NUR 415 Hesi Module Exam (7+8)

A nurse provides instructions to a client about the use of an electric heating pad. The nurse determines that the client needs further instruction if the client makes which statement? "I shouldn't lie on the pad." "I'll avoid using the high setting." "I can pin the pad around the affected area." "I'll need to keep an eye on my skin for redness."

"I can pin the pad around the affected area."

A nurse instructs a client with hypothyroidism about the dosage, method of administration, and side effects of levothyroxine sodium. Which statement by the client indicates an understanding of the nurse's instructions? "I should take the medication in the evening." "I can expect diarrhea, insomnia, and excessive sweating." "If I feel nervous or have tremors, I should only take half the dose." "I need to report any episodes of palpitations, chest pain, or dyspnea."

"I need to report any episodes of palpitations, chest pain, or dyspnea." - One major concern when initiating thyroid hormone-replacement therapy is that the dose is too high, which can lead to cardiovascular problems.

A nurse provides instructions to a client who will be taking furosemide. Which statement by the client indicates to the nurse that the client needs additional instruction? "I need to sit or stand up slowly." "I need to maintain my fluid intake." "This medication will make me urinate." "I should expect to have ringing in my ears."

"I should expect to have ringing in my ears."

A nurse has taught the client with a herniated lumbar disk about proper body mechanics and other information about low back care. The nurse determines that the client needs further instruction if the client makes which statement? "I should bend at the knees to pick things up." "I need to increase the fiber and fluids in my diet." "I can strengthen my back muscles by swimming or walking." "I should get out of bed by sitting up straight and swinging my legs over the side of the bed."

"I should get out of bed by sitting up straight and swinging my legs over the side of the bed."

A client with schizophrenia who has been taking an antipsychotic medication calls the clinic nurse and says, "I need to cancel my appointment with the psychiatrist again, because I still have this awful sore throat. It's so bad that my mouth has a sore." How does the nurse respond to the client? "I wouldn't be upset. It happens when you aren't drinking enough water." "I think you need to come in for blood work today, because this may be an adverse effect of your medicine." "Do you remember when you started this medication? Your psychiatrist told you how important it is to keep your appointments with him." "You probably have a simple flu, but it might help if you gargle with some antiseptic mouthwash every 2 hours or so and drink plenty of water."

"I think you need to come in for blood work today, because this may be an adverse effect of your medicine."

A client is receiving furosemide, 40 mg orally every day. The nurse has provided instructions on dietary changes necessary with this medication. The nurse realizes the client requires further instruction if the client makes which statement? "I will need to increase my intake of sodium" "I will need to eat an orange or a banana daily" "I can continue to eat a spinach salad every day" "I will need to reduce my intake of milk and cheese"

"I will need to increase my intake of sodium" -Furosemide causes excretion of sodium and potassium. The client taking furosemide does not need to increase sodium intake, because the usual reason furosemide is prescribed is to treat sodium and fluid retention. The client will need to increase intake of potassium, which can be accomplished by eating potassium containing foods, such as oranges and bananas.

Warfarin sodium has been prescribed, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary? "I won't play football anymore." "I won't take any over-the-counter medications except aspirin." "I'll use an electric shaver until the doctor stops the Coumadin prescription." "I'll buy one of those medication alert tags that tells people I'm taking an anticoagulant."

"I won't take any over-the-counter medications except aspirin."

A client with heart failure being discharged home will be taking furosemide. Which statement by the client indicates to the nurse that the teaching has been effective? "I'll weigh myself every day." "I'll take my pulse every day." "I'll measure my urine output." "I'll check my ankles every day for swelling."

"I'll weigh myself every day." -A client taking furosemide must be able to monitor fluid status throughout therapy. Weighing oneself each day is the easiest and most accurate way to accomplish this

A client with a thoracic spinal cord injury is receiving dantrolene sodium. Which statement by the client indicates to the nurse that the client is experiencing an adverse effect of the medication? "I'm feeling really drowsy." "My legs are very relaxed." "I can't seem to get enough to eat." "I urinate about the same amount as I always did."

"I'm feeling really drowsy." -Drowsiness, diarrhea, and hepatotoxicity are the adverse effects of this muscle relaxant, which is used to treat the chronic spasticity seen with spinal cord injury.

A home care nurse makes a visit to a new mother who delivered a 7-lb (3.1 kg) girl 72 hours ago. The mother tells the nurse that her newborn seems to sleep almost all day. The nurse most appropriately responds by making which statement to the mother? "Most newborns sleep about 16 hours a day" "We should probably have the baby checked out by the doctor." "If you see any other neurological alterations, call the pediatrician." "It's important to wake the baby every hour to provide stimulation."

"Most newborns sleep about 16 hours a day"

A nurse is instructing a client in the first trimester of pregnancy about nutrition. Which statement by the client indicates the need for further instruction? "I need to eat foods high in calcium." "How I eat can affect my baby's growth." "I need to take vitamins throughout my pregnancy." "My risk for malnourishment is much higher while I'm pregnant."

"My risk for malnourishment is much higher while I'm pregnant."

A young female client with schizophrenia says to the nurse, "Since I started on olanzapine last year, I'm doing well in school and all, but I've gained so much weight, and it's really bothering me. What can I do about this?" Which response by the nurse would be therapeutic? "Well, I think you're overreacting. Today people think they should be skinny-minnies, even though it's not healthy." "Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?" "That medication isn't any more likely to cause weight gain than the others you're taking. Perhaps we could go over your diet and exercise habits." "I want you to stop taking this medication immediately, and I'm calling the doctor, because this is a very serious side effect and you may need dialysis."

"Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?"

The health care provider prescribes an intramuscular dose of 200,000 units of penicillin G benzathine for an adult client. The label on the 10-mL ampule sent from the pharmacy reads, "Penicillin G benzathine, 300,000 units/mL." How many milliliters of medication does the nurse prepares to ensure administration of the correct dose? (Round to the nearest tenth.) _______

0.7 ?????

A client has a prescription for a unit of packed red blood cells (RBCs). Which IV solution should the nurse obtain to hang with the blood product at the client's bedside? 0.9% sodium chloride Lactated Ringer's solution (LR) 5% dextrose in 0.9% sodium chloride 5% dextrose in water in 0.45% sodium chloride

0.9% sodium chloride

The health care provider's prescription reads, "Phenytoin 0.1 g by mouth twice daily." The medication label indicates that the bottle contains 100-mg capsules. How many capsules does the nurse prepare for administration of one dose? _______

1 cap

The nurse is explaining to a client the process for adminsitering a cleansing enema prescribed for an adult client who will be undergoing bowel surgery tomorrow. The nurse explains that which is the maximal volume of fluid that can be administered? 250 mL 500 mL 750 mL 1000 mL

1000ML

The health care provider's prescription for an adult client reads, "Potassium chloride 15 mEq by mouth." The label on the medication bottle reads, "20 mEq potassium chloride/15 mL." How many milliliters of KCl does the nurse prepare to ensure administration of the correct dose of medication? (Round to the nearest whole number.) _______

11

At 1300, the nurse is documenting the receipt of a unit of packed blood cells at the hospital blood bank. The nurse calculates that the transfusion must be started by which time? 1315 1330 1345 1400

1330 -Blood must be hung within 30 minutes after obtaining it from the blood bank. After that time, the temperature of the blood becomes warm and could be unsafe for use.

A nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. For how long does the nurse plan to stay with the client after the unit of blood is hung? 5 minutes 15 minutes 45 minutes 60 minutes

15 minutes

A nurse is administering a high cleansing enema. At what level above the client's hips should the nurse place the enema bag? 4 inches (10 cm) 8 inches (20 cm) 10 inches (25.5 cm) 18 inches (45.5 cm)

18 inches

At 1600 the nurse checks a client's total parenteral nutrition (TPN) infusion bag and notes that the solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The nurse plans to change the infusion bag and tubing this evening at what time? 1700 1800 2000 2100

1800

The health care provider's prescription reads, "Clindamycin phosphate 0.3 g in 50 mL NS, to be administered IV over 30 minutes." The medication label reads, "Clindamycin phosphate 150 mg/mL." How many milliliters of medication does the nurse prepare to ensure that the correct dose is administered? _______

2 ?????

A nurse provides information to a client about the importance of consuming fluids every day. If the client has no renal or cardiac disease or any other disorder requiring fluid alterations, how many milliliters of fluid should the nurse recommend that the client consume each day? 500 to 1000 mL 1000 to 1500 mL 1500 to 2000 mL 2000 to 2500 mL

2000 to 2500 mL

The health care provider prescribes 1000 mL of normal saline 0.45% for infusion over 8 hours. The drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

21

The health care provider prescribes 2000 mL of 5% dextrose and normal saline 0.45% for infusion over 24 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

21

The health care provider prescribes 1000 mL of 5% dextrose in water to be infused over 8 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

31

A nurse is preparing to administer a soap suds enema to an adult client. After explaining the procedure and positioning the client, the nurse begins the procedure. The nurse inserts the rectal tube into the client's rectum a maximal distance of of how many inches? 1½ inches (3.8 cm) 3 inches (7.5 cm) 4 inches (10 cm) 6 inches (15 cm)

4 inches maximum - In an adult client the tube is inserted 3 to 4 inches (7.5 to 10 cm), in a child 2 to 3 inches (5 to 7.5 cm), and in an infant 1 to 1½ inches (2.5 to 3.8 cm).

