NSG 356 Exam 1
Which factors would the nurse include in discharge criteria for a Phase II patient? (select all that apply) A Nausea and vomiting controlled. B. Ability to drive themselves home. C. No respiratory depression present. D. Written discharge instructions understood. E. Opioid pain medication given 45 minutes ago.
A Nausea and vomiting controlled C. No respiratory depression present D. Written discharge instructions understood E. Opioid pain medication given 45 minutes ago
A nurse is teaching a group of clients at a senior center about the risk factors for osteoporosis. Which of the following statements should the nurse include in the teaching? A. "Extended periods of immobility increase your risk of osteoporosis." B. "Prolonged periods of sun exposure increase your risk of osteoporosis." C. "Eating a diet high in protein reduces your risk for osteoporosis." D. "Corticosteroid therapy will reduce your risk of osteoporosis."
A. "Extended periods of immobility increase your risk of osteoporosis."
A nurse is providing discharge teaching to a client with a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to take my immunosuppressant, even if I am in remission." B. "I am thankful this type of lupus only affects the skin." C. "Each day, I should apply sunblock with a sun protection factor of 15." D. "A mild fever is common with SLE and usually does not require medical intervention."
A. "I will need to take my immunosuppressant, even if I am in remission."
A nurse is teaching a client who has a cast on his left arm to treat a forearm fracture. Which of the following statements indicates the client understands the teaching? A. "I'll call the doctors office if my fingers get colder on the arm with the cast." B. "If I have any itching under the cast, I'll try to reach the area with a cotton swab." C. "If my fingers swell, I should put a heating pad on them and rest." D. "If I have any tingling under my cast, I'll know I need to move my fingers more."
A. "I'll call the doctors office if my fingers get colder on the arm with the cast."
A nurse is providing teaching to a client who has type 2 diabetes mellitus about the pathophysiology of the disease. Which of the following statements by the client indicates an understanding of teaching? A. "My cells are resistant to the effects of insulin." B. "My body breaks down sugar too efficiently." C. "My pancreas does not produce insulin." D. "My body produces antibodies against pancreatic beta cells."
A. "My cells are resistant to the effects of insulin."
A nurse is providing discharge teaching to a client who has osteoarthritis. Which of the following instructions should the nurse include? A. "Rest frequently after periods of activity." B. "Perform your exercise only on days that you feel good." C. "Perform your exercises after applying cold packs to your joints." D. "Place a large pillow under your knees when lying down."
A. "Rest frequently after periods of activity."
A nurse is caring for a client who had a below-the-knee amputation for gangrene of the right foot. The client reports sensations of burning and crushing pain in the toes of the absent right foot. Which of the following statements should the nurse make? A. "This type of pain usually decreases over time as the limb becomes less sensitive." B. "Try to look at the surgical wound as a reminder that the limb is gone." C. "Use a cold compress intermittently to decrease these pain sensations." D. "Grief over the lost limb can sometimes cause denial that the limb is really gone."
A. "This type of pain usually decreases over time as the limb becomes less sensitive."
A nurse is caring for a client with a hip fracture who has Buck's traction in place. Which of the following pieces of information should the nurse give the client about this type of traction? (select all that apply) A. "You'll have considerably less pain with the traction in place." B. "You'll have the traction in place for about a week or so." C. "The traction will help decrease muscle spasms." D. "The weights act as a pulling force to keep your leg and hip still." E. "We have to make sure the weights are just barely touching the floor."
A. "You'll have considerably less pain with the traction in place." C. "The traction will help decrease muscle spasms." D. "The weights act as a pulling force to keep your leg and hip still."
