NUR204 exam 3

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An older client is having difficulty handling the specimen cup for a clean catch urine specimen. What can the nurse do to help this client? 1. Provide a clean funnel to pour the urine into the specimen cup. 2. Document that the specimen could not be obtained 3. Catheterize the client for the specimen. 4. Ask the physician to obtain the specimen

For which finding would the nurse assess a presence of after application of a patient's bandage? Select all that apply. One, some, or all responses may be correct. 1 Pallor 2 Paresthesia 3 Pulselessness 4 Presence of odor 5 Presence of drainage

1 2 3

The nurse has taught a client how to manage constipation. Which action by the client would provide evidence of learning? (Select all that apply.) The patient: 1) increases his intake of high-fiber foods. 2) drinks at least four 8-ounce glasses of water a day. 3) goes to the bathroom to evacuate after meals. 4) takes a daily laxative

1 3

Upon review of four clients' urinalysis reports, which client's results support the nurse's suspicion that the client may be developing kidney disease? Client A Serum creatinine: 1.1 mg/dL Client B Blood urea nitrogen: 18 mg/dL Client C Serum creatinine: 2.5 mg/dL Client D Blood urea nitrogen: 20 mg/dL

Client C

The nurse is preparing to initiate antibiotic therapy for a client who developed an incisional infection. Which task would the nurse ensure has been completed before starting the first dose of intravenous antibiotics? a. Red blood cell count b. Wound culture c. Knee x-ray d. Urinalysis

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. Which explanation would the nurse give for why a PEG tube is preferred for administering a tube feeding? 1 There is less chance of aspiration with a PEG tube. 2 The PEG tube does not require a pump. 3 Self-administration of the tube feeding is possible. 4 More tube feeding mixture can be given each time.

Which food provides the only animal source of carbohydrate? 1) Beef 2) Eggs 3) Milk 4) Chicken

Which patient is at highest risk for the development of hypocalcemia? 1 56-year-old with acute renal failure 2 40-year-old with appendicitis 3 28-year-old who has acute pancreatitis 4 65-year-old with hypertension and asthma

Which enzyme level does the nurse monitor in a patient with bone disease? a. Alkaline phosphatase (ALP) b. Alanine aminotransterase(ALI) c. Aspartate aminotransferase (AST) d. Gamma-glutamyltransteraseGG

A patient is admitted to the hospital with severe diarrhea. The patient should be monitored for which complication associated with diarrhea? 1) Hypokalemia 2) Hypocalcemia 3) Hyperglycemia 4) Thrombocytopenia

A client is hospitalized with pressure injuries. Which tasks) could be delegated to an unlicensed assistive personnel (UP)? Select all that apply. One, some, or all responses may be correct. 1 Empty wound drainage containers. 2 Report changes in wound appearance. 3 Apply prescribed dressings and medications. 4 Assess and record data about wound appearance. 5 Choose dressings and therapies for wound treatment.

1 2

A pediatric nurse weighs a newborn and records the weight as 9 pounds. Considering that the baby's weight gain is adequate, what would be the approximate weight of this baby at 5 months? Record your answer using a whole number. _______ pounds

When a patient with darkly pigmented skin is bedridden after a prolonged illness, which characteristic would alert the nurse to the possibility of developing a pressure injury? Select all that apply. One, some, or all responses may be correct. 1 The skin appears flabby. 2 Localized areas of skin may blanch when pressed lightly with a finger. 3 The color remains unchanged when pressure is applied. 4 The circumscribed area of intact skin mav be warmer or cooler than the surrounding area 5 Skin may differ in firmness (either softer or firmer) from surrounding tissue..

3 4 5

Which symptom supports the nurse's assessment that a child with malnourishment has a vitamin C deficiency? 1 Edema 2 Nausea 3 Glossitis 4 Gingivitis

After surgery, a client is prescribed a clear liquid diet. Which items would the nurse offer to the client? Select all that apply. One, some, or all responses may be correct. 1 Jell-O 2 Broth 3 Sherbet 4 Ice milk 5 Ginger ale

1 2 5

Which laboratory result would the nurse expect in a patient with deep vein thrombosis who is on long-term heparin therapy? 1 Platelet count of 420,000 cells/mm? 2 Fibrinogen levels of 180 mg/dL 3 Prothrombin time of 7.8 seconds 4 Activated partial thromboplastin time of 45 seconds

After the nurse has completed teaching a client with hypertension about a heart-healthy diet, which meal choice by the client indicates that the teaching has been effective? 1 Bean soup with ham 2 Grilled steak and green salad 3 Chicken and cheese enchiladas 4 Fried fish and green beans

During an admission assessment, the patient reports that he takes vitamin E supplements twice a day. The nurse should explain that taking vitamin E supplements twice a day 1) ensures healthy vision. 2) can lead to toxicity. 3) strengthens the immune system. 4) helps maintain body tissues

For which factor does the Braden Scale evaluate? 1 Skin integrity at bony prominences, including any wounds 2 Risk factors that place the patient at risk for skin breakdown 3 The amount of repositioning that the patient can tolerate 4 The factors that place the patient at risk for poor healing

The nurse is caring for a patient who has just undergone bronchoscopy. The patient requests a drink of water. What is the nurse's best action? a. Provide ice chips. b. Check the patient for a gag reflex. c. Provide a small cup of ice water with a straw. d. Keep the patient NPO.

The nurse is obtaining a guaiac-based fecal occult blood test (gFOBT) in a patient. Which intervention helps the nurse prevent contamination while performing the test? 1 Applies the smear within the center of the slide 2 Applies a thin smear of the sample on the stick 3 Uses the sample from the center of the specimen 4 Uses a single applicator for both test windows

An older adult had a colon resection 1 week ago. When assessing the abdominal incision, the nurse notes foul-smelling brown drainage seeping from the middle of the incision site. The nurse suspects he has: 1) an infected wound. 2) wound dehiscence. 3) a hematoma. 4) a fistula

The nurse is caring for a patient who is sedated following a colonoscopy. Which is the priority action of the nurse? a. Provide a quiet, dark environment so that the patient can rest comfortably. b. Monitor the patient's pulse oximetry and respirations closely. c. Inform the patient that the procedure has been completed. d. Assess the patient's bowel sounds and passage of flatus.

A patient tells the nurse that he needs to increase his intake of potassium because he has been taking large doses of diuretics. To minimize complications from hypokalemia, the nurse should instruct the patient to include which of the following foods as a part of his diet? A Cheese and crackers B Peanut butter and jelly sandwich C Tomatoes and spinach D Apples and grapes

Upon reviewing a patient's urinalysis report, the nurse notices proteinuria. Which condition would the nurse anticipate from these findings? a. Alcoholic cirrhosis b. Trauma to the kidneys c. acute tubular necrosis d. Glomerulonephritis

Which action would the nurse take after having difficulty in palpating the pedal pulse of a client with venous insufficiency? a. Count the pulse at another site. b. Notify the primary health care provider. c. Lower the legs to increase blood flow. d. Verify the pulse by using a Doppler.

Which of the following is/are not an anthropometric measurement of body composition? A. Using calipers to measure the skinfold on the triceps B. Obtaining the waist-to-hip ratio C. Hydrodensitometry D. 24-hour food recall

True or false. The RN may delegate the collection of nutritional history information to the NAP

false. The nurse aide may obtain height, weight, and document intake and output. The nurse must collect information related to the nutrition history.