An adult client rings the call bell and asks the nurse for assistance in getting to the bathroom to void. The nurse assists the client, estimating that the client has approximately how many mL in the bladder if the client is feeling a sensation of fullness? 100 mL 250 mL 400 mL 800 mL

400 mL

The health care provider prescribes 1000 mL of 5% dextrose in water, to be infused over 24 hours. The drop factor is 60 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number). _______

42 gtt/min

A nurse has taught a client how to stand on crutches. The nurse determines that the client understands the instructions if the client places the crutches in which position? 2 inches (5 cm) to the front and side of the toes 8 inches (20 cm) to the front and side of the toes 15 inches (38 cm) to the front and side of the toes 22 inches (56 cm) to the front and side of the toes

8 inches (20 cm) to the front and side of the toes

Which clients does the nurse recognize as candidates for patient-controlled analgesia (PCA)? Select all that apply. (3) A client who has undergone colectomy A client with acute pancreatitis A client who has undergone gastrectomy A client with renal insufficiency A client with Alzheimer's disease

A client who has undergone colectomy A client with acute pancreatitis A client who has undergone gastrectomy -(Clients who are confused and unresponsive, those with neurological disease, and those with impaired renal or pulmonary functions are not candidates for PCA.)

A nurse is making initial rounds on a group of assigned clients. Which client should the nurse see first? A client receiving total parenteral nutrition (TPN) at a rate of 50 mL/hr for the last 24 hours A client receiving TPN at a rate of 50 mL/hr whose temp was 99° F (37.2°C) on the previous shift A client receiving TPN at a rate of 100 mL/hr who has complained of needing frequent trips to the bathroom to void A client whose TPN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating

A client whose TPN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating -The nurse should assess the client complaining of weakness, headache, and sweating first, because these are signs of hypoglycemia, which could be caused by the decrease in the PN rate.

The nurse is assigned to care for four clients. Which client does the nurse expect is likely to experience chronic pain? A client with osteoarthritis A client with angina pectoris A client who has undergone appendectomy A client with a leg fracture who is in skeletal traction

A client with osteoarthritis

A nurse is caring for a group of adult clients on an acute care nursing unit. Which clients does the nurse recognize as the most likely candidates for total parenteral nutrition (TPN)? Select all that apply. 3 A client with pancreatitis A client with severe sepsis A client with renal calculi A client who has undergone repair of a hiatal hernia A client with a severe exacerbation of ulcerative colitis

A client with pancreatitis A client with severe sepsis A client with a severe exacerbation of ulcerative colitis

A nurse is reviewing the laboratory results of a client receiving intravenous chemotherapy. Which laboratory finding prompts the nurse to initiate neutropenic precautions? A clotting time of 10 minutes An ammonia level of 20 mcg N/dL (14.6 μmol N/L) A platelet count of 100 × 103/μL (100× 109/L). A white blood cell (WBC) count of 2.0 × 103/μL (2.0 × 109/L).

A white blood cell (WBC) count of 2.0 × 103/μL (2.0 × 109/L).

A nurse has taught a client taking a methylxanthine bronchodilator, theophylline, about beverages that must be avoided. Which beverage choices by the client indicate to the nurse that the client needs further education? Select all that apply. (3) Cocoa Coffee Lemonade Orange juice Chocolate milk

A. Cocoa B. Coffee E. Chocolate milk.

A client with tuberculosis is being started on isoniazid and the nurse stresses the importance of returning to the clinic for follow-up blood testing. The nurse realizes the client understands the instructions if the client verbalizes the need to return to the clinic for which blood test? Liver enzymes Serum creatinine Blood urea nitrogen Red blood cell count

A. Liver enzymes. Rationale: INH therapy can increase hepatic enzymes and cause hepatitis

A nurse has just hung a transfusion of packed red blood cells and stayed with the client for the appropriate amount of time. Before leaving the room, the nurse tells the client that it is most important to immediately report which specific signs if it occurs? Select all that apply. (3) Rash Chills Fatigue Backache Tiredness

A. Rash B. Chills D. Backache. Rationale: The nurse should instruct the client to report signs of a transfusion reaction, such as a backache, chills, itching, or rash, immediately. If a transfusion reaction occurs, the nurse would stop the transfusion immediately.

The serum theophylline level of a client who is taking the medication (Theo-24) is 16 mcg/mL. On the basis of this result, the nurse should take which action initially? Document the normal value on the chart Call the health care provider immediately Call the rapid response team to help with the emergency Call the pharmacy to alert the pharmacist regarding the client's theophylline level

A.Document the normal value on the chart. Rationale: The normal therapeutic range for theophylline is 10 to 20 mcg/mL. A level above 20 mcg/mL is considered toxic. A value of 16 mcg/mL is within the therapeutic range.

Carbamazepine is prescribed for a client with trigeminal neuralgia. Which side/adverse effects does the nurse instruct the client to report to the health care provider? Select all that apply. (3) Fever Nausea Headache Sore throat Mouth sores

A.Fever D. Sore throat E. Mouth sores.

A nurse is caring for a client with histoplasmosis who is receiving intravenous amphotericin B . Which is the most critical observation for the nurse to make while the medication is being administered? Monitor the client's urine output Monitor the client for hypothermia Check the client's neurological status Check the client's blood glucose level

A.Monitor the client's urine output. Rationale: Amphotericin B can produce medication toxicity during administration and exhibit symptoms such as chills, fever, headache, vomiting, and impairment of renal function.

Phenelzine sulfate is being administered to a client with depression. The client suddenly complains of a severe frontally radiating occipital headache, neck stiffness and soreness, and vomiting. On further assessment, the client exhibits signs of hypertensive crisis. Which medication should the nurse prepare to administer, anticipating that it will be prescribed as the antidote to treat phenelzine-induced hypertensive crisis? Phentolamine Acetylcysteine Protamine sulfate Calcium gluconate

A.Phentolamine Rationale: The antidote to treat phenelzine-induced hypertensive crisis is phentolamine; a dose of 5 to 10 mg is usually injected intravenously.

The emergency department staff prepares for the arrival of a child who has ingested a bottle of acetaminophen. Which medication does the nurse ensure is available? Pancreatin Phytonadione Acetylcysteine Protamine sulfate

Acetylcysteine (Mucomyst)

A nurse is preparing a list of measures that will help promote sleep. Which measures that would be included on the list? Select all that apply. (3) Exercise just before bedtime. Drink a glass of wine at bedtime. Drink a cup (236 ml) of black tea before bedtime. Adjust the room temperature to a comfortable level. Eliminate lights, noise, and other environmental distractions. Get up at the same time each day and avoid naps during the day.

Adjust the room temperature to a comfortable level. Eliminate lights, noise, and other environmental distractions. Get up at the same time each day and avoid naps during the day.

A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which adverse effect should the nurse monitor the client closely? Akathisia Pelvic thrusts Athetoid limbs Protruding tongue

Akathisia -Approximately 5 to 60 days after starting an antipsychotic medication, the client may exhibit the side effect of akathisia, manifested by motor restlessness (continually tapping a foot, rocking back and forth in a chair, or shifting weight from one foot to another).

A client with a genitourinary tract infection has been prescribed metronidazole and fluid therapy. The nurse concludes that the client understands the dietary regimen to be followed while taking the medication when the client states to eliminate which from the diet? Alcohol Diet cola Bran flakes Chicken livers

Alcohol (A disulfiram-type reaction may result when someone taking metronidazole ingests alcohol. This syndrome includes flushing, palpitations, shortness of breath, severe headache, and nausea. To help prevent this reaction, the nurse must warn the client not to drink alcohol while taking this medication)

A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse provides instruction regarding foods to avoid. Which menu choice by the client indicates to the nurse that the client needs further instruction? Fish Spinach Rhubarb American cheese

American Cheese

Which client does the nurse recognize as being at the greatest risk for injury resulting from the use of heat or cold application? An older client A client with renal calculi A client with osteoporosis A client with rheumatoid arthritis

An older client

A clear liquid diet has been prescribed for client who has just undergone surgery. Which foods should the nurse offer to the client? Select all that apply. (3) Custard Apple juice Orange juice Chicken broth Orange gelatin Vanilla ice cream

Apple juice Chicken broth Orange gelatin

Triamterene has been prescribed for a client with a history of hypertension. Which fruits should the nurse tell the client are acceptable to eat while taking this medication? Select all that apply. (3) Prunes Apples Peaches Avocados Nectarines Cranberries

Apples Peaches Cranberries Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits that are naturally high in potassium include dried prunes, avocado, bananas, fresh oranges and mangoes, nectarines, and papayas.