A nurse in an acute care clinic is talking with a client who reports that the osteoarthritis pain in her knees is increasing each day. The client wants to discuss non-pharmacological approaches to help relieve her pain. Which of the following interventions should the nurse suggest? A. Applying warm compresses to sore joints B. Decreasing the daily intake of dietary protein C. Keeping joints in extension during rest periods D. Limiting sleep to 6 to 7 hr per night
A. Applying warm compresses to sore joints
A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? (Select all that apply) A. Assess and document the client's vital signs B. Restart the IV with a 22-gauge needle C. Verify with another nurse the blood type and Rh of the packed RBCs D. Hang a bag of Lactated Ringer's IV solution E. Change the IV tubing to a set that has a filter
A. Assess and document the client's vital signs C. Verify with another nurse the blood type and Rh of the packed RBCs E. Change the IV tubing to a set that has a filter
A nurse is talking with an older client who has an elevated risk for osteoporosis about strategies for preventing bone loss. Which of the following instructions should the nurse provide? A. Begin a program of brisk walking B. Take 800mg of calcium per day C. Drink plenty of sparkling water D. Drink 8 oz of red win each day
A. Begin a program of brisk walking
A nurse is assessing a client who is 24 hrs postoperative following an above-the-elbow amputation. Which of the following findings should the nurse identify as the priority? A. Client report of muscle spasms B. Inability to get dressed without assistance C. Client report of feelings of anger D. Refusal to look at the affected limb
A. Client report of muscle spasms
A nurse is planning care for a client who has acute systemic lupus erythematosus (SLE) and is scheduled to begin treatment for systemic manifestations. Which of the following types of medications should the nurse plan to administer? A. Corticosteroids B. Antimalarials C. Antidepressants D. Opioids
A. Corticosteroids
Which action is the nurse's primary responsibility for the care of the patient undergoing surgery? A. Developing a patient-centered plan of nursing care B. Carrying out tasks related to surgical policies and procedure C. Ensuring that the patient has been assessed for safe administration of anesthesia D. Performing a preoperative history and physical assessment to identify patient needs
A. Developing a patient-centered plan of nursing care
A nurse is planning care for a client who has type 2 diabetes mellitus. Which of the following should the nurse include in the plan? A. Encourage the client to control weight B. Inspect the client's feet once each week C. Restrict the client's activity D. Apply moisturizer between the client's toes
A. Encourage the client to control weight
A nurse is caring for a client who has an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take? A. Ensure bowel rest B. Offer sparkling water frequently C. Administer a stool softener D. Offer plain warm tea frequently
A. Ensure bowel rest
A nurse is teaching a female client with a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching if she identifies which of the following as an exacerbation factor? A. Exercise B. Pregnancy C. Infection D. Sunlight
A. Exercise
A nurse is caring for a client who has osteoporosis and a new prescription for calcium supplements. Which of the following foods should the nurse recommend to promote calcium absorption? A. Fortified milk B. Ripe bananas C. Steamed broccoli D. Green leafy vegetables
A. Fortified milk
A 59-year-old man scheduled for a herniorrhaphy in 2 days reports that he takes an anticoagulant agent daily. Which action would the nurse take? A. Inform the surgeon since the procedure may have to be rescheduled. B. Tell the patient to continue to take the drug up to the day before surgery. C. Ask the patient if he has any side effects from taking this drug supplement. D. Notify the anesthesia care provider since this drug may interfere with anesthetics.
A. Inform the surgeon since the procedure may have to be rescheduled.
Which factors in positioning a patient for surgery increase the risk of patient injury? (select all that apply) A. Loss of pain perception B. Incorrect musculoskeletal alignment C. Vasoconstriction of the peripheral vessels D. Hypovolemia contributing to decreased perfusion E. Inability to sense pressure over bony prominences
A. Loss of pain perception B. Incorrect musculoskeletal alignment D. Hypovolemia contributing to decreased perfusion E. Inability to sense pressure over bony prominences
A nurse is caring for a client who is wearing a halo fixator. Which of the following interventions should the nurse implement? (Select all that apply) A. Monitor the client's vital signs every 4 hr B. Monitor the client's pin sites for loosening C. Hold the halo device when turning the client D. Check the client's skin to ensure the jacket is not applying pressure E. Adjust the screws holding the client's halo device in place to ensure a proper fit
A. Monitor the client's vital signs every 4 hr B. Monitor the client's pin sites for loosening D. Check the client's skin to ensure the jacket is not applying pressure
After admitting a postoperative patient to the clinical unit, which assessment data require attention first? A. O2 saturation of 85% B. Respiratory rate of 13/min C. Temperature of 100.4°F (38°C) D. Blood pressure of 90/60 mm Hg
A. O2 saturation of 85%
A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. Which interventions would the nurse prioritize? (Select all that apply.) A. Obtain a bladder ultrasound scan. B. Perform a straight catheterization. C. Continue to monitor this normal finding. D. Evaluate the patient's fluid volume status.