The head of the bed of a patient who is receiving enteral feedings is elevated to 45 degrees. Which complication associated with enteral feedings does this intervention help prevent? 1) Aspiration 2) Diarrhea 3) Infection 4) Electrolyte imbalance:

A client has a low hemoglobin level that is attributed to a nutritional deficiency. Which foods should the nurse teach the client to increase in the diet? Select all that apply. One, some, or all responses may be correct. 1 Liver 2 Apples 3 Carrots 4 Cheese 5 Spinach

1 5

The nurse is collecting a sputum specimen from a client. Which action should the nurse take during the collection of this specimen? 1. Collect at least 30 mL of sputum. 2. Offer mouth care. 3. Take shallow breaths. 4. Wear a mask

Which result is most important to communicate to the primary health care provider when the nurse reviews laboratory results in a client who has positive testing for occult blood in the stool? 1 Iron level 100 mcg/dL (22 mcmol/L) 2 Hemoglobin level 8.5 g/dL (85 mmol/L) 3 Platelet count 160,000/mm 3 (160 x 10 9/L) 4 Transferrin level 300 mg/dL (3 g/L)

Which statement by the student nurse about the use of a suction pump in negative- pressure wound therapy indicates the need for further teaching? 1 "The wound site should be monitored at least every 2 hours." 2 "This treatment is used mostly for areas of skin cancer." 3 "The foam dressing should be changed every 48 to 72 hours." 4 "A continuous low-negative pressure should be maintained."

A client is scheduled for a barium enema. What is the nursing priority for this client? 1. Assess bowel sounds. 2. Assess for allergies. 3. Cleanse the bowel. 4. Keep the client NPO.

The nurse needs to obtain a sputum specimen from a client. What should the nurse have the client do? 1. Apply sterile gloves. 2. Clear the throat. 3. Cough to bring up secretions. 4. Rinse the mouth with mouthwash prior to the collection.

Which statement reflects understanding of wet/damp-to-dry dressings for mechanical debridement of a wound? 1 The dressing should be removed when partially dry. 2 The process causes slight bleeding when removed. 3 The dressing should be only moist, not wet, when applied. 4 The nurse should leave the dressing in place for at least 12 hours.

A client has a large, open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing? 1 Use two square gauze pads to cleanse the wound, one for each half of the wound. 2 Apply new Montgomery straps each time the dressing is changed. 3 Hold the wet gauze with the tips of the forceps higher than the wrist. 4 Cleanse the wound with wet, sterile gauze from the center of the wound outward.

A client with tattooed eyeliner is scheduled for an MRI. What should the nurse instruct the client about this diagnostic test? 1. Earplugs will be provided. 2. Lie very still. 3. Report any burning sensation. 4. Wear goggles.

Which return demonstration by a client indicates that teaching about performing a blood glucose monitoring test has been effective? 1. The client punctures the fingertip. 2. The client puts on gloves. 3. The client smears the blood on the reagent strip. 4. The client washes the hands.

Which test is considered the most accurate in the evaluation of the effectiveness of diet and insulin therapy over time? 1 Blood pH 2 Serum protein level 3 Serum glucose level 4 Glycosylated hemoglobin

A Postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which item that are allowed to be consumed on this diet. Select all that apply A Broth B Coffee C Gelatin D Pudding E vegetable juice F Pureed Vegetables

a b c

Which activity can the nurse delegate to unlicensed assistive personnel (UAP): Select all that apply. One, some, or all responses may be correct. a. Voiding urine specimen collection b. Obtaining a throat culture c. Blood glucose testing d. Collecting a stool specimen e. Testing stool for occult blood

a c d e

Which condition is associated with an increased serum bilirubin level? Select all that apply. One, some, or all responses may be correct. a. Hepatitis b. Cholecystitis c. bone tumors d. Anemic conditions e. Biliary obstruction

a d e

The patient tells the nurse that she has been on a high-protein, low-carbohydrate diet for the past 6 months. Which blood test results could be influenced by her diet? A Bilirubin B Creatinine C Blood urea nitrogen D Creatine kinase

Which test requires prior administration of a radionuclide agent into the patient's vein? a. Endoscopy b. Electrocardiogram c. Magnetic resonance imaging d. Positron emission tomography (PET)

A client with a body mass index (BMI) of 35 verbalizes the need to lose weight. The nurse encourages the client to lose weight safely by making which dietary change? 1 Decrease portion size and fat intake. 2 Increase protein and vegetable intake. 3 Decrease carbohydrate and fat intake. 4 Increase fruits and limit fluid intake.

Which supplement does the nurse expect to be prescribed when caring for a burn patient with elevated transferrin levels? 1 Iron 2 Vitamin K 3 Vitamin A 4 Potassium

The nurse applying a bioocclusive, transparent dressing on the abdomen of an elderly frail women is concerned about damaging her fragile skin when removing the dressing at a later time. What action should the nurse take to safegaurd the skin? 1) Gently cleanse the skin with soap and water first. 2) Use a skin sealant before applying the dressing. 3) Remove hair from the site using scissors or clippers. 4) Change the dressing frequently to avoid excessive adhesion

Which diagnostic study is used to determine bone density? 1 Diskogram 2 Standard x-ray 3 Computed tomography (CT) scan 4 Magnetic resonance imaging (MRI)

Which teaching does the nurse provide the patient with a sodium level of 120 mEg/L? 1 "Avoid eating canned vegetables." 2 "It is okay to eat cured meat and cheese." 3 "Refrain from eating potatoes and pickles." 4 "Increase your intake of green leafy vegetables."

Which dressing would the nurse view as beneficial for the recovery of a client's red-colored wound that was caused by pressure? Select all that apply. One, some, or all responses may be correct. 1 Absorptive dressings 2 Hydrocolloid dressings 3 Transparent film dressings 4 Moist gauze dressings with antibiotics 5 Non-adhering dressings with antibiotic ointment

2 3 5

The nurse is providing care to a client during the posttest phase of diagnostic testing. What will the nurse do during this phase? Standard Text: Select all that apply. 1. Provide emotional and physical support to the client. 2. Compare the previous and current test results. 3. Prepare the client for the test. 4. Modify nursing interventions as necessary. 5. Report the results to appropriate health team members

2 4 5

The nurse is obtaining the history of a newly admitted patient. Which element in the history places the patient at risk for urinary tract infection? 1) Hypertension 2) Hypothyroidism 3) Diabetes mellitus 4) Hormonal contraceptive use

The nurse needs to collect a specimen from a client; however, the nurse has never collected this type of specimen in the past. What should the nurse do? 1. Notify the physician. 2. Ask another nurse to collect the specimen. 3. Consult the nursing procedure manual. 4. Delegate the collection of the specimen to unlicensed assistive personnel.

Which laboratory result is important to communicate quickly to the health care provider? 1 Blood glucose 98 mg/dL (5.44 mmol/L) 2 Hemoglobin 14.1 g/dL (141 mmol/L) 3 Potassium 3.0 mEq/L (3.0 mmol/L) 4 White blood cell 9200/mm 3 (9.2 × 10 P/L)

Which instruction should the nurse give to the client when a stool specimen is to be collected? 1. Defecate in the toilet. 2. Follow sterile technique. 3. Send at least 60 mL of specimen. 4. Void before the specimen is collected.

The nurse is caring for a patient with a urinary tract infection. Which test will indicate which antibiotics will be effective to treat the infection? a. Complete blood count (CBC) b. Culture and sensitivity (C&S) c. Renal scan and angiography d. Radioreceptor assay for HCG

Which of the following allergies would be problematic for a patient scheduled for computed tomography with contrast? A Allergy to penicillin B Allergy to shellfish C Allergy to peanuts D Allergy to latex

While reviewing the coagulation results for a patient, the nurse notices that the international normalized ratio (IN) is 3.5 and documents it as normal. Which rationale explains the nurse's action? a. The patient has acquired hemolytic anemia. b. The patient takes diuretic medications. c. The patient has an artificial heart valve. d. The patient has developed venous thrombi.