A client has been given a prescription to begin using nitroglycerin transdermal patches for the management of angina pectoris. What should the nurse tell the client about the medication? Place the patch in the area of a skin fold to promote adherence Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed If the patch becomes dislodged, do not reapply and wait until the next day to apply a new patch. Alternate daily dose times between the morning and the evening to prevent the development of tolerance to the medication

Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed

A nurse has a prescription to get the client out of bed and into a chair on the first postoperative day after total knee replacement. Which action should the nurse take to protect the knee? Assisting the client into the chair, using a walker to minimize weight bearing on the affected leg Securely covering the surgical dressing with an elastic wrap and applying ice to the knee while the client is sitting Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place. Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting

Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting

The nurse instructs an assistive personnel (AP) that a client who is recovering from a myocardial infarction requires a complete bed bath. The nurse would intervene if the nurse observed the AP doing which? Washing the client's feet Washing the client's chest Giving the client a back rub Asking the client to wash his arms

Asking the client to wash his arms -Total care may be necessary for a client recovering from a myocardial infarction as a means of conserving client energy and reduce oxygen requirements.

A nurse is developing a plan of care for a client who reports difficulty sleeping. Which initial intervention does the nurse include in the plan of care? Offering the client a sleeping pill at night Providing the client with a snack at bedtime Asking the client what is done to prepare for sleep Leaving the television in the client's room on at a very low volume

Asking the client what is done to prepare for sleep

A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which action? Asking the client to take slow, deep breaths Removing the catheter and contacting the health care provider (HCP) Aspirating the fluid, advancing the catheter farther, and reinflating the balloon Aspirating the fluid, withdrawing the catheter slightly, and reinflating the balloon

Aspirating the fluid, advancing the catheter farther, and reinflating the balloon

A nurse asks assistive personnel (AP) to provide afternoon care to a client. The nurse expects that the AP will take which action? Give the client a complete bed bath Ask the client whether he would like to wash his face Give the client a back massage and prepare the client for sleep Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens

Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens

A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis? Acetylcysteine Atropine sulfate Protamine sulfate Pyridostigmine bromide

Atropine sulfate -The treatment for cholinergic crisis is atropine sulfate. Protamine sulfate is the antidote for heparin, and acetylcysteine is the antidote for acetaminophen (Tylenol).

Fluoxetine hydrochloride is prescribed for a client, and the nurse provides instruction regarding the use of the medication. The nurse tells the client that it is best to take the medication at what time? At lunchtime In the morning With the evening meal Midafternoon, with an antacid

B. In the morning. Rationale: Fluoxetine hydrochloride (Prozac) is a selective serotonin reuptake inhibitor that elicits an antidepressant response.

Baclofen is prescribed for a client with a spinal cord injury who is experiencing muscle spasms. While providing instructions to the client, which side effect does the nurse tell the client is possible? Photosensitivity Nasal congestion Increased appetite Increased salivation

B. Nasal congestion. Rationale: Common side effects of baclofen include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesia of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion.

A client who is taking bupropion in an attempt to stop smoking tells a nurse that he has been doubling the daily dose to make it easier to resist smoking. The nurse warns the client that doubling the daily dosage is dangerous. Of which adverse effect of the medication does the nurse warn the client? Insomnia Seizures Weight gain Orthostatic hypotension

B. Seizures. Rationale: Bupropion is an antidepressant. Seizure activity is common with dosages greater than 450 mg/day.

A nurse is to administer a dose of digoxin to a client with atrial fibrillation and notes that the client has a potassium level of 4.6 mEq/L (4.6 mmol/L). The nurse determines which about the administration of the dose? Should be withheld that day Should be administered as prescribed Should be preceded with a dose of potassium Should be withheld and the health care provider notified

B. Should be administered as prescribed. Rationale: Hypokalemia can make the client more susceptible to digoxin toxicity, so the nurse monitors the client's potassium level. The normal reference range of potassium for an adult is 3.5 to 5.1 mEq/L. If the potassium level is low, the dose is withheld and the physician is notified

A client who has undergone adrenalectomy is prescribed prednisone. Which finding indicates that the client is experiencing an adverse effect of the medication? Dry mouth Tarry stools Hypotension Hypoglycemia

B. Tarry stools. Rationale: Glucocorticoids increase gastric secretion, which may result in the development of peptic ulcers and gastrointestinal bleeding.

A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the nurse tell the client are acceptable to eat? Select all that apply. (3) Avocados Baked tuna Green olives Baked potato Fresh cherries Cream cheese

Baked tuna Baked potato Fresh cherries

A client requires a partial bed bath. The nurse, giving instructions to an assistive personnel (AP) about the bath, tells the AP to take which action? Just wash the client's hands and face Provide mouth care and perineal care only Let the client decide what she wants washed Bathe the client's body parts that, if left unbathed, would give rise to discomfort or odor

Bathe the client's body parts that, if left unbathed, would give rise to discomfort or odor

A client requests the use of an alternative or complementary therapy to help control pain and asks about the use of guided imagery. The nurse responds by telling the client that in this technique, the client will experience which? Become totally unaware of pain Ignore the pain by focusing on the alternate activity Alter pain perception though the influence of positive suggestion Become less aware of pain by creating and then concentrating on a mental image

Become less aware of pain by creating and then concentrating on a mental image

A client with liver cancer who is undergoing chemotherapy tells the nurse that some foods on the meal tray taste bitter. Which food does the nurse suggest that the client eliminate from the diet, knowing that it is most likely to taste bitter to the client? Beef Custard Potatoes Cantaloupe

Beef - reported to taste metallic / bitter during chemo

A nurse discontinues an infusion of a unit of blood after the client experiences a transfusion reaction. Once the incident has been documented appropriately, where does the nurse send the blood transfusion bag? Blood bank Risk management Microbiology laboratory Infection-control department

Blood bank

A client is found to have ulcerative colitis, and the nurse provides instructions to the client about the diet that should be followed while the disease is in remission. Which menu selection by the client indicates to the nurse that the client best understands the instructions? Milk Cabbage Boiled potatoes Coffee with cream

Boiled potatoes - During remission, the client must avoid intestinal stimulants such as alcohol, caffeinated beverages, high-fat foods, gas-forming foods, milk products, and foods such as raw fruits and some vegetables, that are very high in fiber.

A nurse is teaching a client with an ileostomy about foods that could result in the production of liquid stools. Which food selected by the client indicates further instruction is required? Bran Pasta Boiled rice Low-fat cheese

Bran (Bran is high in dietary fiber and will therefore increase the output of liquid stool by hastening its propulsion through the bowel. Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese.)

Calcitriol is prescribed for a client with hypocalcemia. The nurse has instructed the client in foods that may interfere with calcium absorption. The nurse realizes the teaching has been effective if the client verbalizes the importance of limiting which items? Select all that apply. (2) Bran Milk Clams Spinach Orange juice

Bran Spinach (Good dietary sources of calcium include milk products, dark-green leafy vegetables, clams, oysters, sardines, and orange juice fortified with calcium.)

Disulfiram is prescribed for a client. Which questions does the nurse make a priority of asking the client before administering this medication? Select all that apply. (2) "When did you have your last full meal?" "Do you have a history of diabetes insipidus?" "When was your last drink of alcohol?" "Do you have a history of thyroid problems?" "Do you have a history of cancer in your family?"

C. "When was your last drink of alcohol?" D. "Do you have a history of thyroid problems?" -Disulfiram (Antabuse) is used as an adjunct treatment for selected clients with alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. The most important question is when the client had his last drink of alcohol.

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit values. The nurse takes the client's temperature orally before hanging the blood transfusion and notes that it is 100.0° F (37.7 C). What should the nurse do next? Call the health care provider Begin the transfusion as prescribed Administer an antihistamine and begin the transfusion Administer 2 tablets of acetaminophen and begin the transfusion

Call the health care provider

A client with heart failure is being given furosemide and digoxin. The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first? Administer an antiemetic Administer the daily dose of digoxin Discontinue the morning dose of furosemide Check the result of laboratory testing for potassium on the sample drawn 3 hours ago

Check the result of laboratory testing for potassium on the sample drawn 3 hours ago why?

A client with atrial fibrillation has been placed on warfarin sodium. As part of the instructions for the medication, which foods does the nurse tell the client are acceptable to eat? Select all that apply. (3) Kale Cherries Broccoli Cabbage Potatoes Spaghetti

Cherries Potatoes Spaghetti (NO LEAFY GREENS) Rationale: Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green leafy vegetables such as lettuce, broccoli, spinach, Brussels sprouts, cabbage, and turnip greens. Cherries, potatoes, and spaghetti are foods that are low in vitamin K.

A regular diet has been prescribed for a client with a leg fracture who has been placed in skeletal traction. Which foods that will promote wound healing does the nurse encourage the client to select from the hospital menu? Spare ribs, rice, gelatin, tea Pasta, garlic bread, ginger ale Chicken breast, broccoli, strawberries, milk Peanut butter and jelly sandwich, chocolate cake, tea

Chicken breast, broccoli, strawberries, milk (Protein and vitamin C are necessary for wound healing.)

