N3130 Final
A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate?
"Do not expose the radiation area to direct sunlight."
The nurse interviews an older client with moderate osteoarthritis and her husband. What psychosocial assessment question would the nurse include?
"Do you experience discomfort during sex?"
A nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, "Is my anemia related to my kidney problem?" How would the nurse respond?
"Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow."
A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions would the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.)
"Have you been under a lot of stress lately?", "Have you recently had any other health problems?", "Have you changed any medications recently?"
A nurse assesses a female client who presents with hirsutism. Which question would the nurse ask when assessing this client?
"How do you feel about yourself?"
A nurse is caring for a client who is recovering from an above-the-knee amputation and reports pain in the limb that was removed. How would the nurse respond?
"How would you describe the pain that you are feeling?"
A nurse has educated a client on an epinephrine autoinjector. What statement by the client indicates additional instruction is needed?
"I don't need to go to the hospital after using it."
A nurse is teaching a client who has itchy, raised red patches covered with a silvery white scale how to care for this disorder. What statement by the client shows a need for further information?
"I have to make sure I keep my lesions covered, so I do not spread this to others."
The nurse is teaching assistant personnel (AP) about care of an older ambulatory adult who has osteopenia. Which statement by the AP indicates understanding of the teaching?
"I will remind the client to take frequent walks to strengthen bones."
The nurse is teaching a client diagnosed with stomatitis about special mouth care. Which statement by the client indicates a need for further teaching?
"I will use a more firm toothbrush to keep my mouth clean."
The nurse is teaching a client who had a left humeral biopsy about home care. Which statement by the client indicates understanding of the nurse's teaching?
"I will watch for tenderness and warmth around the biopsy site."
The nurse is teaching a client who is prescribed acetaminophen for control of osteoarthritic joint pain. What statement by the client indicates a need for further teaching?
"I won't take more than 5000 mg of this drug each day."
A client is prescribed celecoxib for joint pain. What statement by the client indicates a need for further teaching?
"I'll be sure to take this drug three times a day only on an empty stomach."
A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching?
"I'm so glad I don't have to give up my juicy steaks."
A nurse has presented an educational program to a community group on Lyme disease. What statement by a participant indicates the need to review the material?
"If Lyme disease is not treated successfully, it is usually fatal."
A nurse is teaching a client and family about self-care at home for the client's wound infected with methicillin-resistant Staphylococcus aureus. What statement by the client indicates a need to review the information?
"If the dressing is dry, I can sit or sleep anywhere in the house."
A nurse manager is preparing an educational session for floor nurses on drug-resistant organisms. Which statement below indicates the need to review this information?
"If you leave work wearing your scrubs, go directly home and wash them right away."
A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate?
"It is normal to be fatigued even for months afterward."
A client is scheduled to have a glycosylated hemoglobin (A1C) drawn and asks the nurse why she has to have it. How would the nurse respond?
"It measures your average blood glucose level for the past 3 months."
An assistive personnel asks why brushing client s' teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best?
"It mechanically removes biofilm on teeth."
A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?
"It's a good thing I love orange and cherry gelatin."
A client has multiple lesions all over the body and a family history of skin cancer. The nurse teaches the client to perform a total skin self-examinations on a monthly basis. Which statements will the nurse include in this patient's teaching? (Select all that apply.)
"Look for asymmetry of shape and irregular borders.", "Assess for color variation within each lesion.", "Report any lesions that change over time in any way."
A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer risk. What response by the nurse is best?
"Maybe; preservatives, dyes, and preparation methods may be risk factors."
A client has a left knee arthrocentesis to remove excess joint fluid. What postprocedure health teaching will the nurse include?
"Monitor the site for bleeding or clear fluid leakage when you are home."
A nurse assesses an older client who has two skin lesions on the chest. Each lesion is the size of a nickel, flat, and darker in color than the rest of the client's skin. What does the nurse tell the client regarding these lesions?
"Monitor these spots for any changes."
A nurse collaborates with assistive personnel (AP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement would the nurse include when teaching the AP about this activity?
"Note the time of the client's first void and collect urine for 24 hours."
A client contacts the clinic to report a life-long mole has developed a crust with occasional bleeding. What instruction by the nurse is most appropriate?
"Please make an appointment to be seen here as soon as possible."
What information does the nurse teach a women's group about osteoporosis?
"Primary osteoporosis occurs in postmenopausal women due to lack of estrogen."
The nurse is teaching an older adult how to prevent buildup of ear wax. Which statement by the nurse is most appropriate?