During parenteral nutrition administration, a nurse breaks sterile technique. For which complication does this place the patient at risk? 1) Air embolism 2) Sepsis 3) Thrombosis 4) Pneumothorax

The nurse teaching a patient who has had surgery will instruct that increasing which nutrient will help with tissue repair? 1 Fat 2 Protein 3 Vitamin 4 Carbohydrate

An adult patient who is receiving a continuous enteral feeding at 80 ml/hr has a residual volume of 120 ml 6 hours after the last check. How should the nurse proceed? 1) Continue administering the enteral feeding. 2) Hold the enteral feeding and notify the provider immediately. 3) Hold the feeding for 1 hour, and recheck. 4) Hold the feeding for 2 hours, then resume the feeding

Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of: 1) milk and cheese. 2) bread and pasta. 3) fruits and vegetables. 4) lean meats

Which statement reflects understanding of wet/damp-to-dry dressings for mechanical debridement of a wound? 1 The dressing should be removed when partially dry. 2 The process causes slight bleeding when removed. 3The dressing should be only moist, not wet, when applied. 4 The nurse should leave the dressing in place for at least 12 hours.

A client is having a timed urine collection done. The unlicensed assistive personnel does not save one specimen. What should the nurse do? 1. Continue with the test, and document that one specimen is missing. 2. End the test immediately, and send what is collected to the laboratory. 3. Document that the test cannot be completed. 4. Start the test over.

Which food item would be consumed by a patient who follows a lacto-ovo vegetarian diet? 1 Poultry 2 Fish 3 Meat 4 Eggs

Mr. Brown is admitted with advanced liver disease. Which of the following lab results would you expect to see? A Albumin 2.6 g/dL B Blood urea nitrogen 18 mg/dL C Homocysteine 2.4 mg/L D Bilirubin 0.7 mg/dL

The nurse is caring for a patient who reports nausea and vomiting. The nurse finds increased bilirubin levels and decreased urobilinogen levels in the patient's laboratory reports. Which clinical manifestation does the nurse expect to find in the patients assessment a. Steatorrhea b. Glycosuria c. Ketonuria d. Hematuria

The nurse is caring for a patient who has a deep leg wound that is badly infected. Which laboratory test results will the nurse expect to find in the patient's chart? a. Elevated C-reactive protein (CRP) 6.5 mg/dL b. Decreased serum creatinine 0.8 mg/dL c. Elevated serum bilirubin 0.5 mg/dL d. Prothrombin time (PT) 11.5 sec

Which topic will the nurse include when teaching a group of clients about risk factors for heart disease? Select all that apply. One, some, or all responses may be correct. a. Obesity b. Hypertension c. Diabetes insipidus d. Asian-American ancestry e. Increased high-density lipoprotein (HDL)

a b

a e

Which laboratory result should immediately be reported by the nurse to the primary care provider? A Hemoglobin: 15.6 B Hematocrit: 27% C Red blood cells: 5.2 (0) White blood cells: 6000

Which information about common expected responses to computed tomography (CT) scan contrast material would the nurse include in preprocedure teaching? Select all that apply. One, some, or all responses may be correct. a. Visual disturbances b. Flushing of the face c. Sensation of warmth d. Lemony taste in the mouth e. Small petechiae on the arms

b c

Which purpose is served by a cystoscopy ordered for a client experiencing decreased and difficult urination? a. To ascertain the size of the kidneys b. To ascertain the protein content in urine c. To ascertain the presence of urethral wall abnormalities d. To ascertain the total amount of catecholamines excreted

Which statement by a client who is receiving total parenteral nutrition (TPN) after extensive colon surgery indicates effective teaching? a "TN provides supplemental nutrition." b "TN provides short-term nutrition after surgery." c "TN provides total nutrition when gastrointestinal function is questionable." d "TPN assists people who are unable to eat but have active gastrointestinal function.

A client is prescribed a diagnostic test requiring a 24-hour stool specimen. What should this test indicate to the nurse? 1. Analyze the stool for dietary products and digestive secretions. 2. Detect the presence of bacteria or viruses. 3. Detect the presence of ova and parasites. 4. Determine the presence of occult blood.

A client is to have an echocardiogram. Which statement by the client indicates the teaching about the test has been effective? 1. Im told this test causes no discomfort. 2. I will have to walk on a treadmill. 3. I will need to remain NPO. 4. I will need to take my pulse prior to the test

Which color would the nurse anticipate when assessing a client's skin tears? 1 Red 2 Gray 3 Black 4 Yellow

Which patient condition would cause the nurse to monitor for development of hypokalemia? Select all that apply. One, some, or all responses may be correct. 1 Diarrhea 2 Vomiting 3 Adrenal insufficiency 4 End-stage renal disease 5 Potassium-wasting diuretics usage

1 2 5

Place the following steps for blood glucose testing in the correct order. 1 2 3 4 5 6 Select the site, which depends on the meter. Perform hand hygiene. Puncture the capillary site and place blood on test strip. Check health care provider prescription and the patient care plan. Gather supplies and equipment. Use two identifiers to ensure correct patient.

1 Check health care provider prescription and the patient care plan. 2 Gather supplies and equipment. 3. Perform hand hygiene. 4. Use two identifiers to ensure correct patient. 5 Select the site, which depends on the meter. 6. Puncture the capillary site and place blood on test strip.

26.Which action should the nurse take after administering a dose of medication through a percutaneous endoscopic gastrostomy (PEG) tube? 1) Continue the enteral feeding. 2) Flush the tube with 30 mL of water. 3) Wait 2 hours before resuming the feeding. 4) Check residual volume

Patients may be deficient in which vitamin during the winter months? 1) A 2) D 3) E 4) K

Five days after a client has abdominal surgery the nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports that the client is experiencing wound dehiscence? 1 Increased bowel sounds 2 Loosening of intact sutures 3 Sudden increase in serosanguineous drainage 4 Purplish color of the incision

The most appropriate nursing diagnosis for a patient with a draining wound would be: 1) Risk for Infection related to dehiscence of wound. 2) Body Image Disturbance related to nonhealing surgical wound. 3) Risk for Impaired Skin Integrity related to wound drainage. 4) Pain related to surgical incision

How would the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate? 1 Red 2 Black 3 Green 4 Yellow

While reviewing the urinalysis report of a patient with cardiac disease, the nurse finds increased levels of sodium in the urine. The patient also has an increase in urinary output. Which finding in the patient's blood results does the nurse correlate with the results from the patient's urinalysis report? a. Increased homocysteine levels b. Increased myoglobin protein levels c. Increased c-reactive protein (CRP) level d. Increased brain natriuretic peptide (BNP)

You are instructing Miss Ford on a sterile urine collection. Which statement would indicate the need for further instruction? A "I separate the folds and clean from back to front. B "I clean the area three times." C "I begin the urine stream and then place the container under the stream midway through." D "I make sure there is no stool in the urine specimen."