A client is receiving total parenteral nutrition (TPN) with fat emulsion (lipids) piggybacked to the TPN solution. For which signs of an adverse reaction to the fat emulsion should the nurse monitor the client? Select all that apply. (4) Chills Pallor Headache Chest and back pain Nausea and vomiting Subnormal temperature

Chills Headache Chest and back pain Nausea and vomiting

The health care provider (HCP)prescribes the administration of total parenteral nutrition (TPN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the TPN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse should take which immediate action? Obtain blood for culture Clamp the TPN infusion line Obtain an electrocardiogram (ECG) Obtain a sample for blood glucose testing

Clamp the TPN infusion line

A nurse is administering an enema to a client. While the enema solution is being instilled, the client complains of abdominal cramping. Which action should the nurse take? Clamp the enema bag tubing Remove the enema tube and allow the client to rest Stop the instillation and allow the client to expel the solution Raise the enema bag to quickly finish instillation of the solution

Clamp the enema bag tubing (If the client complains of cramping during instillation of the enema solution, the nurse should either reduce the height of the enema bag or clamp the tubing. Temporary cessation of instillation will alleviate the cramping.)

The nurse provides instructions to a client who is beginning therapy with oral theophylline. The nurse recognizes that the client understands the instructions when the client states to limit consumption of which items? Coffee, cola, and chocolate Oysters, lobster, and shrimp Apples, oranges, and pineapple Cottage cheese, cream cheese, and dairy creamers

Coffee, cola, and chocolate Rationale: Theophylline is a methylxanthine bronchodilator, and the nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, tea, cola, and chocolate. The items in the remaining options are acceptable to consume.

A client with HIV infection has been started on therapy with zidovudine. The nurse tells the client to report to the laboratory in 3 months for testing to detect adverse effects of the therapy. Which laboratory test is most important to monitor for this client? Creatinine Serum potassium Blood urea nitrogen (BUN) Complete blood count (CBC)

Complete blood count (CBC)

A client arrives at the emergency department after sustaining an ankle injury, and the health care provider (HCP) prescribes the application of a cold compress to the ankle. The nurse, preparing to apply the compress, assesses the ankle and notes that it is extremely edematous. The nurse should take which action? Apply the cold compress to the ankle Consult with the HCP before applying the cold compress Apply the cold compress for 20 minutes, and then apply a hot compress for 20 minutes Elevate the ankle and place cold compresses under and on top of the ankle

Consult with the HCP before applying the cold compress -Cold is usually contraindicated if the site of injury is extremely edematous because it further retards circulation to the area and prevents absorption of the interstitial fluid.

A nurse discontinues an infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which action should the nurse take next? Remove the IV catheter Contact the health care provider Change the solution to 5% dextrose in water Obtain a culture of the tip of the catheter device removed from the client

Contact the health care provider

A nurse is preparing to perform a digital removal of feces on a client with an impaction. The nurse checks the client's heart rate before performing the procedure and counts 88 beats per minute. The nurse begins to loosen the fecal mass and then stops the procedure to allow the client to rest. During this time the nurse checks the client's heart rate again and counts 82 beats per minute. The nurse should take which action? Contact the health care provider Discontinue the digital removal procedure Continue the digital removal procedure Wait 1 hour and then continue the digital removal procedure

Continue the digital removal procedure -Excessive rectal manipulation may cause irritation to the mucosa, bleeding, and stimulation of the vagus nerve, which may result in a reflexive slowing of the heart rate.

Which food should the nurse offer to a client who has been prescribed a full liquid diet? Toast Plain bagel Cooked custard Scrambled eggs

Cooked custard

Risperidone is prescribed for a client with a diagnosis of schizophrenia. Which laboratory study does the nurse expect to see among the health care provider's prescriptions? Platelet count Creatinine level Sedimentation rate Red blood cell count

Creatinine level -Baseline assessment includes renal and liver function parameters. Risperidone is used with caution — often at a reduced dosage — in clients with renal or hepatic impairment, clients with underlying cardiovascular disorders, and in older or debilitated clients

A client with rheumatoid arthritis is taking high doses of acetylsalicylic acid. While assessing the client for aspirin toxicity, which question should the nurse ask the client? "Are you constipated?" "Are you having any diarrhea?" "Do you have any double vision?" "Do you have any ringing in the ears?"

D. "Do you have any ringing in the ears?" Rationale: Mild intoxication with acetylsalicylic acid, called salicylism, is common when the daily dose is more than 4 g. Tinnitus (ringing in the ears) is the effect most frequently noted with intoxication.

Zidovudine is prescribed for an adult client with HIV infection. The nurse should provide which instruction to the client about the medication? That the medication must be taken with milk That aspirin can be taken to treat headache To discontinue the medication if nausea occurs To space the doses evenly around the clock

D.To space the doses evenly around the clock Rationale: The adult dosage of zidovudine is usually 200 mg every 8 hours or 300 mg every 12 hours.

A nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which parameter does the nurse use to determine the effectiveness of the tube feedings? Daily weight Serum protein level Calorie count sheets Daily intake and output records

Daily weight - the most accurate measurement of the effectiveness of nutritional management of the client is the daily weight.

A nurse is assessing a client who is being hospitalized with a diagnosis of pneumonia. The client's husband tells the nurse that the client is taking donepezil hydrochloride. The nurse should ask the husband about the client's history of which disorder? Dementia Seizure disorder Diabetes mellitus Posttraumatic stress disorder

Dementia

A client who needs to receive a blood transfusion has experienced a pruritic rash during previous transfusions. The client asks the nurse whether it is safe to receive the transfusion. Which medication does the nurse anticipate will most likely be prescribed before the transfusion? Ibuprofen Acetaminophen Diphenhydramine Acetylsalicylic acid

Diphenhydramine

A nurse administers a tap water enema to an adult client who is constipated. The client defecates a scant amount of brown fecal matter, which the nurse interprets as a poor result. The nurse should take which action? Document the results Administer a second tap water enema Add soap suds to the enema bag and repeat the enema Administer a Fleet enema, then a tap water irrigation

Document the results -Tap water enemas should not be repeated, because water toxicity or circulatory overload may occur if a large amount of water is absorbed.

A nurse is teaching a client how to mix regular and NPH insulin in the same syringe. The nurse should provide the client with which information about the insulin? Keep insulin refrigerated at all times Draw the regular insulin into the syringe first Shake the NPH insulin bottle before mixing the two types Remove all of the air from the bottle before mixing the two types

Draw the regular insulin into the syringe first

A nurse is caring for a client with a diagnosis of chronic kidney disease who is receiving dialysis. Epoetin alfa, to be administered subcutaneously, has been prescribed, and the nurse is drawing the medication from a single-use vial. What should the nurse do to prepare the medication? Shake the vial before drawing up the medication Draw up the medication and discard the unused portion Obtain the medication from the medication freezer and allow it to thaw Mix the medication with 0.1 mL of heparin before administration to prevent clotting

Draw up the medication and discard the unused portion

A home health nurse provides instructions to a client who is taking allopurinol for the treatment of gout. The nurse realizes the instructions have been effective if the client verbalizes the importance of which teaching point? Place an ice pack on the lips if they swell Drink at least 8 glasses of fluid every day Take the medication on an empty stomach 2 hours before meals Use an over-the-counter (OTC) antihistamine lotion if a rash develops

Drink at least 8 glasses of fluid every day. Rationale: Clients taking allopurinol are encouraged to drink 3000 mL/day of fluid.

A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. Which menu selection, cited by the client as a good source of potassium, indicates to the nurse that the client needs further instruction? Pork Beef Eggs Raisins

Eggs - One large egg provides 66 mg of potassium. A half-cup (114 gm) of raisins contains 700 mg of potassium. Four ounces (113 gm) of beef contains 420 mg of potassium, and 4 oz of pork (113 gm) contains 525 mg.

The first bag of total parenteral nutrition (TPN) solution has arrived on the clinical unit for a client beginning this nutritional therapy. The solution is to be infused by way of a central line. Which essential piece of equipment should the nurse obtain before hanging the solution? Pulse oximeter Blood glucose meter Electronic infusion device Noninvasive blood pressure monitor

Electronic infusion device

A nurse develops a plan of care for a postoperative client who is receiving intravenous morphine sulfate every 4 hours as needed for pain. Which priority intervention does the nurse include in the plan? Encouraging oral fluid intake Maintaining the client in a supine position Encouraging coughing and deep breathing Administering the morphine sulfate around the clock

Encouraging coughing and deep breathing -Morphine sulfate can depress respiration and suppress the cough reflex, putting the postoperative client at greater risk for atelectasis and subsequent pneumonia.

Metoprolol has been prescribed for a client with hypertension. For which common side effects of the medication does the nurse monitor the client? Select all that apply. 3 Fatigue Dry eyes Weakness Erectile dysfunction Nightmares

Fatigue Weakness Erectile dysfunction

Betaxolol eye drops have been prescribed for the treatment of a client's glaucoma. The nurse tells the client to return to the clinic for follow-up for which purpose? To have weight checked To give a sample for urinalysis To have the blood glucose level checked For measurement of blood pressure and apical pulse

For measurement of blood pressure and apical pulse

An assistive personnel (AP) is providing morning care to a client with a fractured leg who is in skeletal traction. The nurse determines that the AP needs instruction regarding the guidelines for client bathing if the AP is implementing which action? Giving the client a complete bed bath Pulling the room curtains around the bathing area Turning up the thermostat in the client's room for the bath Keeping the side rails (per agency policy)up while away from the client 42.