A. Obtain a bladder ultrasound scan
A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include n the client's plan or care? A. Offering the client a diet high in fluid and fiber B. Encouraging active range-of-motion in the affected leg C. Removing the weights prior to repositioning the client D. Inspecting pin sites every 24 hours for drainage
A. Offering the client a diet high in fluid and fiber
A nurse is reviewing a client's repeat laboratory results 4 hrs after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? A. Prothrombin time B. WBC count C. Platelet count D. Hematocrit
A. Prothrombin time
A nurse is determining a client's risk for osteoporosis. The nurse should identify which of the following as risk factors for bone loss? (Select all that apply) A. Small body frame B. Hypertension C. African-Amercian ethnicity D. Low vitamin D intake E. Smoking
A. Small body frame D. Low vitamin D intake E. Smoking
A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of a pulmonary embolism? A. Sudden onset of dyspnea B. Tracheal Deviation C. Bradycardia D. Difficulty swallowing
A. Sudden onset of dyspnea
A nurse is assessing a client who is 48 hrs postoperative following open reduction and internal fixation of a fractured tibia. Which of the following findings should the nurse report to the provider? A. Toes that are cold to the touch B. Serous drainage from the pin sites C. Blanching of the toenail beds with pressure D. Pink tissue around the fixator insertion sites
A. Toes that are cold to the touch
The nurse is caring for a patient undergoing surgery for a knee replacement. Which factors are critical to the patient's safety during the procedure? (select all that apply) A. Universal protocol is followed. B. The ACP is an anesthesiologist. C. The patient has adequate health insurance. D. The patient's family is in the surgery waiting area. E. The patients allergies are conveyed to the surgical team
A. Universal protocol is followed. E. The patients allergies are conveyed to the surgical team
A nurse is caring for a client who had a fiberglass cast placed on her left arm several hours ago and now reports itching under the cast. Which of the following actions should the nurse plan to take? A. Use a hair dryer on a cool setting to blow air into the cast B. Ask the provider to bivalve the cast C. Provide the client with a sterile cotton swab to rub the affected skin D. Wrap the extremity with a dry heating pad
A. Use a hair dryer on a cool setting to blow air into the cast
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? A. Wheat toast B. Tapioca pudding C. Hard-boiled egg D. Mashed potatoes
A. Wheat toast
A 17-year-old patient with a leg fracture who is scheduled for surgery is an emancipated minor. She has a statement from the court for verification. Which action would the nurse take? A. Witness the patient signing the permit after the surgeon obtains consent. B. Call a parent or legal guardian to sign the permit since the patient is under 18. C. Notify the hospital attorney that an emancipated minor is consenting for surgery. D. Obtain verbal consent since written consent is not necessary for emancipated minors.
A. Witness the patient signing the permit after the surgeon obtains consent.
A nurse is providing discharge teaching to a client who had a left total hip arthroplasty. Which of the following client statements indicates the teaching was effective? A. "I should expect swelling of the affected leg for several weeks." B. "I should not cross my legs at the ankles or knees." C. " I will inspect my hip incision every other day for redness." D. "I can bend over at the hip to pick up objects."
B. "I should not cross my legs at the ankles or knees."
A nurse is caring for a client with ulcerative colitis. The provider prescribes rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, which of the following responses should the nurse provide? A. "You need to conserve your energy at this time." B. "Lying quietly in bed helps slow down the activity in your intestines." C. "Staying in bed promotes the rest and comfort you need." D. "Staying in bed will help prevent injury and minimize your fall risk."