The nurse notes that there has only been 100 mL of urine output from his patient's Foley catheter in 6 hours. The nurse should first do which of the following? A. Instruct the patient to drink two glasses of water. B. Call the doctor immediately. C. Irrigate the Foley catheter with 30 mL of sterile saline. D. Assess the catheter tubing and the patient's abdomen

A patient has anemia. An appropriate goal for that the patient would be for him to increase his intake of which nutrient? 1) Calcium 2) Magnesium 3) Potassium 4) Iron

A postsurgical patient who is morbidly obese informs the nurse that as she was coughing, she felt a "pop" at her abdominal incision site. Upon inspection, the nurse notes the sutures to the incision are intact; however, there is an increase in the amount of serosanguineous drainage. The nurse would suspect wound: 1) Evisceration 2) Fistula 3) Hemorrhage 4) Dehiscence

The nurse administers 1 g of a drug to a patient. If the half-life of the drug is 4 hours, how many hours would it take to reach 250 mg of the original dosage? Record the answer using a whole number. _____ hours

Place the steps the nurse will take to irrigate a wound in the proper order of performance. Mark the options in rank order (priority rating) with 1 being the first thing you would do, and 8 last. 1) Don clean nonsterile gloves. 2) Set up a sterile field with supplies. 3) Pour irrigation solution into sterile bowl. 4) Remove soiled dressing. 5) Don sterile gloves. 6) Gently irrigate wound. 7) Fill the irrigation syringe. 8) Administer pain medication

8 1 4 2 3 5 7 6

The nurse is caring for a patient who has had severe acid reflux. Which test will allow the physician to directly check for damage to the esophagus? a. Esophagogastroduodenoscopy (EGD) b. MRI scan with contrast c. Abdominal ultrasound d. Positron emission tomography (PET) scan

A client is being treated for tuberculosis, and the doctor writes an order to collect a sputum specimen. What is the rationale behind this order? 1. To test for acid-fast bacillus 2. To assess the effectiveness of therapy 3. To identify origin, structure, function, and pathology of cells 4. To identify the specific organism

While reviewing a patient's laboratory reports, the nurse finds a blood urea nitrogen (BUN) level of 30 mg/dL. Which complication does the nurse anticipate in the patient? Select all that apply. One, some, or all responses may be correct. 1 Liver failure 2 Alcohol abuse 3 Severe dehydration 4 Congestive heart failure 5 Acute glomerulonephritis

3 4 5

The nurse is admitting a bed-ridden older adult client to an extended care facility. During the initial assessment, the nurse notices the client's bone to be visible in a sacral pressure injury. Which staging will the nurse document in the client's record? 1. I 2. II 3. III 4. IV

A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which reply by the nurse is best? a. "Don't worry, these tests are routine" b. "They are done to identify other health risks" c. "they determine whether surgery will be safe" d. "I don't know, your HCP prescribed them"

Which laboratory test provides evidence consistent with a client having renal impairment? Select all that apply. One, some, or all responses may be correct. a. Serum albumin: 4.7 g/dL(6.815 umol/L) b. Serum creatinine: 2.0 mg/dL (176.8 umol/L) c. Serum potassium: 5.9 mEg/L (5.9 mmol/L) d. Serum cholesterol: 120 mg/dL (3.108 mmol/L) e. Blood urea nitrogen (BUN): 32 mg/dL (11.424 mmol/L)

b c e

A client who had thoracic surgery reports pain at the incision site when coughing and deep breathing. Which action would the nurse take? 1 Instruct the client to splint the wound with a pillow when coughing. 2 Place the client in the supine position and inspect the site of the incision. 3 Assess the intensity of the pain and administer the prescribed analgesic. 4 Notify the health care provider immediately and then check for wound dehiscence.

A patient is admitted with pyelonephritis. Which anatomic structure is affected by this disorder? 1) Kidneys 2) Bladder 3) Urethra 4) Prostate gland

A primary health care provider prescribes three stool specimens for occult blood for a client who reports blood-streaked stools and a 10-pound (4.5 kg) weight loss in 1 month. To ensure valid test results, which instruction would the nurse give to the client? 1 Avoid eating red meat before testing. 2 Test the specimen while it is still warm. 3 Discard the day's first stool and use the next three stools. 4 Take three specimens from different sections of the fecal sample.

After a partial gastrectomy, a client has a nasogastric (NG) tube in place. The nurse identifies that there is no NG drainage for 30 minutes. After verifying that appropriate NG instillation treatments have been prescribed, the nurse would take which action? 1 Instill 30 mL of normal saline, then continue the suction. 2 Instill 20 mL of air, then clamp off the suction for 1 hour. 3 Instill 50 mL of saline, then increase the pressure of the suction. 4 Instill 15 mL of distilled water, then disconnect the suction for 30 minutes

An older adult has a 3 cm × 2 cm eschar on the right heel. The initial treatment choice for this wound is to: 1) elevate the right heel off the surface of the bed. 2) request a surgical consult for debridement of the area. 3) apply a hydrocolloid to promote autolytic debridement of the wound. 4) request an order for an enzymatic debridement medication

Compromised nutrition during chemotherapy can contribute to an increased risk of infection and other problems. Which actions would the nurse take to offset nutritional deficiencies? 1 Provide oral supplements. 2 Offer the client's favorite foods. 3 Restrict intake from dairy products. 4 Encourage the client to drink low-protein shakes.

The home care nurse visits a client to assess an abdominal surgery site. The client is elderly, lives alone, and takes multiple medications for chronic illnesses. The nurse notes that the client's wound shows signs of delayed healing. Which factor does the nurse recognize as being least likely to be a contributing factor for the delayed healing? 1. The client has an agency deliver two cold meals and one hot meal daily. 2. The client admits to having difficulty managing dressing changes. 3. The client takes medication for heart and respiratory problems. 4. The client does not shower due to fear of falling while alone

The nurse answers a client's emergency call light, which is activated from the client's bathroom. The nurse discovers pinkish-gray organs protruding from the bottom of an abdominal dressing. Which action does the nurse take first? 1. Get the client to bed and place in a semi-Fowler position with knees bent. 2. Call the physician and report the client has an incisional evisceration. 3. Cover the eviscerated organs with sterile dressings soaked in sterile saline. 4. Make the client NPO in anticipation of surgery to close the open suture line.

The nurse is caring for a client with diabetes mellitus who has a non-healing wound on the bottom of the foot. Which assessment finding causes the nurse to conclude that the wound is likely infected with Clostridia? 1. A crackling sensation under the skin can be felt when palpating around the wound. 2. The area surrounding the wound is dark red, swollen, and draining yellow exudate. 3. The infected area around the wound appears to be expanding to surrounding tissue. 4. The wound drainage has a strong smell of rotten grapes and appears green in color.

The nurse is caring for a patient with knee pain who is scheduled for an arthroscopy. Which instruction does the nurse give to the patient? 1 "Refrain from drinking alcohol for a day after the procedure." 2 "Make sure that you do not elevate your leg after the procedure." 3 "Make sure that you sleep on your stomach after the procedure." 4 "Do not ingest any liquids for about 6 hours after the procedure."

The nurse is counseling a client with type 1 diabetes about choosing food items that are low in carbohydrate (CHO) content. Which food selection made by the client indicates effective teaching? 1 Skim milk 2 Apple juice 3 Nonfat yogurt 4 Fresh orange juice

The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse can conclude that learning occurs if the patient says, "For 3 days prior to testing, I should avoid eating 1) beef. 2) milk. 3) eggs. 4) oatmeal

The nurse is providing care for a client after surgery for repair for a penetrating wound to the abdomen. Which characteristic of the wound will make the nurse most vigilant for signs of infection? 1. The object that entered the client's abdomen remained embedded until surgery. 2. The object was removed by first responders and the wound flushed for foreign bodies. 3. The object inflicted no injury on the client's internal organs or boney structures. 4. The object was smooth, nonporous metal, and a diameter of less than one inch.