"Put one drop of mineral oil in each ear once a week at bedtime."
The nurse is teaching new assistive personnel (AP) about caring for older adults. Which statement would the nurse include about hearing ability of this client group?
"Remember to face the client when talking with him or her."
A client had a retinal detachment and has undergone surgical correction. What discharge health teaching is most important for the nurse to include?
"Report immediate loss of vision of pain in the affected eye."
A nurse cares for a client placed in skeletal traction. The client asks, "What is the primary purpose of this type of traction?" How would the nurse respond?
"Skeletal traction will assist in realigning your fractured bone."
A nurse teaches a client about prosthesis care after amputation. Which statements would the nurse include in the health teaching? (Select all that apply.)
"The device has been custom made specifically for you.", "Make sure that you wear the correct liners with your prosthetic.", "I have scheduled a follow-up appointment for you."
The primary health care provider prescribes methotrexate (MTX) for a client with a new diagnosis of rheumatoid arthritis. The nurse provides health teaching about the drug. What statement by the nurse is appropriate to include about methotrexate?
"The drug can increase your risk for infection, so you should avoid crowds."
A client with HIV-III asks the nurse why gabapentin is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best?
"This drug helps treat the pain from nerve irritation."
A nurse teaches an older woman who has a decreased production of estrogen. Which statement would the nurse include in this client's teaching to decrease injury?
"Walk around the neighborhood for daily exercise."
A nurse assesses a client who has inflamed soft-tissue folds around the nail plates. Which question will the nurse ask to elicit useful information about the possible condition?
"What do you do for a living?"
A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question will the nurse ask first?
"What medications are you taking?"
A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, "The cast is loose enough to slide off." How would the nurse respond?
"You need a new cast now that the swelling is decreased."
The nurse is teaching a client about cataract surgery. Which statement would the nurse include as part of preoperative preparation?
"You will need to put several types of eyedrops in your eyes before and after surgery."
A client had a bunionectomy with osteotomy. The client asks why healing may take up to 3 months. What explanation by the nurse is best?
"Your feet have less blood flow, so healing is slower."
The nurse is teaching assistive personnel about postoperative care for an older adult who had a posterolateral total hip arthroplasty. What teaching will the nurse include? (Select all that apply.)
(all but "please let me know if you see red/open areas during bathing") "Move the client slowly to prevent dizziness and a possible fall.", "Encourage the client to deep breathe and cough at least every 2 hours.", "Help the client use the incentive spirometer at least every 2 hours.", "Keep the abduction pillow in place at all times while the client is in bed.", "Let me know if the client has an elevated temperature or pulse.", "Keep in mind that the client may be a little confused after surgery."
The nurse is teaching a client about risk factors for esophageal cancer. Which risk factors would the nurse include? (Select all that apply.)
(all but NSAIDs) Alcohol intake, Obesity, Smoking, Lack of fresh fruits and vegetables, Untreated GERD
A female client is preparing to have open magnetic resonance imaging (MRI) of the spine. What action(s) by the nurse is (are) most important to assess before the test? (Select all that apply.)
(all but claustrophobia) Ask if the client has a history of kidney disease., Ask the client if she could possibly be pregnant., Ensure that the patient has no metal or electronic implants., Assess the client for the ability to communicate.
A nurse knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.)
(all but electrician) Coal miner, Metal worker, Plumber, Textile worker
A client has mucositis. What actions by the nurse will improve the client's nutrition? (Select all that apply.)
(all but hot liquids) Assist with rinsing the mouth with saline frequently., Encourage the client to eat room-temperature foods., Provide local anesthetic medications to swish and spit., Remind the client to brush teeth gently after each meal., Offer the client fluids to drink each hour.
The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.)
(all but increased peristalsis) Decreased hydrochloric acid production, Diminished sensation that can lead to constipation, Fat not digested as well in older adults, Pancreatic vessels become calcified
Which are steps in the process of making an antigen-specific antibody? (Select all that apply.)
(all but opsonization) Antibody-antigen binding, Invasion, Recognition, Sensitization, Production
The nurse is teaching a client with mild rheumatoid arthritis (RA) about how to protect synovial joints. Which health teaching will the nurse include? (Select all that apply.)
(all but use small joints instead of larger ones) "Use both hands instead of one with holding objects.", "When getting out of bed or a chair, use the palms of your hands.", "Bend your knees instead of your waist and keep your back straight.", "Do not use multiple pillows under your head to prevent neck flexion.", "Use a device or rubber grip to open jars or bottle tops.", "Use long-handled devices such as a hairbrush with an extended handle."