B. "Lying quietly in bed helps slow down the activity in your intestines."
A nurse is providing teaching about exercise to a client who has type 1 diabetes mellitus. Which of the following statements should the nurse include? A. "You should exercise during a peak insulin time." B. "Wear a medical alert identification tag when you exercise." C. "Exercise can decrease the effects of insulin and cause your blood glucose levels to increase." D. "You will get the most benefit from exercise when your blood glucose levels are higher than normal."
B. "Wear a medical alert identification tag when you exercise."
A nurse is caring for a client who has a platelet count of 50,000/mm^3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take? A. Apply warm compresses B. Apply pressure to the catheter removal site for 5 minutes C. Place the affected arm in a dependent position D. Clean the insertion site with alcohol
B. Apply pressure to the catheter removal site for 5 minutes
The patient reports that she has noticed a skin reaction when wearing disposable gloves. Which action would the nurse take? A. Notify the surgeon so that the surgery can be canceled. B. Ask further questions to assess for a possible latex allergy. C. Notify the OR staff at once so they can use latex-free supplies. D. No action is needed because the patient's reaction has no bearing on surgery.
B. Ask further questions to assess for a possible latex allergy.
A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? A. Obtain sample menus from the dietician to give to the client B. Ask the client to identify the types of foods she prefers C. Identify the recommended range of the client's blood glucose level D. Discuss long-term complications that can result from non-adherence to the dietary plan
B. Ask the client to identify the types of foods she prefers
A nurse has several tasks to complete while preparing a client scheduled for surgery. Which of the following tasks can the nurse delegate to an assistive personnel (AP)? A. Verify the client's list of allergies in the medical record B. Assist with placing the client onto the stretcher for transport to the surgical suite C. Complete the preoperative checklist for the client D. Call to inform the provider about the client's preoperative elevated glucose level
B. Assist with placing the client onto the stretcher for transport to the surgical suite
A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? (Select all that apply) A. Inter a 23-gauge angiocatheter with an IV adapter B. Check to determine the packed RBCs are less than 1 week old C. Administer the packed RBCs over a 6-hour period D. Ask another nurse to check the packed RBCs label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride
B. Check to determine the packed RBCs are less than 1 week old D. Ask another nurse to check the packed RBCs label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride
A nurse is preparing an in-service presentation about the basics of bone injuries. Which of the following types of fractures when a client's bone breaks into multiple pieces? A. Avulsion B. Comminuted C. Compression D. Spiral
B. Comminuted
A nurse is teaching a client who has diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include? (Select all that apply) A. Bradycardia B. Diaphoresis C. Deep, rapid respirations D. Palpitations E. Shakiness
B. Diaphoresis D. Palpitations E. Shakiness
A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4 hr ago. Which of the following actions should the nurse take? A. Inspect the client's skin underneath the boot every 12 hr B. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr C. Remove the weights from the traction while repositioning the client in bed D. Loosen the ropes if the client reports muscle spasms in the affected extremity
B. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr
A nurse is caring for a client who is 2 days postoperative. Which of the following findings indicates the client is developing an infection? A. Temperature 37.8 degrees C (100 degrees F) B. Erythema at the incision site C. WBC count 9,000/mm^3 D. Pain reported as 6 on a scale of 0 to 10
B. Erythema at the incision site
A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures of his tibia, ulna, and several ribs. The client is now disoriented to time and place and has a SaO2 of 87%. The nurse notes generalize petechiae on the client's skin. Which of the following complications should the nurse suspect? A. Hypovolemic shock B. Fat embolism syndrome C. Thrombophlebitis D. Avascular bone necrosis
B. Fat embolism syndrome
A patient who takes metformin 500 mg every morning for control of type 2 diabetes asks if she should take her medication the day of surgery. Which recommendation would the nurse make? A. Skip her medication the day of surgery. B. Get instructions from the surgeon about medication adjustments. C. Take her usual morning dose at bedtime the night before surgery. D. Take her medication as usual with a sip of water in the morning.