The urinalysis report of a client reveals a pH of 6.0, turbidity/cloudiness, specific gravity of 1.020, and 0.6 mg/dL of proteins. Which condition can be inferred from the findings? 1 Infection 2 Glomerular disorder 3 Acid-base imbalance 4 Decreased kidney perfusion

Three days after a patient had abdominal surgery, the nurse notes a 4-cm periwound erythema and swelling at the distal end of the incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Heart rate is 96 beats/min and oral temperature 100.8°F (38.2°C). The nurse would suspect that the patient has what kind of complication? 1) Infection at the incision site 2) Dehiscence of the wound 3) Hematoma under the skin 4) Formation of granulation tissue

To obtain the most accurate culture information of a chronic wound, the nurse would recommend: 1) tissue biopsy. 2) swab culture. 3) sterile culture. 4) needle aspiration culture

When a patient states "I eat all fruits and vegetables except bananas, and I eat very little meat and cheese," the nurse infers the patient adheres to which diet? 1 Renal 2 Cardiac 3 Pureed 4 Regular

When caring for a client who is receiving enteral feedings, the nurse would take which measure to prevent aspiration? 1 Elevate the head of the bed between 30 and 45 degrees. 2 Decrease flow rate at night. 3 Check for residual daily. 4 Irrigate regularly with warm tap water.

When performing an assessment for a patient with a 2-week-old wound, the nurse notes the formation of granulation tissue in the wound bed and recognizes the wound is most likely in which phase of wound healing? 1) Proliferative 2) Maturation 3) Aggregation 4) Inflammatory

Which action would be appropriate to implement when collecting a 24-hour urine test? 1 Start the time of the test after discarding the first voiding. 2 Discard the last voiding in the 24-hour period for the test. 3 Insert a urinary retention catheter to promote the collection of urine. 4 Strain the urine after each voiding before adding the urine to the container.

Which action would the nurse take when collecting a client's 24-hour urine specimen? 1 Check to verify whether a preservative is needed. 2 Weigh the client before starting the collection. 3 Discard the last voided specimen of the 24-hour period. 4 Assess the client's intake and output for the previous 24-hour period.

Which instruction would the nurse provide a client needing to collect a clean-catch urine specimen? 1 'Urinate a small amount, stop flow, and then fill one half of the specimen cup:' 2 'Collect a sample of the last urine voided during the night!' 3 'If anticipating a delay in delivery, keep the urine sample in a warm, dry area.' 4 'Send the urine sample to the laboratory within 6 hours of collection.!

Which intervention by a nurse providing nasogastric feeding to an unresponsive patient indicates a correct technique of feeding? 1 Check residual volume every 4 to 6 hours, 2 Stimulate the gag reflex every 8 hours. 3 Administer only small amounts of the feeding formula. 4 Administer the feeding to the patient in a supine position.

Which process is the removal of devitalized tissue from a wound? 1 Debridement 2 Pressure reduction 3 Negative-pressure wound therapy (NPWT) 4 Sanitization

Which statement made by the student nurse about precautions to take when treating a client with open burn wounds indicates the need for further teaching? 1 "I should use nonsterile gloves when applying ointments." 2 "I should use nonsterile, disposable gloves when.removing old dressings." 3 "I should wear personal protective equipment before caring for the client." 4 "I should remove personal protective equipment before leaving one client to treat another."

While assessing a client's surgical incision, the nurse notes that it is dry, clean, and intact, with edges approximated. The nurse is aware that which type of healing is taking place? 1. First intention 2. Second intention 3. Third intention 4. Tertiary intention

While assessing a patient with a sacral pressure injury, which finding would the nurse use to support labeling the wound as a stage Il pressure injury? 1 Presence of a pink wound bed 2 Presence of nonblanchable erythema 3 Presence of a tunnel in the wound 4 Presence of a lip around the wound

Which change would the nurse assess for in a client who sustained skin injuries 3 days ago? Select all that apply. One, some, or all responses may be correct. 1 Local edema 2 Erythema 3 Pale color of scar tissue 4 Formation of scar tissue 5 Red colored granulation tissue

1 2

Which client complication may be caused by total parenteral nutrition (TPN)? Select all that apply. One, some, or all responses may be correct. 1 Hyperglycemia 2 Infection 3 Hepatitis 4 Anorexia 5 Dysrhythmias

1 2

A nurse providing care on a long-term care unit would identify which patient as having a high risk of developing pressure injuries? Select all that apply. One, some, or all responses may be correct. 1 A patient with spinal cord injury 2 A patient who is comatose 3 A patient with urinary incontinence 4 An immobile patient with excessive wound drainage 5 A postoperative patient after a laparoscopic cholecystectomy

1 2 3 4

Which manifestation in a patient who is on tube feeding suggests intolerance to feedings? Select all that apply. One, some, or all responses may be correct. 1 High gastric residual 2 Nausea 3 Vomiting 4 Constipation 5 Cramping

1 2 3 5

Which organ would the nurse expect to be involved when caring for a 16-year-old patient who has symptoms of malnutrition despite eating a well-balanced diet and whose stool samples reveal undigested fats? Select all that apply. One, some, or all responses may be correct. 1 Stomach 2 Liver 3 Gall bladder 4 Submandibular gland 5 Pancreas

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Which intervention would the nurse undertake before a scheduled intravenous pyelogram (IVP) for a client with a renal disorder? Select all that apply. One, some, or all responses may be correct. 1 Ensure that the consent form has been signed. 2 Assess the client for iodine sensitivity. 3 Have the client remove all metal objects. 4 Administer an enema or cathartic to the client. 5 Instruct the client to lie still during the procedure.

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When admitting an older adult patient to the hospital after a fall, which assessment finding places the patient at a higher risk of developing pressure ulcers? Select all that apply. One, some, or all responses may be correct. 1 Urinary incontinence 2 Diagnosis of Alzheimer's 3 Immobilization due to a leg fracture 4 Impaired sensory perception 5 Blood pressure of 112/78 mm Hg

1 3 4

Which point would be included when a nurse is teaching a program on healthy nutrition at the senior community center? Select all that apply. One, some, or all responses may be correct 1 Avoid grapefruit and grapefruit juice, which impair drug absorption. 2 Decrease the amount of milk consumed. 3 Take a multivitamin that includes vitamin D for bone health. 4 Cheese and eggs are good sources of protein. 5 Limit fluids to decrease the risk of edema.

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The nurse is caring for multiple clients. The nurse recognizes which clients as being at greatest risk for development of pressure injuries? Select all that apply. 1. A 32-year-old client who is quadriplegic 2. A 59-year-old one day postoperative 3. A 66-year-old with diabetes mellitus 4. A 40-year-old with bilateral leg casts 5. An 80-year-old with thin and inelastic skin

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Which food does the nurse include when preparing a diet plan for a patient with hypokalemia (low potassium)? Select all that apply. One, some, or all responses may be correct. 1 Fish 2 Olives 3 Oranges 4 Bananas 5 Cantaloupe

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A client is scheduled for a bronchoscopy. What should the nurse instruct the client about this procedure? Standard Text: Select all that apply. 1. Tissue samples may be taken for biopsy. 2. Eating will not be permitted for 12 hours. 3. A local anesthetic is sprayed on the throat. 4. Bed rest for 8 hours is necessary after the test. 5. Informed consent is required for this procedure

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Which physical sign is indicative of poor nutritional status in a 70-year-old hypertensive patient who has experienced a weight loss of 5 pounds? Select all that apply. One, some. or all responses may be correct. 1 Dry lips with cracks and fissures 2 Pain in the chest region 3 Flaccid, "wasted" muscles 4 Tiredness after climbing stairs 5 Hair that is dull, dry, and stiff-textured

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Which term would be used by a nurse conducting a health awareness program on eating disorders? Select all that apply. One, some, or all responses may be correct. 1 Anorexia in teens 2 Diabetes mellitus 3 Anorexia nervosa 4 Obesity in children 5 Bulimia nervosa