The nurse is teaching a family member who is caring for a client who is hearing impaired. What health teaching would the nurse include about communicating with the client? (Select all that apply.)
(all) "Make sure that the room is well lighted.", "Speak slowly and clearly.", "Do not shout but you may need to speak loudly.", "Have conversations in a quiet room with minimal noise.", "Get the client's attention before you begin to speak.", "Move closer to the better hearing ear if possible."
The nurse is teaching a client about care after surgery to repair a retinal detachment. What health teaching would the nurse include? (Select all that apply.)
(all) "Report sudden pain in the surgical eye.", "Report if the surgical eye remains dilated.", "Avoid close vision activities in the first week.", "Avoid activities that increase intraocular pressure.", "Report sudden reduced visual acuity."
The nurse is teaching a client about the risk of uncontrolled or untreated gastroesophageal reflux disease (GERD). What complication(s) may occur if the GERD is not successfully managed? (Select all that apply.)
(all) Asthma, Laryngitis, Dental caries, Cardiac disease, Cancer
The nurse is caring for a client diagnosed with probable gastroesophageal reflux disease (GERD). What assessment finding(s) would the nurse expect? (Select all that apply.)
(all) Dyspepsia, Regurgitation, Belching, Coughing, Chest discomfort, Dysphagia
The nurse is assessing a client with long-term rheumatoid arthritis (RA) who has been taking prednisone for 10 years. For which complications of chronic drug therapy would the nurse assess? (Select all that apply.)
(all) Osteoporosis, Diabetes mellitus, Glaucoma, Hypertension, Hypokalemia, Decreased immunity
The nurse is teaching a client and family regarding symptoms to report to the primary health care provider after cataract surgery. Which symptoms would the nurse include in the teaching? (Select all that apply.)
(all) Sharp sudden pain in the surgical eye, Green or yellow discharge from the surgical eye, Eyelid swelling of the surgical eye, Decreased vision in the surgical eye, Blindness in the surgical eye, Flashes or floaters seen in the surgical eye
The nurse is performing a neurovascular assessment for an older client who has an extremity fracture. How many seconds would the nurse expect for a capillary refill in it is within normal range?
5 seconds
A nurse is teaching a community group about preventing hearing loss. What instruction is appropriate?
: "Always wear a bicycle helmet."
A nurse is caring for several clients with fractures. Which client would the nurse identify as being at the highest risk for developing deep vein thrombosis?
A 74-year-old male who smokes and has a fractured pelvis
A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.)
A sore that does not heal, Changes in menstrual patterns, Indigestion or trouble swallowing, Obvious change in a mole, Frequent indigestion
A nurse is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which drug does the nurse plan health teaching?
Acetaminophen
A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply.)
Adherence to the antibiotic regimen, Eating high-protein and high-carbohydrate foods, Proper use of the intravenous equipment
A client with HIV-III is hospitalized and has weeping Kaposi sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important for the nurse's safety?
Adhering to Standard Precautions
A primary health care provider notifies the nurse that a client has a "bandemia." What action does the nurse anticipate?
Administer antibiotics.
A nurse assesses an older adult who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless with an oxygen saturation of 88%. Which action would the nurse take first?
Administer oxygen via nasal cannula.
A client has a metastatic bone tumor in the left leg. What action by the nurse is appropriate?
Administer pain medication as prescribed.
A client has a foreign body in one eye. What action by the nurse is appropriate for the client's care?
Administering ordered antibiotics
A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.)
Admit the client to a negative-airflow room., Obtain specialized respirators for caregiving.
The nurse assesses a client for factors that place the client at risk for cataracts. Which factor places the client at the highest risk for cataract development?
Advanced age
The nurse is teaching assistive personnel (AP) about the risk for osteoporosis associated with race or ethnicity. Which population typically has a decreased incidence of osteoporosis when compared to Euro-Americans?
African Americans
The nurse learns that which risk factors can affect immunity? (Select all that apply.)
Age, Environmental factors, Drugs, Nutritional status
A client is admitted with a large oral tumor. What assessment by the nurse takes priority?
Airway
A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.)
Alcohol, Caffeine, Carbonated beverages, Vitamin D
The nurse is teaching assistive personnel (AP) about hormones that are produced by the adrenal glands. Which hormone has the primary responsibility of maintaining fluid volume and electrolyte composition?
Aldosterone
The nurse is presenting information to a community group on safer sex practices. The nurse would teach that which sexual practice is the riskiest?