B. Get instructions from the surgeon about medication adjustments.
A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate the client's affected joints will require which of the following treatments? A. An assistive device when the client is ambulating B. Heat paraffin therapy applied to the client's joints C. Gentle massage of the client's hands D. Active range-of-motion exercises on the client's affected joints
B. Heat paraffin therapy applied to the client's joints
A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever, chills, fatigue, and pallor over the past week. When checking the client's laboratory results, which of the following values should the nurse identify as contributing to the client's fatigue and pallor? A. Magnesium 2.0 mEq/L B. Hgb 6.5 g/dL C. WBC 9.6/mm3 D. Creatinine 0.8 mg/dL
B. Hgb 6.5 g/dL
A nurse is caring for a client who has type 2 diabetes mellitus and is displaying manifestations of hyperglycemia. Which of the following findings indicates the client has hyperglycemia? A. Hunger B. Increased urination C. Cold, clammy skin D. Tremors
B. Increased urination
A nurse is planning a community health screening for a group of clients who are at risk for type 2 diabetes mellitus. Which of the following groups should the nurse include in her screening? A. Men who smoke B. Men and women who are obese C. Women who have hepatitis D. Men and women who consume high-protein and low-carbohydrate foods
B. Men and women who are obese
A nurse is caring for a client immediately following the application of a plaster cast. The nurse should monitor for and report which of the following findings as an indication of compartment syndrome? A. Sensation of heat on the surface of the cast B. Paresthesia of the extremity C. Pruritus of the extremity D. Musty odor noted from cast materials
B. Paresthesia of the extremity
Which activities might the nurse perform in the role of a scrub nurse during surgery? (select all that apply) A. Checking electrical equipment B. Preparing the instrument table C. Assisting with draping the patient D. Passing instruments to the surgeon and assistants E. Documenting activities occurring in the operating room
B. Preparing the instrument table C. Assisting with draping the patient D. Passing instruments to the surgeon and assistants
A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is O-negative. Which of the following actions should the nurse take first? A. Continue to monitor for manifestations of a transfusion reaction B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution C. Continue the transfusion and repeat the type and crossmatch D. Prepare to administer a dose of diphenhydramine IV
B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution
A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following laboratory values can indicate arthritis? A. Reticulocyte count B. Rheumatoid factor C. Direct Coombs' test D. Platelet count
B. Rheumatoid factor
A nurse is providing dietary teaching to a client who has ulcerative colitis. Which of the following food selections by the client indicates an understanding of the teaching? A. Raw vegetable salad with low-fat dressing B. Roast chicken and white rice C. Fresh fruit salad and milk D. Peanut butter on whole wheat bread
B. Roast chicken and white rice
A nurse is administering a unit of packed red blood cells (RBCs) to a client who is postoperative. The client reports itching and hives 30 min after the infusion begins. Which of the following actions should the nurse take first? A. Maintain IV access with 0.9% sodium chloride B. Stop the infusion of blood C. Send the blood container and tubing to the blood bank D. Obtain a urine sample
B. Stop the infusion of blood
A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about skin lesions on her face and neck. The client asks the nurse, "What should I do about these spots?" Which of the following responses should the nurse give? A. "Keep the lesions covered with a light sterile dressing when going outdoors." B. "Rub lesions with a washcloth to dry after washing." C. "Apply moisturizer after bathing the lesions with warm water." D. "Apply antibiotic cream on the lesions twice per day until scabs form on the lesions."
C. "Apply moisturizer after bathing the lesions with warm water."
A nurse is teaching a client who has type 2 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching? A. "I will apply moisturizer between my toes." B. "I will soak my feet daily." C. "I will be sure to wear cotton socks ever day." D. "I'll use a heating pad to warm my feet."