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The nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods would the nurse include in the teaching? Select all that apply. One, some, or all responses may be correct. 1 Carrots 2 Oranges 3 Tomatoes 4 Leafy greens 5 Cantaloupe

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The nurse needs to obtain a urine specimen from a client with an indwelling urinary catheter. What should the nurse do when collecting this specimen? Standard Text: Select all that apply. 1. Withdraw 30 mL of urine for a routine urinalysis. 2. Perform catheter care before obtaining the specimen. 3. Apply sterile gloves before retrieving the urine specimen. 4. Send the specimen immediately or refrigerate it for later pickup. 5. Clamp the drainage tubing for 30 minutes if there is no urine in the catheter

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Upon examination of a 56-year-old patient who is hemiplegic, the nurse providing care at the long-term care facility notices a pressure injury of the skin over the sacrum. Which factor may influence the development of bed ulcers in this patient? Select all that apply One, some, or all responses may be correct. 1 Chronic immobility can cause pressure injuries 2 Excessive moisture prevents pressure injuries. 3 Nutrition has no effect on pressure injury incidence. 4 Edema of the skin can cause pressure injuries. 5 Dehydration of the body can cause pressure injuries.

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Which statement describes negative pressure wound therapy? Select all that apply. One, some, or all responses may be correct. 1 A suction pump is used. 2 Necrotizing infections are treated. 3 Oxygen is administered under high pressure. 4 A low-voltage current is applied to a wound area. 5 Chronic ulcers are reduced by removing fluids from the wound.

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A client has a nasogastric feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. Which action would the nurse take first? 1 Instill normal saline into the tube to maintain patency. 2 Obtain an x-ray to verify that the tube is in the stomach. 3 Auscultate the epigastric area while instilling 30 mL of air. 4 Withdraw stomach contents to observe color and consistency.

A nursing student is listing factors that may improve the quality of life of clients in the community with chronic leg ulcers. Which factor listed by the nursing student needs correction? 1 Offer suggestions to improve a client's level of independence: 2 Inform clients that the cost of care may be expensive and that the level of pain may increase. 3 Instruct clients that as their wounds heal, their capability and desire to socialize with others may increase.' 4 'Understand that some clients have depression and anxiety related to the chronic nature of their wounds.'

The nurse assesses the client's incision site after bariatric surgery for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? 1 Loosening of the sutures 2 Sharp increase in serosanguineous drainage 3 Purplish color of the incision 4 Protrusion of organs through an open incision

The nurse in a long-term care facility is teaching a group of residents about increasing dietary fiber. Which foods should she explain are high in fiber? 1) White bread, pasta, and white rice 2) Oranges, raisins, and strawberries 3) Whole milk, eggs, and bacon 4) Peaches, orange juice and bananas

The nurse is assessing an ischial pressure ulcer on a client. She observes that the pressure ulcer is 3 cm × 2 cm × 1 cm and involves only subcutaneous tissue. The nurse also notes an area extending 3 cm from 12 o'clock to 3 o'clock under the wound edges. The nurse would document this as: 1) stage IV pressure ulcer with undermining of 3 cm from 12:00 to 3:00. 2) stage III pressure ulcer with undermining of 3 cm from 12:00 to 3:00. 3) stage IV pressure ulcer with sinus tract from 12:00 to 3:00. 4) tage III pressure ulcer with sinus tract from 12:00 to 3:00

The nurse is assisting a client with a diagnostic test. Which role should the nurse expect to perform in the intratest phase? 1. Assess the data. 2. Collect the specimen. 3. Observe the client. 4. Prepare the client

The nurse is caring for a client admitted with chronic venous insufficiency. The nurse assesses the client's lower extremities, which are edematous and discolored. Which additional finding should the nurse expect to find during assessment? 1. Sinus tract development on the ankles 2. Skin wounds known as stasis ulcers 3. Pressure injuries where the knees touch 4. Contusions from unsteady ambulation

The nurse is caring for a client immediately after surgery. During assessment the nurse notes sanguineous drainage on the client's dressing. Which action by the nurse is most correct? 1. Notify the physician about the possibility of hemorrhage. 2. Mark and initial the edges of the drainage, including the date and time. 3. Reinforce the dressing and monitor for additional bleed through. 4. Monitor vital signs for changes indicating excessive bleeding.

The nurse is caring for a client who is five days postoperative. The physician orders that every other staple be removed from the incision. The nurse notices that the staples appear to be far apart and after the first staple is removed, the incision begins to gap open. Which action will the nurse take? 1. Finish removing the staples as ordered. 2. Call the physician and report wound dehiscence. 3. Apply a sterile dressing and document the event. 4. Use adhesive strips to re-approximate the gaping edges.

The nurse is caring for a patient who is scheduled for a colonoscopy in 10 days. The nurse determines that the patient is taking aspirin daily to relieve knee pain. Which nursing intervention is best in this situation? 1 Teach the patient to take both vitamin E supplements and aspirin daily until the test. 2 Instruct the patient to discontinue aspirin for 1 week before undergoing the test. 3 Administer intravenous fluids for 1 hour after giving the patient aspirin before the test. 4 Instruct the patient to refrain from taking aspirin 3 hours before the test.

The nurse is providing care for a client with a surgical wound exhibiting signs of delayed healing but no redness or drainage. The physician orders a culture of the wound. Which condition does the nurse understand the culture will reveal? 1. A necrotic wound 2. A colonized wound 3. An infected wound 4. A closed wound

The nurse is providing care to a client who is receiving enteral feedings via a nasogastric (NG) tube. Which serious complication would the nurse take measures to prevent? 1 Skin breakdown 2 Aspiration pneumonia 3 Retention ileus 4 Profuse diarrhea

The nurse observes that an older client seldom eats the meat on the meal trays. The nurse discusses this observation with the client, and the client states, 'I only eat meat once a week because old people don't need protein every day. Which need would the nurse address in her or his reply? 1 Need for home-delivered meals 2 Foods that meet basic nutritional needs 3 Effect of aging on the need for some foods 4 Need for meat at least once per day throughout life

What should the nurse instruct a client for obtaining a clean voided urine specimen? 1. Collect at least 5 mL of urine. 2. Collect the first voided specimen in the morning. 3. Keep the specimen on ice. 4. Void in a sterile cup

When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia? 1 Giving influenza vaccine to the client 2 Having suction available during meals 3 Assisting the client to take deep breaths 4 Teaching about incentive spirometer use

Which action would the nurse confirm before approving a client's transfer to radiology for magnetic resonance imaging (MRI)? 1 The client received the scheduled preprocedure medications. 2 All metal objects, such as jewelry, hair ornaments, and clothing containing metal were removed. 3 Infusion of intravenous (IV) fluids completed per the preprocedure hydration protocol. 4 The client emptied the bladder, donned a gown that which opens in the front, and removed underwear.

Which physiological activity is associated with the 'proliferative phase' of normal wound healing? 1 White blood cells migrate into the wound. 2 Epithelial cells grow over the granulation tissue. 3 Scar tissue gradually becomes thinner and pale. 4 Vasodilation occurs with increased capillary permeability.

Which response indicates the need for further teaching when the nurse is teaching feeding techniques to the parents of a child who is unable to eat properly and is on complete bed rest? 1 "I should encourage my child to eat slowly." 2 "I should feed my child 1 hour before going to bed." 3 "I should place the bed at a 45-degree angle after eating." 4 "I should alternate feeding solid food and fluids to my child."