Giving the client a complete bed bath

A nurse is caring for an older adult client. When planning care, which occurrence does the nurse recognize as part of the normal aging process? Tubular reabsorption increases. Urine-concentrating ability increases. Glomerular filtration rate (GFR) is diminished. Medications are metabolized in larger amounts.

Glomerular filtration rate (GFR) is diminished. (GFR decreases, like all of the other functional capabilities of the kidney.)

A nurse answers a call bell and finds that the total parenteral nutrition (TPN) solution bag of an assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which action should the nurse take first? Call the health care provider Call the pharmacy for further instructions Hang a solution of 10% dextrose in water Hang a solution of 5% dextrose in 0.9% sodium chloride

Hanging a solution of 10% dextrose in water. Rationale: The solution containing the highest amount of dextrose should be hung until the new bag of PN becomes available. Because PN solutions contain high glucose concentrations, the 10% dextrose solution is the best solution to infuse because it will minimize the risk of hypoglycemia.

A nurse notes documentation in a client's medical record indicating that the client is experiencing oliguria. On the basis of this notation, the nurse determines which about the client when planning care? Is unable to produce urine Is voiding large amounts of urine Has difficulty with leakage of urine Has a diminished capacity to form urine

Has a diminished capacity to form urine Oliguria, diminished capacity to form urine, is most often the result of a decrease in renal perfusion. Anuria is the inability to produce urine. Polyuria is the voiding of excessively large amounts of urine. Urinary incontinence is the involuntary loss of urine.

A client tells the nurse that during the past 2 weeks her urine output has been greater than usual. The nurse, gathering subjective data from the client, should most appropriately ask the client about which? Has she been regularly exercising Has she been experiencing headaches Has she been having heavy menstrual cycles Has she been drinking an excessive amount of coffee

Has she been drinking an excessive amount of coffee

The nurse is supervising an assistive personnel (AP) in caring for a client who has just undergone lumbar spinal fusion after herniation of a lumbar disc. Which action by the AP while repositioning the client would cause the nurse to INTERVENE? Keeping the head of the bed flat Placing pillows beneath the full length of the legs Using a log-rolling technique for repositioning Having the client assist by using the overhead trapeze

Having the client assist by using the overhead trapeze

A client is taking a folic acid supplement. Which laboratory parameter does the nurse use to evaluate the effectiveness of this therapy? Select all that apply. 2 Magnesium Hemoglobin Blood glucose Hematocrit Alkaline phosphatase

Hemoglobin Hematocrit

Diverticulitis has been diagnosed in a client who has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet, during the asymptomatic period? Low in fat High in fiber Low in residue High in carbohydrates

High in fiber When a client's diverticulitis is asymptomatic, a soft high-fiber diet containing fruits, vegetables, and whole grains is recommended. The client is also instructed to consume a small amount of bran daily and to take bulk-forming laxatives, if prescribed, to increase stool mass and softness. Increasing fluid intake to 2500 to 3000 mL daily (unless contraindicated) is also important. A low-fat diet may be healthy but is not specific to this disorder. A high-carbohydrate diet is not helpful for the client with this condition.

A nurse is preparing a plan of care for a client who will be receiving meperidine hydrochloride. Which side/adverse effects does the nurse make a note of needing to be alert to in the plan of care? Select all that apply.(4) Hypotension Constipation Bradycardia Urine retention Respiratory depression

Hypotension Constipation Urine retention Respiratory depression Side effects of meperidine hydrochloride (Demerol) include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urine retention.

A nurse is preparing a client for the insertion of a central intravenous line into the subclavian vein by the health care provider. The nurse gathers the equipment, places it at the bedside, and prepares to assist the health care provider with the procedure. As further preparation for the procedure, the nurse places the client in which position? Flat on the left side In the prone position In the supine position In a slight Trendelenburg position

In a slight Trendelenburg position -The client is placed in a slight Trendelenburg position. This position is used to increase dilation of the veins and positive pressure in the central veins, reducing the risk of air embolus during insertion.

A nurse provides instructions to a client about preventing injury while using crutches. The nurse tells the client to avoid resting the underside of the arm on the crutch pad, mainly because it could result in which problem? Skin breakdown Injury to the nerves An abnormal stance A fall and further injury

Injury to the nerves -This ensures that the client's axillae are not resting on the crutches or bearing the weight of the crutches, which could result in injury to the nerves of the brachial plexus.

A nurse is inserting an indwelling urinary catheter into a female client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. At this point, the nurse should take which action? Immediately inflate the balloon Insert the catheter 2.5 to 5 cm and inflate the balloon Wait until the urine flow stops and inflate the balloon Insert the catheter until resistance is met and inflate the balloon

Insert the catheter 2.5 to 5 cm and inflate the balloon

A nurse is monitoring a client's fluid balance. Which 24-hour intake and output totals indicates to the nurse that the client has the proper fluid balance? Intake 1600 mL, output 800 mL Intake 1500 mL, output 1400 mL Intake 2400 mL, output 2900 mL Intake 3000 mL, output 2400 mL

Intake 1500 mL, output 1400 mL

A nurse notes that a client has a diagnosis of acute back pain. The nurse plans care based on which characteristic of acute pain? It has a prolonged presence It is a result of injury It lasts longer than 6 months It is usually the result of a chronic disorder

It is a result of injury

A nurse has taught a client who is taking lithium carbonate about the medication. The nurse determines that the client needs additional teaching if the client makes which comment to the nurse? The medication should be taken with meals The lithium blood levels must be monitored very closely It is important to decrease fluid intake while taking the medication to avoid nausea The health care provider must be called if excessive diarrhea, vomiting, or diaphoresis occurs

It is important to decrease fluid intake while taking the medication to avoid nausea

A nurse is providing instructions to a client regarding the use of crutches. Which information should the nurse include in the teaching plan? Select all that apply. It is not safe to use someone else's crutches. Rubber crutch tips will not slip, even when wet. The client should use both crutches when navigating stairs. Lean into the crutches as needed to support the body's weight. Crutch tips are made of a material that will not wear down.

It is not safe to use someone else's crutches. The client should use both crutches when navigating stairs. (The client should use only crutches that have been measured and set for him. When ascending or descending stairs, the client generally uses a three-phase sequence involving both crutches.)

A nurse is caring for a client who has been taking acetazolamide for glaucoma. Which, if documented in the assessment data, indicates to the nurse that the client may be experiencing an adverse effect of the medication? Tinnitus Jaundice No change in peripheral vision Pupillary constriction in response to light

Jaundice -Adverse effects include nephrotoxicity, hepatotoxicity, and bone marrow depression. Jaundice is a sign of hepatotoxicity.

A nurse is preparing to administer an enema to a client. In which position does the nurse place the client?

LEFT LAYING SIMS

A client who has recently been started on enteral feedings complains of abdominal cramping and diarrhea. The nurse reviews the nutritional content on the label of the can of feeding solution. Which ingredient is the nurse looking for that may be causing this problem? Maltose Lactose Sucrose Fructose

Lactose

A client with right-sided weakness must learn how to use a cane. The nurse tells the client to position the cane by holding it in which way? Left hand, 6 inches (15 cm) lateral to the left foot Right hand, 6 inches (15 cm) lateral to the right foot Left hand, placing the cane in front of the left foot Right hand, placing the cane in front of the right foot

Left hand, 6 inches (15 cm) lateral to the left foot

A nurse suspects that a client receiving total parenteral nutrition (TPN) through a central line has an air embolism. The nurse immediately places the client in which position? Left side with the head lower than the feet Left side with the head higher than the feet Right side with the head lower than the feet Right side with the head higher than the feet

Left side with the head lower than the feet

A nurse provides dietary instructions to a client with iron-deficiency anemia. Which foods does the nurse recommend to the client? Select all that apply. (3) Lentils Raisins Pineapple Egg whites Kidney beans Refined white bread

Lentils Raisins Kidney beans (The best sources of dietary iron are red meat, liver, and other organ meats, blackstrap molasses, and oysters. Other good sources are kidney beans, soybeans, lentils, whole-wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots.)

A client is receiving intravenous bleomycin sulfate. During administration of the chemotherapy, nursing assessment is the priority? Heart rate Lung sounds Peripheral pulses Level of consciousness

Lung sounds -Bleomycin sulfate, an antineoplastic medication, can cause interstitial pneumonitis that may progress to pulmonary fibrosis. Pulmonary function parameters, along with hematologic, hepatic, and renal function tests, must be monitored.

