any lumps deep in the center of the testicle.

a nurse is caring for a client who has a closed head injury and has an intravascular catheter placed. which of the following findings indicate that the client is experiencing increased intracranial pressure (ICP)?

sleepiness exhibited by the client widening pulse pressure decerebrate posturing

a nurse is assessing a client who had extracorporeal shock wake lithotripsy (ESWL) 6 hr ago. which of the following findings should the nurse expect?

stone fragments in the urine ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones.

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 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 providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. the nurse should instruct the client that the medication provides relief by which of the following actions.

suppressing gastric acid production Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production.

A nurse is assessing a client following IV urography. Which of the following findings is the priority?

swollen lips

a nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse's priority?

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 female client who has a history of urinary tract infections (UTIs). which of the following information should the nurse include in the teaching?

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 caring for a client who has colorectal cancer and is receiving chemotherapy. the client asks the nurse why blood is being drawn for a CEA level. which of the following responses by the nurse is appropriate?

the CEA determines the efficacy of your chemotherapy. the provider uses the CEA level to determine the efficacy of the chemotherapy. the client's CEA levels will decrease will decrease if the chemotherapy is effective

a nurse is caring for a client who has a duodenal ulcer. which of the following findings should the nurse expect?

the client states the pain occurs 1.5 to 3 hours after meals and during the night

a nurse is teaching a client how to prepare for a colonoscopy. which of the following instructions should the nurse including in the teaching?

the nurse should instruct the client to drink clear liquids for 24 hr prior to colonoscopy to promote adequate bowel cleansing. maintaining NPO status for 4 to 6 hr prior to colonoscopy preserves the bowel's cleansed state

a nurse is caring for a client who is having a seizure. which of the following interventions is the nurse's priority?

turn the client to the side. The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration.

a nurse is caring for a client who has a stage 3 pressure injury. which of the following findings contributes to delayed wound healing?

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

a nurse is planning to irrigate and dress a client, granulating wound for a client who has a pressure injury. which of the following actions should the nurse take?

use a 30-mL syringe. The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.

a nurse is caring for a client who has ulcerative colitis. the client has had several exacerbations over the past 3 years. which of the following instructions should the nurse include in the plan of care to minimize the risk of further exacerbations?

use progressive relaxation techniques. progressive relaxation techniques, a form of biofeedback, are recommended to help the client minimize stress, which can precipitate an exacerbation. arrange activities to allow for daily rest periods is correct. daily rest periods decrease stress and reduce intestinal motility. restrict intake of carbonate beverages. the client should avoid gastrointestinal stimulants, such as carbonated beverages, nuts, pepper, and smoking.

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 neurological deficits should the nurse expect to find when assessing the client?

visual spatial deficits left hemianopsia one-sided neglect

a nurse is providing teaching for a female client who has recurrent urinary tract infections. which fo the following information should the nurse include in the teaching?

void before and after intercourse. The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and prevents the occurrence of infection.

a nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. which of the following actions should the nurse include in the client's plan of care?

wear a lead apron while providing care to the client. The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure.

a nurse and an assistive personnel are caring for a client who has bacterial meningitis. the nurse should give the AP which of the following instructions?

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 assessing a client who has graves disease. which of the following images should indicate to the nurse that the client has exophthalmos?

wide eyes The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve.

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?

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.

a nurse is providing discharge teaching for a client who has a new colostomy and is concerned about flatus and order. which of the following foods should the nurse recommend?

yogurt

a nurse is caring for a client who has hepatic encephalopathy. the client asks the nurse if she can have a larger portion of beef for dinner. which of the following responses by the nurse is appropriate?

you should limit your animal protein intake. can i get you a veggie burger instead?