Anal intercourse
For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.)
Antibody-mediated immunity, Cell-mediated immunity, Inflammation
The nurse is caring for a client with sialadenitis. What comfort measures are appropriate for this client? (Select all that apply.)
Applying warm compresses, Offering fluids every hour
A client with osteoporosis is going home where the client lives alone. What action by the nurse is best?
Arrange a home safety evaluation.
An older client is distressed at body changes related to kyphosis. What response by the nurse is appropriate?
Ask the client to explain more about these feelings.
A client with HIV-III is hospitalized with P. jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values would be most important for the nurse report to the primary health care provider? (Select all that apply.)
Aspartate transaminase, alanine transaminase: elevated, Platelet count: 80,000/mm3 (80 × 109/L), Serum sodium: 120 mEq/L (120 mmol/L)
A client is admitted to the emergency department with a fractured femur resulting from a motor vehicle crash. What the nurse's priority action?
Assess airway, breathing, and circulation.
A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below:
Assess blood pressure and pulse.
An older adult in the family practice clinic reports a decrease in hearing in one ear for over a week. What action by the nurse is most appropriate?
Assess for cerumen buildup.
A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the client's psychosocial needs?
Assess the client's coping skills and support systems.
A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is appropriate?
Assess the client's gag reflex.
A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important?
Assess the client's gait and balance.
A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The client states, "My pain has suddenly increased from a 3 to a 10 on a scale of 0-10." Which action would the nurse take first?
Assess the client's pulse rate and blood pressure.
A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV). The test is negative and the client states "Whew! I was really worried about that result." What action by the nurse is most important?
Assess the client's sexual activity and patterns.
A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with a 1+ pedal pulse. What action would the nurse perform first?
Assess the neurovascular status of the right leg.
A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which action would the nurse take first?
Assess the right leg for pulses, skin color, and temperature.
A client with HIV-III has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most important with this condition?
Assessing mucous membranes
A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
Assessing the IV site and blood return every hour
A clinic nurse is working with an older client. What action is most important for preventing infections in this client?
Assessing vaccination records for booster shot needs
A client with HIV-III is in the hospital with severe diarrhea. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.)
Assisting the client to get out of bed to prevent falls, Obtaining a bedside commode if the client is weak, Providing gentle perianal cleansing after stools, Reporting any perianal abnormalities
A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem?
Assisting the client to pre-plan for this event
A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections?
Auditing staff members' hand hygiene practices
The nurse is taking a history from an older client who reports having frequent falls. Which dietary habit could be contributing to the client's problem?
Avoids dairy products.
A nurse assesses clients on a medical-surgical unit, all of whom have stage 2 or 3 pressure injuries. Which client would the nurse evaluate further for a wound infection?
Boggy feel to granulation tissue
A nurse learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ?
Bone marrow
A client had a myringotomy. What would the nurse include as part of discharge teaching?
Buy dry shampoo to use for a week.
Which findings are AIDS-defining characteristics? (Select all that apply.)
CD4+ cell count less than 200/mm3 (0.2 × 109/L) or less than 14%, Infection with P. jiroveci, Presence of HIV wasting syndrome, Confusion, dementia, or memory loss
A nurse caring for clients with systemic lupus erythematosus (SLE) plans care understanding the most common causes of death for these clients is which of the following? (Select all that apply.)
Cardiovascular impairment, Chronic kidney disease
A client with an infection has a fever. What actions by the nurse help increase the client's comfort? (Select all that apply.)
Change the client's gown and linens when damp., Offer cool fluids to the client frequently., Sponging the client with tepid water.
A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse teaches the client and family about the signs of potential complications which include what problems? (Select all that apply.)
Cholangitis, Pancreatitis, Perforation, Sepsis
A nurse assesses clients in an osteoporosis clinic. Which client would the nurse assess first?
Client taking raloxifene who reports unilateral calf swelling.
A nurse is seeing clients in the ophthalmology clinic. Which client would the nurse see first?
Client who has had cataract surgery and has worsening vision
A nurse participates in a community screening event for oral cancer. What client is the highest priority for referral to a primary health care provider?
Client who smokes and drinks daily.
The nurse is aware of the most recent American Cancer Society Screening Guidelines for colon cancer, which include which accepted testing modalities for people over the age of 50? (Select all that apply.)
Colonoscopy every 10 years, Computed tomography (CT) colonography every 5 years, Flexible sigmoidoscopy every 5 years
What statements about the complement system are correct? (Select all that apply.)