A client is resuming eating after undergoing partial gastrectomy. What measures should the nurse tell the client to take to minimize the risk of complications? Select all that apply. (3) Lying down after eating Eating high-protein foods Drinking liquids with meals Eating six small meals per day Eating concentrated sweets during the day

Lying down after eating Eating high-protein foods Eating six small meals per day (The client who has undergone partial gastrectomy is at risk for dumping syndrome. This client should be prescribed a diet that is high in protein, moderate in fat, and low in carbohydrates. The client should lie down after meals and avoid drinking liquids with meals. Frequent small meals are encouraged. The client should also avoid concentrated sweets.)

A nurse is providing instruction to a client who is taking codeine sulfate for severe back pain. Which instruction should the nurse provide to the client? Decrease fluid intake Maintain a high-fiber diet Avoid all exercise to help prevent lightheadedness Avoid the use of stool softeners to help prevent diarrhea

Maintain a high-fiber diet

A nurse is providing dietary instructions to a client with tuberculosis. Which foods would the nurse specifically instruct the client to include more of in the daily diet? Rice and fish Eggs and bacon Cereals and broccoli Meats and citrus fruits

Meats and citrus fruits - The nurse teaches the client with tuberculosis to increase intake of protein, iron, and vitamin C.

A nurse is developing a plan of care for a client, hospitalized with heart failure, who has a history of Parkinson disease and is taking benztropine mesylate daily. Which intervention does the nurse identify as a priority in the plan? Monitoring intake and output Monitoring the client's pupillary response Placing the client in a right side-lying position Checking the client's hemoglobin level daily

Monitoring intake and output

A nurse is preparing a plan of care for a client with a diagnosis of cancer who is receiving morphine sulfate for pain. Which action does the nurse identify as a priority in the plan of care for this client? Monitoring urine output Encouraging increased fluids Monitoring the client's temperature Monitoring the client's respiratory rate

Monitoring the client's respiratory rate

A nurse is reading the medical record of a client receiving haloperidol. The nurse notes that the health care provider has documented that the client is experiencing signs of akathisia. On the basis of the health care provider's note, which clinical manifestation would the nurse expect to find during assessment of the client? Motor restlessness Puffing of the cheeks Puckering of the mouth Protrusion of the tongue

Motor restlessness

A nurse is evaluating the client's use of a cane for left-sided weakness. The nurse determines that the client needs further teaching if the client is observed doing what? Holds the cane on the right side Moves the cane when the right leg is moved Leans on the cane when the right leg moves forward Keeps the cane 6 inches (15 cm) out to the side of the right.

Moves the cane when the right leg is moved

A client asks a nurse about complementary and alternative measures to promote sleep. What should the nurse suggest? Herbal therapy Acupuncture Muscle relaxation techniques Traditional Chinese medicine

Muscle relaxation techniques

A nurse is monitoring a client who is receiving total parenteral nutrition (TPN). Which signs and symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication? Pallor, weak pulse, and anuria Nausea, vomiting, and oliguria Nausea, thirst, and increased urine output Sweating, chills, and decreased urine output

Nausea, thirst, and increased urine output

A client complains of feeling fatigued because of the need to get up several times during the night to urinate. The nurse documents that the client is experiencing which problem? Anuria Oliguria Polyuria Nocturia

Nocturia

The health care provider (HCP) prescribes "enemas until clear" for a client. The nurse has administered three enemas to the client, but the client is still passing brown stool and fluid. Which action should the nurse take? Notify the HCP Continue administering enemas until the fluid returns clear Administer a glycerin suppository and then administer one more enema Allow the client to rest for 1 hour and then continue with another enema

Notify the HCP - Excessive enema use seriously depletes fluids and electrolytes. If the fluid fails to return clear after three enemas (check agency policy), the physician should be notified. Therefore the other options are incorrect.

A client with diabetes mellitus who has been taught about food exchange system of dietary management of the disease wishes to have 8 oz (240 ml) of nonfat yogurt with breakfast. The nurse determines that the client understands diet management when the client states that which action will be taken after eating the nonfat yogurt? Not eating ice cream for 2 days Omitting 8 oz (240 ml) of skim milk from that meal Omitting salad dressing and butter at lunchtime Eating only half of an allowed meat product at supper

Omitting 8 oz (240 ml) of skim milk from that meal

Erythromycin is prescribed for a client with a respiratory tract infection. The nurse provides instructions to the client regarding the administration of the oral medication and tells the client that it is best to take the medication in which way? With juice With a meal On an empty stomach At bedtime, with a snack

On an empty stomach. Rationale: Oral erythromycin should be taken on an empty stomach with a full glass of water

A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client? One low in protein One high in fluids One high in carbohydrates One with a moderate amount of fat

One low in protein - The liver breaks down protein, resulting in the formation of ammonia. Therefore the client would benefit from a low-protein diet.

A client who experienced a stroke (brain attack) is experiencing residual dysphagia. Which foods should the nurse remove from the client's meal tray? Peas Scrambled eggs Cheese casserole Mashed potatoes

Peas

A nurse notes that the site of a client's peripheral IV catheter is reddened, warm, painful, and slightly edematous in the area of the insertion site. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced which problem? Phlebitis of the vein Infiltration of the IV line Hypersensitivity to the IV solution An allergic reaction to the IV catheter material

Phlebitis of the vein

A nurse is repositioning a client who has returned to the nursing unit after internal fixation of a fractured right hip. The nurse should use which for repositioning? Pillow to keep the right leg abducted while turning the client Rolled bath blanket to prevent abduction while turning the client Trochanter roll to keep the right leg adducted while turning the client Rolled bath blanket to prevent external rotation while turning the client

Pillow to keep the right leg abducted while turning the client -After internal fixation of a hip fracture, the client is turned to the affected side or the unaffected side as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction.

A nurse is instructing a client about the foods that will acidify the urine and inhibit the growth of microorganisms. Which foods does the nurse tell the client are most likely to acidify the urine? Select all that apply. Plums Prunes Apples Broccoli Cabbage Cranberries

Plums Prunes Cranberries

A client has just undergone insertion of a central venous catheter by the health care provider at the bedside. Which result would the nurse be sure to check before initiating infusion of the IV solution that the health care provider has prescribed? Serum osmolality Serum electrolytes Portable chest x-ray Intake and output record

Portable chest x-ray

A client recovering from acute kidney injury (AKI) is being discharged home. The nurse determines that the client understands the therapeutic dietary regimen when the client states that he will plan to eat foods that are low in which substance? Fats Vitamins Potassium Carbohydrates

Potassium (Most excretion of potassium and control of potassium balance is carried out by the kidneys. In the client with AKI, potassium intake is limited. The primary mechanism of potassium removal during AKI is dialysis.)

Methylergonovine intramuscularly is prescribed for a postpartum client. Before administering the medication, the nurse explains to the client that the medication will promote which effect? Reduce lochial drainage Prevent postpartum bleeding Maintain a normal blood pressure Decrease the strength of uterine contractions

Prevent postpartum bleeding -Methylergonovine (Methergine), an ergot alkaloid /oxytocic agent, is used to prevent or control postpartum hemorrhage by inducing uterine contraction and enhancing myometrial tone.

A nurse is developing a plan of care for an older client who is being admitted to a long-term care facility. Which intervention should the nurse include in the plan of care to help maintain an appropriate bowel elimination pattern? Limiting vegetable intake to one serving per day Limiting whole grains to three servings per week Providing cooked fruits such as prunes or apricots Including spicy foods in the diet to increase peristalsis

Providing cooked fruits such as prunes or apricots

A nurse is developing a bowel-training program for a client after a cerebral vascular accident (CVA or stroke). Which interventions are appropriate for inclusion in the plan? Select all that apply. (4) Providing privacy and time for defecation Assisting the client into a sitting position Limiting the amount of fiber in the client's diet Providing a cool drink before defecation time Initiating defecation measures every day at the same time Administering a cathartic suppository a half-hour before defecation time

Providing privacy and time for defecation Assisting the client into a sitting position Initiating defecation measures every day at the same time Administering a cathartic suppository a half-hour before defecation time

A client with a peripheral intravenous (IV) line in place has a new prescription for infusion of total parenteral nutrition (TPN), a solution containing 25% glucose. Which action should be taken by the nurse? Hanging the IV solution as prescribed Questioning the health care provider about the prescription Diluting the solution with sterile water to half-strength Hanging the IV solution but setting the infusion at just half the prescribed rate

Questioning the health care provider about the prescription -PN solutions containing as much as 10% glucose can be infused through peripheral vessels. A PN solution containing 25% glucose is hypertonic. The nurse should question the prescription in the absence of a central venous catheter or a peripherally inserted central catheter.

The nurse teaches a client who has begun taking phenelzine, a monoamine oxidase inhibitor (MAOI), about the medication. Which foods, when selected by the client, indicate the need for further instruction? ? Select all that apply. (3) Peas Broccoli Potatoes Red wine Avocados Cereal with raisins

Red wine Avocados Cereal with raisins Because phenelzine is an MAOI, the client should avoid foods that are high in tyramine, which could trigger a potentially fatal hypertensive crisis. Foods to avoid include aged cheeses, smoked or processed meats, red wines, beer, and certain fruits, including avocados, raisins, and figs. Vegetables, with the exception of broad-bean pods, are generally acceptable.