Which urinary system structure is largely responsible for storing urine? 1) Kidney 2) Bladder 3) Ureters 4) Nephrons

Which urine characteristic is consistent with a urinary tract infection? 1 Smoky 2 Cloudy 3 Orange-amber 4 Yellow-brown

In which order would the nurse explain the three phases of wound healing? 1 Proliterative phase 2 Infammatory phase 3 Maturation

2 1 3

A client who is 3 days postoperative states a slight increase in pain level from the day before. Which additional assessment will the nurse make to determine the condition of the client's wound? Select all that apply. 1. Skin turgor 2. Color of drainage 3. Type of closure 4. Odor of drainage 5. Closed or open

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The nurse provides care to an obese client who is at risk for pressure injuries. The client's plan of care places the client on pressure injury prevention. Which actions should the nurse be implementing? Select all that apply. 1. Turning the client from side position to prone position every 2 hours 2. Maintaining a bed with clean, dry linens that are free of wrinkles 3. Encouraging an adequate fluid intake and a nutritious diet 4. Performing hygiene care as needed to keep skin clean and moist 5. Assessing the client's skin every 2 hours for indications of breakdown

2 3 5

Arrange the events in the order that a nurse will follow to obtain a sterile urine specimen from an indwelling Foley catheter. 1 Clean the specimen port with an antiseptic 2 Empty urine from the tube into the drainage bag. 3 Clamp the catheter tube below the specimen port 4 Connect the syringe and transfer the urine sample. 5 Wait for 10 to 30 minutes to allow urine to accumulate in the tubing. 6 Place a waterproof pad under the catheter.

2 3 5 6 1 4

Upon finding redness, a foul odor, and increased drainage at the site of a patient's wound, which action, taken by a recently employed nurse, indicates a need for further teachings about wound care? Select all that apply. One, some, or all responses may be correct. 1 Uses gloves while dressing the wound 2 Covers the wound with a transparent film 3 Cleans the patient's wound using tap water 4 Uses a hydrocolloid dressing for the wound 5 Sends drainage samples for culture and sensitivity

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After the nurse teaches a client, who is obese, measures to calculate the body mass index, which client statement indicates effective learning? Select all that apply. One, some, or all responses may be correct. 1 "I should include sugared beverages in my diet!' 2 "I should lose at least half a pound to a pound each week." 3 "My daily nutritional fat intake should be more than 30%." 4 "'Il make sure to eat foods meeting my daily nutritional requirement." 5 "I should stay away from unhealthy foods between meals and after dinner."

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1. The nurse is caring for a client admitted through the emergency department (ED) following an accident. The client's injuries include an open fracture of the leg and multiple bruises. Which terminology will the nurse use to document the client's wounds? 1. Closed leg injury with multiple cuts 2. Massive bruising with broken bones 3. Compound leg fracture with multiple contusions 4. Puncture leg wound with surface skin scrapes

A 14-year-old adolescent with diabetes has been self-administering insulin twice a day. This morning, the parents found their child lethargic and confused. Laboratory testing reveals a hemoglobin Alc level of 10% and a blood glucose level of 200 mg/dL (11.1 mmol/L). Which occurrence would the nurse suspect as the cause of this client's condition? 1 Hypoglycemia 2 Somogyi effect 3 Uncontrolled blood glucose level 4 Noncompliance with the prescribed insulin regimen

A client arrives at a clinic with a wound received by an ax two days ago while cutting firewood. The client states that initial wound care was performed at home. The nurse assesses a deep open wound on the lower leg, which will need surgical closure. Which complication does the nurse recognize is a probability for this client? 1. Delayed healing because of the passage of time before surgery 2. The possibility of lower limb amputation due to muscle damage 3. A high risk for infection from Staphylococcus aureus contamination 4. A wound that will be treated by using a secondary intention closure

A client asks the nurse, Why do I have to monitor my blood glucose levels? What is an appropriate response from the nurse? 1. Because your doctor ordered it. 2. If I were you, I would monitor the blood glucose when I didnt feel good. 3. Monitoring your blood glucose better enables you to manage your diabetes. 4. You can eat anything you want.

The nurse is caring for a client who was involved in a motor vehicle accident. The client was thrown from the vehicle and has several areas where skin appears to have been scraped away. The nurse identifies the wounds as abrasions. Which statement is true about this type of wounds? 1. They are much like burns and take an extended period of time to heal. 2. They involve deep tissue and can cause muscle and bone infection. 3. They are generally superficial and will heal quickly if kept clean. 4. They will require systemic antibiotics for treatment of infection.

The nurse is caring for a patient who has multiple fractures from a skiing accident. To best promote bone growth, the nurse should encourage the patient to eat foods high in calcium and vitamin D. Which food selection by the client indicates an understanding of foods that are high in calcium? 1) Orange juice from concentrate 2) Cottage cheese 3) Tofu 4) Brie cheese

The nurse is preparing to clean a surgical wound that is closed with staples. Assessment reveals that the incision is clean, dry, well approximated, and without redness or tenderness. Which wound cleaning procedure will the nurse use? 1. Use antiseptic swabs and clean from the inferior end of the incision to the superior end. 2. Use antiseptic swabs and clean around the wound using a wide circular motion. 3. Use forceps with a sterile antiseptic swab and move from the superior to the inferior end. 4. Use an antiseptic swab to cleanse the left side, right side, and then the center of the incision.

The nurse is preparing to irrigate a client's wound with a syringe and sterile saline. Which action by the nurse demonstrates correct procedure? 1. The irrigation of the wound is performed slowly to eliminate client discomfort. 2. The nurse places the tip of the syringe against the skin to help debride the wound. 3. The solution flow is directed from the least contaminated to the most contaminated area. 4. The wound is irrigated with high pressure in order to force out pathogens

The nurse is providing care for a client with a stage III pressure injury on the right trochanter area. The physician has ordered the use of hydrocolloid dressings. Which action will the nurse perform in the maintenance of the prescribed dressing? 1. Change the dressing daily to prevent infection from collected drainage. 2. Use warm compresses to keep the dressing flat and adhered to the skin. 3. Inspect the dressing for escaping drainage, wrinkling, and excessive exudate. 4. Document the application process and a description of the wound.

The nurse is providing care for multiple clients in an extended care facility. Which client does the nurse identify for being at the most risk for the development of pressure injuries? 1. An elderly client with daily urinary incontinence 2. A client who is immobile and underweight for age and height 3. An elderly client with diabetes mellitus who is immobile 4. A client who has limited mobility due to poor circulation

The nurse is reviewing laboratory results for a client. Which diagnostic study determines how well blood glucose levels have been controlled in the client? 1. Blood chemistry 2. Capillary blood glucose 3. Hemoglobin A1c 4. Serum electrolytes

Two days after delivery a client has a temperature of 101°F (38.3°C), general malaise, anorexia, and chills. Which clinical finding would the nurse expect to identify on the client's laboratory report? 1 Increased hemoglobin level 2 Decreased C-reactive protein 3 Increased white blood cell (WBC) count 4 Right-shift differential WBC count

Which action would the nurse implement for a client scheduled for surgery who reports a history of methicillin-resistant Staphylococcus aureus (MRSA) in a healed surgical site from 9 months ago? 1 Notify the infection control officer and obtain blood cultures. 2 Inform the operating room of the MRSA infection. 3 Obtain an order for a polymerase chain reaction (PC) screen. 4 Call the surgeon for an infectious disease consultation.

Which action would the nurse take when a client who had a total hip replacement states that the plan is to go swimming at the community pool the day after discharge? 1 Tell the client to take a friend along for safety. 2 Encourage participation in this activity because it provides excellent range-of-motion exercise. 3 Explain that the incision should not be immersed in water until it has healed. 4 Let the client know that swimming can substitute for the prescribed physical therapy.