Comprised of 20 types of inactive plasma proteins., Act as enzymes when activated to enhance innate immunity., Sticks to the antigen and forms a membrane attack complex., Is part of the innate immune system.
A client with HIV-III is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate?
Conduct frequent neurologic assessments.
A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important?
Consult with the primary health care provider about obtaining stool cultures.
A nurse evaluates the following data in a client's chart: A 78-year-old male with a past medical history of atrial fibrillation is admitted with a chronic leg wound Warfarin sodium (Coumadin) & Sotalol (Betapace) Negative-pressure wound therapy (NPWT) to leg wound Based on this information, which action would the nurse take first?
Contact the primary health care provider to discuss the treatment
A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing would the nurse prepare the client?
Corneal staining
The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?
Correctly identifying the client prior to a blood transfusion
A nurse is providing education about HIV risks at a health fair. What groups would the nurse include as needing to be tested for HIV on an annual basis? (Select all that apply.)
Couples planning on getting married, Those who are sexually active with multiple partners, Injection drugs users, Sex workers and their customers
The nurse is reviewing the laboratory profile for a client who has muscular dystrophy. Which laboratory value(s) would the nurse expect to be elevated? (Select all that apply.)
Creatine kinase (CK), Lactic dehydrogenase (LDH), Aspartate aminotransferase (AST), Aldolase (ALD)
A nurse assesses a client recovering from a cystoscopy. Which assessment findings would alert the nurse to urgently contact the primary health care provider? (Select all that apply.)
Decrease in urine output, Blood clots present in the urine
The nurse teaches assistive personnel about age-related changes that affect the eyes and vision. Which changes would the nurse include? (Select all that apply.)
Decreased eye muscle tone, Development of arcus senilis, Decrease in general color perception, Increase in point of near vision
The nurse assesses an older client. What age-related physiologic changes would the nurse expect?
Dehydration
The nurse learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? (Select all that apply.)
Differentiated function, Nonmigratory, Specific morphology, Orderly and specific growth
During skin inspection, the nurse observes lesions with wavy borders that are widespread across the client's chest. Which descriptors will the nurse use to document these observations?
Diffuse and serpiginous
The nurse is assessing a client for signs and symptoms of systemic lupus erythematosus (SLE). Which of the following would be consistent with this disorder? (Select all that apply.)
Discoid rash on skin exposed to sunlight, Urinalysis positive for casts and protein, Pain on inspiration, Serum positive for antinuclear antibodies (ANA)
The nurse is educating a client with HIV-II and the partner on self-care measures to prevent infection when blood counts are low. What information does the nurse provide? (Select all that apply.)
Do not work in the garden or with houseplants., Do not empty the kitty litter boxes., Bathe daily using antimicrobial soap., Avoid people who are sick and large crowds., Make sure meat, fish, and eggs are cooked well.
The nurse learning about cellular regulation understands that which process occurs during the S phase of the cell cycle?
Doubling of DNA
The nurse notes that the primary health care provider documented the presence of mucosal erythroplasia in a client. What does the nurse understand that this most likely means for this client?
Early sign of oral cancer
The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.)
Edema, Redness, Warmth, Decreased function
A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/kg (1200 mmol/kg). Which action would the nurse take?
Encourage the client to drink more fluids.
A client is in the hospital and has received two doses of an angiotensin-converting enzyme for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below: What action by the nurse takes is most appropriate?
Ensure a patent airway while calling the Rapid Response Team.
A nurse plans care for an older adult patient. Which interventions should the nurse include in this client's plan of care to promote kidney health? (Select all that apply.)
Ensure adequate fluid intake., Leave the bathroom light on at night., Provide thorough perineal care after each voiding., Assess for urinary retention and urinary tract infection.
A client is having a catheter placed to deliver chemotherapy beads into a liver tumor via the femoral artery. What action by the nurse is most important?
Ensuring that informed consent is on the chart
A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care?
Everything between the entry and exit wounds can be damaged.
A nurse assesses clients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.)
Excessive thyroid-stimulating hormone—increased bone formation, Excessive melanocyte-stimulating hormone—darkening of the skin
A client is scheduled to have a tumor of the middle ear removed. Which perioperative health teaching is most important for the nurse to include?
Expecting hearing loss in the affected ear
The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.)
Exposure to carcinogens, Genetic predisposition, Immune function
The nurse is caring for an older client who has kyphosis and a widened gait. For which health problems is the client at risk?
Falls
A client asks the nurse about what medications may be included for nonopioid multimodal analgesia following a total knee arthroplasty. What medications may be given to the client? (Select all that apply.)