A client has a prescription for short-term therapy with enoxaparin . The nurse explains to the client that this medication is being prescribed for which purpose? Prevent pain Relieve back spasms Increase the client's energy level Reduce the risk of deep vein thrombosis

Reduce the risk of deep vein thrombosis

A client has been told to apply cold packs to a knee injury, and the client asks the nurse how this will help the injury. The nurse should provide the client with which information about a cold pack? Reduces muscle tension Dilates the blood vessels Promotes muscle relaxation Reduces blood flow to the extremity

Reduces blood flow to the extremity -The application of cold reduces blood flow through its vasoconstriction action and eases localized pain.

A nurse is caring for a client whose urine output was 25 mL for 2 consecutive hours. When planning care, which client-related factors does the nurse recognize as increasing blood flow to the kidneys? Physiological stress Release of dopamine Release of norepinephrine Sympathetic nervous system stimulation

Release of dopamine - Release of dopamine exerts a vasodilating effect on the renal arteries, improving renal function and increases urine flow. The factors set forth in the other options result in renal vasoconstriction.

A nurse is assessing a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the insertion site. What should the nurse do first? Remove the IV Apply a warm compress Check for blood return Measure the area of infiltration

Remove the IV

A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse should take which action first? Remove the IV catheter Slow the rate of infusion Notify the health care provider Check for loose catheter connections

Remove the IV catheter

The client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. Which actions should the nurse take? Select all that apply. (3) Removing the IV catheter at that site Applying warm, moist compresses to the IV site Notifying the health care provider about the finding Encouraging the client to scrub the site while in the shower Starting a new IV line in a proximal portion of the same vein

Removing the IV catheter at that site Applying warm, moist compresses to the IV site Notifying the health care provider about the finding

A client receiving total parenteral nutrition (TPN) requires fat emulsion (lipids), which will be piggybacked to the TPN solution. On obtaining a bottle of fat emulsion, the nurse notes that fat globules are floating at the top of the solution. Which action should the nurse take? Shake the bottle vigorously Request a new bottle from the pharmacy Rotate the bottle gently back and forth to mix the globules Run the bottle under warm water until the globules disappear

Request a new bottle from the pharmacy

A nurse is monitoring a client who is receiving a continuous intravenous infusion of morphine sulfate. Which finding should cause the nurse to contact the health care provider? Temperature of 97.6° F (36.4°C) Urine output of 30 mL/hr Blood pressure of 100/60 mm Hg Respiratory rate of 10 breaths/min

Respiratory rate of 10 breaths/min

A nurse administers an oil retention enema to a client. Afterward, the nurse should provide which instruction to the client? Immediately expel the enema Retain the enema for several hours Expect to defecate within 30 minutes Expect to experience cramping induced by the solution

Retain the enema for several hours (Oil retention enemas lubricate the rectum and colon. The feces absorb the oil and become softer and easier to pass. The amount of enema solution is small, and the client usually does not experience cramping. To enhance the action of the oil, the client should retain the enema for several hours, if possible.)

A client with a urinary tract infection has been started on nitrofurantoin, a urinary antiseptic medication, and is taught about the foods that will maintain the urinary pH in the acid range. Which food does the nurse tell the client to eliminate from the diet while taking this medication? Prunes Oranges Rhubarb Cranberries

Rhubarb - reduces the acidity of the urine and should be avoided when acidic urine is required.

A nurse is providing dietary instructions to a client taking spironolactone. The nurse realizes the teaching has been effective if the client selects which food items from the menu? Select all that apply. 3 Rice Cereal Carrots Bananas Citrus fruits

Rice Cereal Carrots -Spironolactone is a potassium-sparing diuretic. Hyperkalemia is the principal adverse effect. Clients are instructed to restrict their intake of potassium-rich foods, such as citrus fruits and bananas

A client who has sustained multiple fractures of the left leg is in skeletal traction. The nurse has obtained an overhead trapeze to improve the client's bed mobility. To which high-risk area must the nurse pay particular attention during assessment for indications of pressure and skin breakdown? Left heel Scapulae Right heel Back of the head

Right heel

A nurse provides dietary instructions to a client with cholecystitis. Which menu selection by the client indicates to the nurse that the client understands the instructions? Roast turkey with a baked potato Fruit plate with fresh whipped cream Fried chicken with macaroni and cheese Barbecued spare ribs with buttered noodles

Roast turkey and baked potato - The client with cholecystitis should reduce intake of fat. Foods that should generally be avoided to achieve this end include sauces and gravies, fatty meats, fried foods, products made with cream, and heavy desserts

A nurse has provided dietary instructions to a client with a new diagnosis of gout. Which menu suggestions by the client indicate to the nurse that the client needs additional instruction? Select all that apply. (2) Carrots Tapioca Scallops Broccoli Chicken liver

Scallops Chicken liver

A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which action should the nurse take first? Remove the IV Sit the client up in bed Shut off the IV infusion Slow the rate of infusion

Shut off the IV infusion

A health care provider states that a client's insensible fluid loss is approximately 600 mL/day. For a critically ill client, the nurse interprets this statement to reflect fluid loss occurring through which routes? Wound drain and skin Skin and mechanical ventilator Nasogastric tube and wound drain Indwelling catheter and nasogastric tube

Skin and mechanical ventilator - insensible fluid losses are those that cannot be measured because they occur through the skin and the lungs. They occur on a daily basis, without the client's awareness.

A client has been placed in Buck's extension traction. The nurse can provide counter traction to reduce shear and friction by implementing which measure? Flexing the feet against a footboard Slightly elevating the foot of the bed Keeping the head of the bed elevated 45 degrees Placing the bed in reverse Trendelenburg position

Slightly elevating the foot of the bed

The nurse is instructing a client with hypertension about foods that are low in sodium. Which menu selections by the client indicate to the nurse that the client understands what has been taught? Select all that apply. (2) Spaghetti with fresh tomatoes Boiled lobster with baked potato Grilled chicken with turnip greens Instant hot cereal with bacon Tomato soup with a ham sandwich

Spaghetti with fresh tomatoes Grilled chicken with turnip greens

A client with renal calculi is instructed to follow an alkaline ash diet. Which menu choice by the client indicates to the nurse that the client understands the prescribed regimen? Chicken, potatoes, and cranberries Spinach salad, milk, and a banana Peanut butter sandwich, milk, and prunes Linguini with shrimp, tossed salad, and a plum

Spinach salad, milk, and a banana Rationale: In an alkaline ash diet, all fruits are allowed except cranberries, prunes, and plums. The incorrect options represent components of an acid ash diet.

A nurse has a written prescription to remove an intravenous (IV) line. Which item should the nurse obtain from the unit supply area for use in applying pressure to the site after removing the IV catheter? Alcohol swab Adhesive bandage Sterile 2 × 2 gauze Povidone-iodine (Betadine) swab

Sterile 2 × 2 gauze

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. Which assessment finding indicates to the nurse that the client is experiencing magnesium toxicity? Proteinuria of +3 Sudden drop in fetal heart rate Presence of deep tendon reflexes Serum magnesium level of 2.5 mEq/L (1.25 mmol/L)

Sudden drop in fetal heart rate

A client is receiving intravenous meperidine hydrochloride as prescribed. For which side/adverse effects does the nurse assess the client while the client is receiving this medication? Select all that apply. (3) Polyuria Diarrhea Tachycardia Hypotension Mental clouding

Tachycardia Hypotension Mental clouding (Side/adverse effects of meperidine hydrochloride include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urine retention.)

The nurse is preparing to change the solution bag and intravenous tubing of a client receiving total parenteral nutrition (TPN) through a left subclavian central venous line. Which essential action does the nurse ask the client to perform just before switching the tubing? Turn the head to the left Turn the head to the right Exhale slowly and evenly Take a deep breath and hold it

Take a deep breath and hold it

A client is receiving heparin sodium by way of continuous IV infusion. For which adverse effects of the therapy does the nurse assess the client? Select all that apply. 2 Tinnitus Tarry stools Slowed pulse Bleeding from the gums Increased blood pressure

Tarry stools Bleeding from the gums

A nurse is providing information to a mother of a 1-year-old who has asked about bladder-training her child. The nurse should provide which information to the mother? That she may start bladder training at any time That her child is too young and that she should not yet be worrying about it That a child cannot begin to control urination until approximately the age of 24 months That bowel training should be started immediately and then begin bladder training in about 1 month

That a child cannot begin to control urination until approximately the age of 24 months

A client taking metronidazole for the treatment of trichomoniasis vaginalis calls the clinic nurse to express concern because her urine has turned dark in color. The nurse should provide which information to the client? To increase her fluid intake To discontinue the medication That darkening of the urine is a harmless side effect To report to the clinic to see the health care provider

That darkening of the urine is a harmless side effect

A nurse provides instructions to a female client regarding the procedure for collecting a midstream urine specimen. What should the nurse tell the client? That she should douche before collecting the specimen That she should cleanse the perineum from front to back That she should collect the urine in the cup as soon as the urine flow begins That she should collect the specimen at bedtime and bring it to the laboratory the next morning

That she should cleanse the perineum from front to back

A nurse has taught a client how to ambulate with the use of a cane. The nurse determines that the client needs additional instruction if which is observed? The client holds the cane close to the body The client holds the cane on the unaffected side The client moves the cane and the unaffected side together The client uses the cane to support the affected side and to maintain balance

The client moves the cane and the unaffected side together

A client has been taking metoprolol. Which finding indicates to the nurse that the medication is effective? The client's ankles are swollen. The client's weight has increased. The client's blood pressure has decreased. The client has wheezes in the lower lobes of the lungs.