C. "I will be sure to wear cotton socks ever day."
A nurse is providing teaching to a client who has type 2 diabetes mellitus. The client states, "I eat pasta everyday. I can't imagine giving it up." Which of the following responses should the nurse provide? A. "Lets discuss this with your doctor; giving up daily pasta may not be necessary." B. "Is there another favorite dish you can substitute?" C. "You don't have to give up pasta; just adjust the amount you eat." D. "You can use no-added-salt tomato products on your pasta."
C. "You don't have to give up pasta; just adjust the amount you eat."
A nurse is preparing a client who is postoperative following total hip arthroplasty for discharge. Which of the following statements indicates that the client understands the instructions? A. "I'll use alcohol pads to clean my incision daily." B. "When I'm doing my exercises, I will include bent-leg raises." C. 'I'll use a reacher to help me pick up anything I drop on the floor." D. "When I can walk without my walker, I can stop attending physical therapy."
C. 'I'll use a reacher to help me pick up anything I drop on the floor."
A nurse is caring for a client who is 2 days postoperative following gastric surgery and has an NG tube inserted. Which of the following findings should the nurse report to the provider? A. Dryness of the mucous membranes B. Hypoactive bowel sounds in all quadrants C. 200 mL of bright red drainage from the NG tube D. Suction set at a continuous low suction
C. 200 mL of bright red drainage from the NG tube
Which actions would the nurse prioritize when admitting a patient to the PACU? A. Assess the surgical site, noting presence and character of drainage. B. Assess the amount of urine output and the presence of bladder distention. C. Assess for airway patency and quality of respirations and obtain vital signs. D. Review results of intraoperative laboratory values and medications received.
C. Assess for airway patency and quality of respirations and obtain vital signs
A nurse is performing medication reconciliation for a newly admitted client who has rheumatoid arthritis (RA). Which of the following medications should the nurse identify as the treatment for this condition? A. Misoprostol B. Dantrolene C. Celecoxib D. Colchicine
C. Celecoxib
A nurse in the emergency department is caring for a client who reports pain in her left leg following a motor-vehicle crash. The client's left leg has bruising, swelling, and displacement of the bones. Which of the following actions should the nurse take first? A. Obtain an x-ray of the injured leg B. Apply ice packs to the affected area C. Check neuromuscular status distal to the injury D. Elevate the affected leg on 2 pillows
C. Check neuromuscular status distal to the injury
A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? A. Ecchymosis of the thigh B. Serous drainage at the pin site C. Chest petechiae D. Muscle spasms in the left leg
C. Chest petechiae
A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpitation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus
C. Crepitus
Why is IV induction for general anesthesia the method of choice for most patients? A The patient is not intubated. B. The agents are nonexplosive. C. Induction is rapid and controlled. D. Emergence is longer but with fewer complications.
C. Induction is rapid and controlled
A nurse is teaching a client with systemic lupus erythematosus who has a new prescription for prednisone. The nurse should instruct the client to monitor for which of the following adverse effects of this medication? A. Hypoglycemia B. Tendinitis C. Infection D. Weight loss
C. Infection
A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU? A. Prepoperative B. Postoperative C. Intraoperative D. Admission
C. Intraoperative
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse expect? A. Urine negative for ketones B. Distended neck veins C. Kussmaul resporations D. Elevated blood pressure
C. Kussmaul resporations
Which preoperative considerations would the nurse plan for the care of an older adult? (Select all that apply.) A. Using only large-print educational materials. B. Speaking louder for patients with hearing aids. C. Recognizing that sensory deficits may be present. D. Providing warm blankets to prevent hypothermia. E. Teaching important information early in the morning.
C. Recognizing that sensory deficits may be present. D. Providing warm blankets to prevent hypothermia.
A nurse is caring for a client who is scheduled to undergo surgery to repair an open hip fracture. In which of the following positions should the nurse plan to place the client postoperatively? A. With the leg on the affected side adducted B. With the hip externally rotated on the affected side C. With the leg on the affected side abducted D. With the hip flexed 90 degrees on the affected side
C. With the leg on the affected side abducted
A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first? A. Hang an IV infusion of 0.9% sodium chloride with the blood B. Compare the client's identification number with the number of the blood C. Witness the informed consent document D. Obtain pre transfusion vital signs
C. Witness the informed consent document
In a severely anemic patient, the nurse would expect to find A. cyanosis and hypertension. B. pulmonary edema and fibrosis. C. dyspnea and increased heart rate. D. dysrhythmias and expiratory wheezing.