Gabapentin, Ketorolac, Ketamine, Bupivacaine
A client who has rheumatoid arthritis is prescribed etanercept. What health teaching by the nurse about this drug is appropriate?
Giving subcutaneous injections
A nurse is learning the difference between normal cells and benign tumor cells. What information does this include?
Growing in the wrong place or time is typical of benign tumors.
The nurse takes a history on a male client reporting chronic back pain. Which factor(s) in the client's history may have contributed to his pain? (Select all that apply.)
Had a motor vehicle crash 10 years ago., Played football in college and high school., Has installed carpet and other flooring for 30 years.
The nurse is teaching a client about postoperative care after a LASIK procedure. Which common complications/adverse effects could occur either immediately or later after this type of surgery? (Select all that apply.)
Halos around lights, Blurred vision, Infection, Dry eyes
A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding would indicate that the medication is effective?
Heart rate of 92 beats/min
A nurse plans care for a client who has a wound that is not healing. Which focused assessments will the nurse complete to develop the patient's plan of care? (Select all that apply.)
Height, Alcohol use, Prealbumin laboratory results, Weight
A client with cancer has anorexia and mucositis, and is losing weight. The client's family members continually bring favorite foods to the client and are distressed when the client won't eat them. What action by the nurse is best?
Help the family show other ways to demonstrate love and caring.
A nurse assesses a client and identifies that the client has pale conjunctivae. Which focused assessment will the nurse complete next?
Hemoglobin and hematocrit
A client is taking timolol eyedrops. The nurse assesses the client's pulse at 48 beats/min. What action by the nurse is the priority?
Hold the eyedrops and notify the primary health care provider.
A nurse cares for clients with hormone disorders. Which are common key features of hormones? (Select all that apply.)
Hormones may travel long distances to get to their target tissues., Continued hormone activity requires continued production and secretion., Control of hormone activity is caused by negative feedback mechanisms.
A nurse reviews the health history of a client with an oversecretion of renin. Which disorder would the nurse correlate with this assessment finding?
Hypertension
The nurse is learning about immunoglobulins. . Which principles does the nurse learn? (Select all that apply.)
IgA is found in high concentrations in secretions from mucous membranes., IgE is associated with antibody-mediated hypersensitivity reactions., IgG comprises the majority of the circulating antibody population., IgM is the first antibody formed by a newly sensitized B-cell.
The nurse is caring for a client who recently sustained a sports injury to his right leg. What nursing interventions are appropriate for this client? (Select all that apply.)
Immobilize the right leg., Use compression to support the leg., Obtain an x-ray to detect possible fracture., Elevate the right leg to decrease swelling.
A nurse cares for a client with a urine specific gravity of 1.040. What action would the nurse take?
Increase the client's fluid intake.
A nurse is caring for a patient who has excessive catecholamine release. Which assessment finding would the nurse correlate with this condition?
Increased pulse
The nurse reads on a chart that a client has lichenification. What assessment finding confirms this description?
Increased skin thickness
A nurse is working with a client who has a painful rash consisting of grouped weeping and crusting lesions in distinct lines. What actions by the nurse are most appropriate? (Select all that apply.)
Instruct the client to report lesions near the eyes., Show the client how to make a baking soda compress., Advise the client to avoid exposure to UV light rays.
A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.)
Instructing people on the use of chemoprevention, Providing vaccinations against certain cancers, Teaching teens the dangers of tanning booths, Educating adults about healthy eating habits
A nurse is caring for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication would the nurse most likely administer?
Intravenous calcitonin
A nurse prepares a client for a percutaneous kidney biopsy. What actions should the nurse take prior to this procedure?(Select all that apply.)
Keep the client NPO for 4 to 6 hours., Review coagulation study results., Administer client's antihypertensive medications.
A nurse reviews a client's laboratory results. Which results from the client's urinalysis would the nurse recognize as abnormal?
Ketone bodies present
The nurse is interviewing a client who reports having abdominal cramping, bloating, and diarrhea after drinking milk or ingesting other dairy products. What health problem does the client most likely have?
Lactose intolerance
When caring for an older client who has hypothyroidism, what assessment findings will the nurse expect? (Select all that apply.)
Lethargy, Low body temperature, Slowed speech, Weight gain
A nurse is assessing a client reporting right upper quadrant (RUQ) abdominal pain. What technique would the nurse use to assess this client's abdomen?
Lightly palpate the RUQ last.
The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?