The client's blood pressure has decreased.

A nurse has administered a dose of furosemide to a client with diminished urine output. How does the nurse BEST determine effectiveness? The client reports less thirst as compared with yesterday The client's urine output is 1500 ml more than the fluid intake The client reports socks which seem less tight on the ankle area The client's weight remains stable, over the past two to three days

The client's urine output is 1500 ml more than the fluid intake

A nurse is providing information to the mother of an 18-month-old about bowel training. The nurse should provide the mother with which information? The child should be able to control defecation at the age of 18 months The child will let you know when she is ready to begin bowel training Girls usually achieve the neuromuscular development necessary for controlling defecation much sooner than boys do The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of age

The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of age

An older adult client tells the nurse that she is tired during the day because she awakens frequently during the night. Which information should the nurse provide to the client? She should avoid napping during the day The only thing that will help is a sleeping pill This is a normal occurrence as a person gets older She needs to stay up later at night to prevent these awakenings

This is a normal occurrence as a person gets older

A client who has been taking lisinopril complains to the nurse of a persistent dry cough. What should the nurse tell the client? This is a side effect of therapy He probably has an upper respiratory infection He needs to have his blood counts checked A chest x-ray is required because the cough is a sign of heart failure

This is a side effect of therapy

A client with newly diagnosed angina pectoris has taken 2 sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client complains of a headache. What should the nurse tell the client? This is an indication that the medication should not be used again Headache indicates medication tolerance, and the dosage must be increased This may be an allergic reaction to the nitroglycerin, and the health care provider must be notified This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen

This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen

A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The nurse notes moisture under the dressing covering the catheter insertion site. What should the nurse assess next? Temperature Time of the last dressing change Expiration date on the infusion bag Tightness of the tubing connections

Tightness of the tubing connections

Cyclophosphamide has been prescribed for a client with a diagnosis of breast cancer, and the nurse is providing instructions to the client. The nurse realizes the instructions have been effective if the client makes the statement she will change which aspect of care? To avoid salt while taking this medication That it is best to take the medication with food To increase fluid intake to 2000 mL to 3000 mL/day To drink at least 2 glasses of orange juice every day

To increase fluid intake to 2000 mL to 3000 mL/day -Hemorrhagic cystitis is a toxic effect of cyclophosphamide. The client must be instructed to drink copious amounts of fluid during administration of this medication. The client should also monitor her urine for hematuria.

A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse should provide the client with which instruction? To increase the intake of legumes That seafood should be included in the diet That organ meats should be included in the diet To have at least one serving each day of a citrus fruit

To increase the intake of legumes -Dietary instructions to the client with a uric acid type stone include increasing consumption of legumes, green vegetables, and fruits (except prunes, grapes, cranberries, and citrus fruits) to increase the alkalinity of the urine

A nurse is providing instructions to a client regarding quinapril hydrochloride. The nurse should teach the client to implement which measure? To take the medication with meals To rise slowly from a lying to a sitting position To discontinue the medication if nausea occurs That a therapeutic effect will be felt immediately

To rise slowly from a lying to a sitting position

A client with heart failure and hypertension who has been admitted to the hospital is unable to make own selections from the menu. Which meal does the nurse select for the client's supper on the day of admission? Smoked ham, fresh carrots, boiled potato Hot dog in a bun, sauerkraut, baked beans Turkey, baked potato, salad with oil and vinegar Shrimp, baked potato, salad with blue cheese dressing

Turkey, baked potato, salad with oil and vinegar (Foods that are high in sodium should be limited in the diet of the client with hypertension and heart failure. Foods in the meat group that are higher in sodium include bacon, luncheon meat, chipped or corned beef, ham, hot dogs, kosher meat, smoked or salted meat or fish, and a variety of shellfish. These foods should be avoided or strictly limited for hypertensive clients)

A nurse is caring for a client who has just returned from a cardiac catheterization through the right femoral artery. The client tells the nurse that he feels the urge to urinate. The nurse assists the client in using a urinal, but the client is unable to void. Which action should the nurse take to stimulate the client's micturition reflex? Helping the client stand Elevating the head of the bed 90 degrees Turning on the water in the sink in the client's room and allowing it to run Obtaining assistance to ambulate the client to the bathroom in the client's room

Turning on the water in the sink in the client's room and allowing it to run

A client has been found to have a bladder infection. When planning care, which area of dysfunction would cause the nurse to monitor the client most closely for signs of a kidney infection? Urethra Nephron Glomerulus Ureterovesical junction

Ureterovesical junction

A nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's urinary output and laboratory values, anticipating which about the client? Urine output will be decreased Urine production will be increased Serum osmolality will be decreased Urine specific gravity will decreased

Urine output will be decreased -A febrile client would be expected to have some degree of dehydration resulting from increased metabolic demands. In response to dehydration, the body attempts to restore fluid balance by reducing urine production

A nurse is preparing a plan of care for a pregnant client who will be given oxytocin to induce labor. Which occurrence does the nurse include in the plan of care as a reason for immediate discontinuation of the oxytocin infusion? Uterine atony Severe drowsiness Uterine hyperstimulation Early decelerations of the fetal heart rate

Uterine hyperstimulation -Hyperstimulation of the uterus, which may result in diminished placental perfusion, may cause fetal distress. Therefore an oxytocin infusion must be stopped if there are any signs of uterine hyperstimulation

Intravenous tobramycin sulfate is prescribed for a client with a respiratory tract infection. For which of the following symptoms, indicative of an adverse effect, does the nurse monitor the client? Nausea Vertigo Vomiting Hypotension

Vertigo

A nurse has obtained a unit of blood from the blood bank and properly checked the blood bag with another nurse. Which parameter should the nurse assess just before hanging the transfusion? Skin color Vital signs Latest platelet count Urine output over the last 24 hours

Vital signs

For which vitamin deficiency should the nurse monitor the client who is on a vegan diet? Vitamin A Vitamin B12 Vitamin C Vitamin E

Vitamin B12 - The client on a vegan diet does not consume animal products and is therefore at risk for vitamin B12 deficiency.

Codeine sulfate is prescribed for a client with severe back pain. Which parameters does the nurse monitor while the client is taking this medication? Select all that apply. Volume of urine output Strength of peripheral pulses Ability to move the extremities Frequency of bowel movements Color, motion, and sensation of extremities

Volume of urine output Frequency of bowel movements -(Because urine retention may occur with the use of opioid analgesics, the nurse would monitor the volume of the client's urine output. Because the client is also at risk for constipation, the nurse would monitor the frequency of bowel movements.)

A home care nurse has been assigned a client who has been discharged home with a prescription for total parenteral nutrition (TPN). Which parameters does the nurse plan to check at each visit as a means of identifying complications of the TPN therapy? Select all that apply. Weight Glucose test Temperature Peripheral pulses Hemoglobin and hematocrit

Weight Glucose test Temperature

A nurse has taught a client with a new colostomy about measures to control stool odor in the ostomy drainage bag. Which foods listed on the client's shopping list indicate to the nurse that the client has understood the information? Select all that apply. (3) Eggs Yogurt Parsley Broccoli Cucumbers Cranberry juice

Yogurt Parsley Cranberry juice (Deodorizing foods for the client with an ostomy include beet greens, parsley, buttermilk, cranberry juice, and yogurt. Eggs, broccoli, and cucumbers are gas-forming foods.)

A client taking hydrochlorothiazide reports to the clinic for follow-up blood tests. For which side/adverse effect of the medication does the nurse monitor the client's laboratory results? Hypokalemia Hypocalcemia Hypernatremia Hypermagnesemia

hypokalemia

A nurse is caring for a client with cirrhosis. As part of the teaching regarding dietary means of minimizing the effects of the disorder, the nurse educates the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase the intake of which foods? Select all that apply. (3) Milk Peanuts Chicken Broccoli Asparagus Whole-grain cereals

peanuts asparagus whole-grain cereals Pork products are especially rich in the vitamin, but other good sources are peanuts, asparagus, legumes, and whole-grain and enriched cereals

A client about to undergo surgery is instructed in postoperative pain relief measures is asked whether he would like to use a patient-controlled analgesia (PCA) pump. The client asks the nurse to describe the pump. Which information should the nurse provide to the client? The PCA pump eliminates the need for an intravenous (IV) line The client will be able to deliver his own dose of medication every 4 hours The client's spouse will be able to administer medication for the client The client administers his own medication by pressing a control button

the client administers his own medication by pressing a control button