C. dyspnea and increased heart rate
A nurse is planning discharge teaching for a client with systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include? A. "Avoid the use of NSAIDs." B. "Stop taking the corticosteroids when your symptoms resolve." C. "Exposure to ultraviolet light will help control the skin rashes." D. "Monitor your body temperature and report any elevations promptly."
D. "Monitor your body temperature and report any elevations promptly."
A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly licensed nurse. Which of the following pieces of information should the nurse include about osteoarthritis? A. "Osteoarthritis is caused by autoimmune processes." B. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate." C. "Osteoarthritis affects other organ systems." D. "Osteoarthritis can impair a joint on a single side of the body."
D. "Osteoarthritis can impair a joint on a single side of the body."
A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following pieces of information would the nurse include in the teaching? A. "Wear nylon socks with shoes." B. "Wear flip flops instead of going barefoot when outside." C. "Apply moisturizing cream in between your toes." D. "Wash your feet daily using lukewarm water and soap."
D. "Wash your feet daily using lukewarm water and soap."
A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should the nurse include? A. "You will need to apply a cold pack to the site 3 times per day." B. "Your provider might ask you to walk frequently to increase circulation to the area." C. "You will need to limit your consumption of high-protein foods." D. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."
D. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."
A nurse in the emergency department is getting ready to discharge a client following a Grade II (moderate) ankle sprain. Which of the following instructions should the nurse plan to give to the client? A. Perform passive range of motion exercises to the ankle hourly B. Keep the affected extremity in a dependent position C. Wrap a loose dressing around the affected ankle D. Apply cold compresses to the extremity intermittently
D. Apply cold compresses to the extremity intermittently
A nurse is caring for a client who has a fractured right hip. Which of the following types of traction should the nurse expect the client to have prior to hip arthroplasty surgery? A. Balanced skeletal traction B. Pelvic belt C. Pelvic sling D. Buck's traction
D. Buck's traction
A nurse is reviewing the laboratory data of a client who reports manifestations suggesting systemic lupus erythomatosus (SLE). The nurse should expect an increase in which of the following parameters for a client who has SLE? A. Platelet count B. RBC count C. Hct D. Erythrocyte sedimentation rate (ESR)
D. Erythrocyte sedimentation rate (ESR)
Which intervention would the nurse prioritize to aid a preoperative patient in coping with the fear of postoperative pain? A. Inform the patient that pain medication will be available. B. Teach the patient to use guided imagery to help manage pain. C. Describe the type of pain expected after the patient's surgery. D. Explain the pain management plan and the use of a pain rating scale.
D. Explain the pain management plan and the use of a pain rating scale.
A nurse is reviewing the laboratory results of a client who has diabetes mellitus. Which of the following results indicates that the client's diabetes is controlled? A. HbA1c 8.5% B. Postprandial blood glucose 190 mg/dL C. Casual blood glucose 205 mg/dL D. Fasting blood glucose 95 mg/dL
D. Fasting blood glucose 95 mg/dL
A nurse is preparing an in-service presentation about the basics of bone injuries. Which of the following types of fractures is especially common in children? A. Impacted B. Depressed C. Compound D. Greenstick
D. Greenstick
A nurse is reviewing the medical record of a female client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? A. Decreased intake of phosphate-containing food B. Spending several hours in the sun daily C. Increased estrogen levels D. History of anorexia nervosa
D. History of anorexia nervosa
A nurse is teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse include? A. Smoking cessation B. Benefits of a diet high in cruciferous vegetables C. New types of ostomy appliances D. Importance of colonoscopy screening starting at age 50 years old
D. Importance of colonoscopy screening starting at age 50 years old
A nurse is assessing a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction? A. Bradycardia B. Paresthesia C. Hypertension D. Low back pain
D. Low back pain
A nurse is assessing a client who has several risk factors for osteoporosis. Which of the following finding indicates that the client requires further evaluation for this disorder? A. Leg cramps with exercise B. Stress incontinence C. Abdominal distension D. Lower back pain
D. Lower back pain
A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. Which action would the nurse take? A. Tell the patient to come back tomorrow since he ate a meal. B. Have the patient void before giving any preoperative medication. C. Proceed with the preoperative checklist, including site identification. D. Notify the anesthesia care provider of when and what the patient last ate.