Liver
The nurse caring for clients admitted for infectious diseases understands what information about emerging global diseases and bioterrorism?
Many infections are or could be spread by international travel.
The nurse is assessing a client's medication profile to determine risk for tinnitus. Which drug classification is most likely to cause this health problem?
NSAIDs
The nurse understands that which type of immunity is the longest acting?
Natural active
A nurse is assessing a client with glioblastoma. What assessment is most important?
Neurologic examination
A nurse is teaching the client with systemic lupus erythematosus about prednisone. What information is the priority?
Never stop prednisone abruptly.
A hospitalized client's strength of the upper extremities is rated at a 4. What does the nurse understand about this client's ability to perform activities of daily living (ADLs)?
No difficulties are expected with ADLs.
An older client's serum calcium level is 8.7 mg/dL (2.18 mmol/L). What possible etiology(ies) does the nurse consider for this result? (Select all that apply.)
Normal age-related decrease in serum calcium, Possible occurrence of osteoporosis or osteopenia
A client is being administered the first dose of belimumab for a systemic lupus erythematosus flare. What actions by the nurse are most appropriate? (Select all that apply.)
Observe the client for at least 2 hours afterward., Ensure emergency equipment is working and nearby.
A client is admitted with possible sepsis. Which action will the nurse perform first?
Obtain specified cultures.
The assistive personnel note that a client had a dark stool. What stool test would the nurse obtain for this client?
Occult blood test
A nurse is observing as an assistive personnel (AP) performs hygiene and provides comfort measures to a client with an infection. What action by the AP requires intervention by the nurse?
Ordering an oscillating fan for the client
Which of these client assessment findings is typically associated with oral cancer?
Painless red or raised lesion
A nurse reviews the urinalysis of a client and notes the presence of glucose. What action would the nurse take?
Perform a finger stick blood glucose assessment.
A nurse assesses an older adult client with the skin disorder shown below: How will the nurse document this finding?
Petechiae
A client with Ménière disease is in the hospital when the client has an episode of this disorder. What action by the nurse is appropriate?
Place the client in bed with the upper side rails up.
The nurse is caring for a client diagnosed with oral cancer. What is the nurse's priority for client care?
Place the client on Aspiration Precautions.
A client with known HIV-II is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action would the nurse take first?
Place the client under Airborne Precautions.
A nurse is caring for four clients. After the hand-off report, which client would the nurse see first?
Post-microvascular bone transfer client whose distal leg is cool and pale
A client has an open traditional hiatal hernia repair this morning. What is the nurse's priority for client care at this time?
Preventing respiratory complications
A nurse asks the staff development nurse what "apoptosis" means. What response best?
Programmed cell death
A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride. The client's respiratory rate is 8 breaths/min. What action by the nurse is appropriate?
Provide physical stimulation.
The nurse learns that the most important function of inflammation and immunity is which purpose?
Providing maximum protection against infection
The nurse assesses a client who is scheduled to have a laboratory test to determine if the client's adrenal glands are hypoactive. What type of testing would the client likely have?
Provocative testing
A nurse assesses a client who has open skin lesions. Which action by the nurse is most important?
Put on gloves.
A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge?
Raises the head of the bed no more than 45 degrees.
A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is appropriate?
Remind the client that a small amount of bleeding is possible.
A nurse is caring for a client with diabetes mellitus who has fractured her arm. Which action would the nurse take first?
Remove the medical alert bracelet from the fractured arm.
A nurse evaluates the following data in a client's chart: A 66-year-old male with a health history of a cerebral vascular accident and left-side paralysis White blood cell count: 8000/mm3 (8 × 109/L)Prealbumin: 15.2 mg/dL (152 mg/L)Albumin: 4.2 mg/dL (42 mg/L)Lymphocyte count: 2000/mm3 (2 × 109/L) Sacral ulcer: 4 × 2 × 1.5 cm Based on this information, which action would the nurse take?
Request a dietary consult.
A nurse is caring for a client admitted for Non-Hodgkin's lymphoma and chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nurse is most important?
Request an order for serum electrolytes and uric acid.
A nurse assesses a client who presents with early koilonychias. Which assessments will the nurse complete next? (Select all that apply.)
Review the client's health history for a diagnosis of iron deficiency anemia., Request a prescription to assess the client's hemoglobin A1C.
The nurse is caring for a young client who has been diagnosed with osteopenia. Which risk factor in the client's history most likely contributed to the bone loss?
Rheumatoid arthritis
A nurse plans care for a client who has an external fixator on the lower leg. Which intervention would the nurse include in the plan of care to decrease the client's risk for infection?
Scheduling for pin care to be provided every shift
The nurse caring for clients assesses their daily laboratory profiles. Which lab results are considered to be in the normal range? (Select all that apply.)
Segmented neutrophils: 68%, Lymphocytes: 38%, Eosinophils: 2%, Basophils: 1%
The nurse delegates completing a bladder scan to assistive personnel (AP). Which action by the AP indicates that the nurse must provide additional instructions when delegating this task?
Selecting the female icon for all female patients and male icon for all male patients
The nurse is performing an assessment of a client with possible plantar fasciitis in the right foot. What assessment finding would the nurse expect in the right foot?
Severe pain in the arch of the foot
A nurse assesses a client who has psoriasis. Which action would the nurse take first?
Shake the client's hand and introduce self.
A client has been placed on Contact Precautions. The client's family is very afraid to visit for fear of being "contaminated" by the client. What action by the nurse is best?
Show the family how to avoid spreading the disease.
The nurse learning about infection discovers that which factor is the best and most important barrier to infection?
Skin and mucous membranes
A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.)
Strengthening exercises are important., Take recommended calcium and vitamin D., Walk for 30 minutes at least three times a week.
The nurse is teaching a client about factors that can cause external otitis. Which of these factors would the nurse emphasize as the highest risk?
Swimming
A client's intraocular pressure (IOP) is 28 mm Hg. What action would the nurse anticipate?
Teach about drugs for glaucoma.
A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?
Teaching measures to prevent scalp injury
A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client's chart that the cancer classification is TISN0M0. What does the nurse conclude about this client's cancer?
There are no distant metastases noted in the report.
Which statement about carcinogenesis is accurate?
Tumor cells need to develop their own blood supply.
The nurse is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.)
Type I—examples include hay fever and anaphylaxis., Type III—immune complex deposits in blood vessel walls., Type IV—examples are poison ivy and transplant rejection.
Which statements are true regarding Standard Precautions? (Select all that apply.)
Use personal protective equipment as needed for client care., Wear gloves when touching clients' excretions or secretions.
While assessing a client, a nurse detects a bluish tinge to the client's palms, soles, and mucous membranes. Which action will the nurse take next?
Use pulse oximetry to assess the patient's oxygen saturation.
The nurse assesses a client with rheumatoid arthritis (RA) and Sjögren syndrome. What assessment would be most important for this client?
Visual acuity
The nurse is caring for a client who had an open traditional esophagectomy. Which assessment findings would the nurse report immediately to the primary health care provider? (Select all that apply.)
Wound dehiscence, Fever, Tachycardia
A nurse reviews a client's laboratory results. Which results from the client's urinalysis would the nurse identify as normal? (Select all that apply.)
pH: 6, Specific gravity: 1.015, Glucose: negative
A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?
"Antihistamines do not help poison ivy."
The nurse is caring for a client after ear surgery. What health teaching instruction(s) would the nurse provide for this client to promote healing? (Select all that apply.)
"Avoid straining when having a bowel movement.", "Avoid drinking through a straw for 2 to 3 weeks.", "Avoid air travel for 2 to 3 weeks after surgery.", "Avoid crowds and people with infection, especially respiratory infection.", "Avoid moving your head quickly, jumping, or bending over for 2 to 3 weeks.", "Blow your nose very gently without blocking either nostril and keep your mouth open."
The nursing is teaching a client diagnosed with gastroesophageal reflux disease (GERD) who is planning to have an endoscopic radiofrequency (Stretta) procedure. What preprocedure health teaching would the nurse include? (Select all that apply.)
"Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure.", "Contact the primary health care provider after the procedure if you have increased pain."
A client has been newly diagnosed with systemic lupus erythematosus and is reviewing self-care measures with the nurse. Which statement by the client indicates a need to review the material?
"Baby powder is good for the constant sweating."
A client has a hearing aid. What care instructions does the nurse provide the assistive personnel (AP) in the care of this client? (Select all that apply.)
"Be careful not to drop the hearing aid when handling.", "Turn the hearing aid off when the client goes to bed.", "Use a toothpick to clean debris from the device.", "Avoid using hair or cosmetic products near the hearing aid."
The nurse is teaching a client about the use of viscous lidocaine for oral pain. What health teaching would the nurse include?
"Be sure to check food temperatures before eating."
An older adult has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best?
"Changes in your liver cause drugs to be metabolized differently."
A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.)
"Chemo" gloves, Face mask, Impervious gown, Eye protection