D. Notify the anesthesia care provider of when and what the patient last ate.
A nurse is teaching a client who has osteoporosis. Which of the following instructions should the nurse include in the teaching? A. Reduce dietary protein intake B Apply ice to painful areas C. Increase calcium intake to 900 mg/day D. Perform weight-bearing exercises
D. Perform weight-bearing exercises
A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse, "I think I am going to throw up." Which is the priority intervention? A. Increase the rate of the IV fluids. B. Give antiemetic medication as ordered. C. Obtain vital signs, including O2 saturation. D. Position patient in lateral recovery position.
D. Position patient in lateral recovery position
A nurse is caring for a client who is postoperative following a laparotomy. the client has an indwelling urinary catheter and a Jackson-Pratt drain in place. Which of the following findings indicates that the client is developing a postoperative infection? A. Pain scale score of 5 out of 10 B. Urine output of 65 mL/hr C. 20 mL of bright red drainage from the drain D. Pulse oximetry of 85%
D. Pulse oximetry of 85%
A patient with obesity (BMI 42.1 kg/m2) is scheduled for a laparoscopic cholecystectomy in an outpatient surgery setting. Which information would the nurse include in the plan of care? A. The patient will be in the hospital for several days. B. Surgery will involve removing a part of the liver. C. The setting is not appropriate for the planned procedure. D. Special equipment may be needed for the patient's care.
D. Special equipment may be needed for the patient's care.
Which items would the nurse wear for proper attire in the semirestricted area of the surgery department? A. Street clothing B. Surgical attire and head cover C. Street clothing and shoe covers D. Surgical attire, head cover, shoe covers
D. Surgical attire, head cover, shoe covers
A nurse is conducting discharge teaching for a client who has diabetes mellitus. Which of the following instructions should the nurse include? A. Wear nylon socks with shoes everyday B. Trim toenails by rounding the edges of the nail C. Apply lotion between the toes after bathing D. Test water temperature with the wrist
D. Test water temperature with the wrist
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? A. The client fully understands the provider's explanation of the procedure B. The client has been informed about the risks and benefits of the procedure C. The nurse witnessed the provider's explanation of the procedure D. The signature on the preoperative consent form is the client's
D. The signature on the preoperative consent form is the client's
A nurse is caring for a client following hip arthroplasty. The nurse places an abduction pillow on the client for which of the following purposes? A. To raise the bed linens off the client's feet to prevent plantar flexion B. To keep the client's heels off the bed to prevent pressure ulcers C. To position the client off the operative site while in bed D. To prevent dislocation of the hips during position changes or movement
D. To prevent dislocation of the hips during position changes or movement
A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following interventions should the nurse use to prevent these manifestations in the client's next transfusion? A. Warm the unit of blood to room temperature before administering it B. Administer acetaminophen prior to the blood transfusion C. Give an antihistamine prior to the transfusion D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate
D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate
A nurse is caring for a client who has pernicious anemia. Which of the following factors should the nurse identify with this condition? A. Iron deficiency B. Hemolytic blood loss C. Folic Acid deficiency D. Vitamin B12 deficiency
D. Vitamin B12 deficiency
A nurse is providing teaching to the guardian of a child who has celiac disease. Which of the following food's should the nurse instruct the guardian to omit from the child's diet? A. Corn tortillas B. Reduced-fat milk C. Canned fruits D. Wheat bread
D. Wheat bread