Which condition in a client with a brain injury is contraindicated for magnetic resonance imaging (MRI) with contrast? 1 Renal failure 2 Claustrophobia 3 Metal aneurysm clips 4 Soft tissue imaging needs

Which condition would the nurse expect to find in a patient with a troponin I value of 0.8 ng/ml? 1 Liver tissue injury 2 Brain tissue injury 3 Cardiac muscle injury 4 Skeletal muscle injury

Which condition would the nurse question using a negative-pressure wound treatment device? 1 Chronic ulcer 2 Upper thigh wound 3 Hip wound with slight bleeding 4 Treated osteomyelitis within the vicinity of the wound

Which description would the nurse associate with serous drainage from a wound? 1 Fresh bleeding 2 Thick and yellow 3 Clear, watery plasma 4 Beige to brown and foul smelling

Which factor increases the risk of wound infection? 1 Absence of necrotic tissue 2 Absence of foreign body in the wound 3 Reduced local tissue defenses 4 Adequate blood supply

Which is a key treatment intervention for the patient admitted with diverticulitis? 1) Antacid 2) Antidiarrheal agent 3) Antibiotic therapy

Which other nutrient would the nurse include in the teaching while counseling the parents of an adolescent with anemia related to an inadequate diet after explaining that several different nutrients, including protein, iron, and vitamin B 12, are involved? 1 Calcium 2 Thiamine 3 Folic acid 4 Riboflavin

Which procedure is the client undergoing when a nurse explains that contrast dye will be administered before a diagnostic procedure and instructs the client to drink lots of fluids after the procedure? 1 Renal scan 2 Electromyography 3 Computed tomography 4 Kidney ultrasonography

Which process would the nurse use to determine the length of tube needed to reach a client's stomach for nasogastric feeding? 1 The tube is advanced until resistance is met. 2 The tube is advanced until gastric contents are aspirated. 3 A measurement is made from nose to earlobe and then to the epigastric area. 4 A measurement is made from mouth to umbilicus and then half that distance is added.

Which rationale is correct for the nurse to empty a Hemovac wound suction device when it is half full? 1 Emptying the unit is safer when it is half full. 2 Accurate measurement of drainage is facilitated. 3 Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. 4 Fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound

Which represents appropriate nursing management of a client's nasogastric (NG) tube in the immediate postoperative period after gastroduodenostomy? 1 Advancing the tube to the original insertion depth if the tube becomes dislodged 2 Obtaining a prescription to vigorously irrigate the nasogastric tube if clogging is noted 3 Carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working 4 Reporting the presence of bright red gastric aspirant in the suction canister during the immediate postoperative period

Which statement indicates the nurse has a correct understanding of kidney ultrasonography? 1 'Kidney ultrasonography primarily makes use of iodinated contrast dye. 2 "Kidney ultrasonography is performed on the client with an empty bladder" 3 "Kidney ultrasonography makes use of sound waves and has minimal risk.! 4 "Kidney ultrasonography provides three-dimensional information regarding kidneys.

Which term would the nurse use to describe the exudate characteristic of a serosanguineous wound? 1 Greenish-blue pus 2 Creamy yellow exudate 3 Blood-tinged amber fluid 4 Beige pus with a fishy odor

Which would the nurse conclude about a client when planning teaching strategies based on the results of a glycosylated hemoglobin measurement of 6%? 1 The client is experiencing a rebound hyperglycemia. 2 The client needs the insulin changed to a different type. 3 The client has followed the treatment plan as prescribed. 4 The client requires further teaching regarding nutritional guidelines.

Which would the nurse include in the plan of care for a toddler who follows a vegetarian or vegan diet? 1 Monitoring an arterial blood gas analysis 2 Monitoring serum sodium concentrations 3 Monitoring for hemoglobin and hematocrit 4 Monitoring serum potassium concentrations

While performing a needle aspiration biopsy, the health care provider inserts the needle into the pleural...cavity. Which complication is being assessed in the patient? 1 Meningitis 2 Pancreatitis 3 Hemothorax 4 Cardiac failure

Which action would the nurse take to decrease the patient's risk of developing pressure injuries? Select all that apply. One, some, or all responses may be correct. 1 Position the patient in the most comfortable position and do not move 2 Cover the hyperemic skin area with a sterile dressing and apply antiseptics. 3 Check the skin around the casts regularly for any signs of impaired skin integrity. 4 Take care to avoid friction injuries during repositioning, bathing, or transferring of the patient. 5 Use good hygiene techniques to ensure the patient's skin is clean and dry after bowel movements.

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All women of childbearing age are advised to include at least 400 mg of folic acid in the daily diet to decrease the risk of neural tube defects in pregnancy. Which foods or supplements would the nurse recommend to meet the recommendation? Select all that apply. One, some, or all responses may be correct. 1 Vitamin A 2 Vitamin B 6 3 Vitamin B 9 4 Vitamin B 12 5 Legumes, dark-green leafy vegetables, and citrus fruits 6 Eggs, meat, and poultry

3 5

A client is admitted to the hospital with a diagnosis of acute pancreatitis. The health care provider's prescriptions include nothing by mouth and total parenteral nutrition (TPN). The nurse explains that the TPN therapy provides which benefit? 1 Is the easiest method for administering needed nutrition 2 Is the safest method for meeting the client's nutritional requirements 3 Will satisfy the client's hunger without the discomfort associated with eating 4 Will meet the client's nutritional needs without causing the discomfort precipitated by eating

A client with dementia is discharged home with a percutaneous endoscopic gastrostomy (PEG) tube in place. A family member receives instructions about how to care for the tube Which action observed by the home health nurse indicates that the family member is effectively managing the client's care? 1 Keeps the empty feeding bag attached to the tubing 2 Flushes the tube with air after medication is given 3 Replaces the tube on a weekly basis 4 Elevates the head of the bed after the feeding

The nurse assesses a client's wound. Which documentation will the nurse make to indicate a possible infection? 1. Dressing intact, with a small amount of serosanguineous drainage 2. Incision line well approximated, moderate amount of drainage noted 3. Incision intact, suture line is well approximated, and no drainage 4. Incision intact, moderate amount of purulent drainage, foul odor

The nurse is providing care for a client readmitted to the hospital following a modified mastectomy. The nurse notes that the primary surgical wound is inflamed, painful, and edematous. Under the client's arm, the nurse notices a small open area draining a moderate amount of green drainage. Which condition does the nurse identify? 1. Infection in a contaminated surgery wound 2. Skin breakdown caused from migrated drainage 3. Stasis ulcer from decreased arm movement 4. Sinus tract between infected and healthy tissue

The nurse is providing discharge teaching to a client who had surgery to remove a growth on the tongue. The nurse understands that the surgery site is identified as a clean-contaminated wound. Which teaching will the nurse provide? 1. The wound is considered to have been grossly contaminated during surgery. 2. Due to the location of the wound, the presence of purulent drainage is expected. 3. Mouth wounds are known to heal quickly and usually without complications. 4. Because of the normal flora in the mouth, the wound is at risk for infection.

When repositioning an immobile patient, the nurse notices redness over a bony prominence. Which condition would the nurse associate with a reddened area that becomes lighter on fingertip touch? 1 A localized skin infection requiring antibiotics 2 Sensitive skin that requires special linen for the bed 3 stage Ill pressure injury needing the appropriate dressing 4 Blanching hyperemia, indicating body's attempt to overcome the ischemic episode

Which action would the nurse expect the health care provider to perform for a patient with symptoms of pharyngitis and a negative rapid antigen detection test (RADT)? 1 Prescribe saltwater gargles for the patient. 2 Initiate medical treatment immediately. 3 Recommend additional urine and blood tests. 4 Wait for the report from the throat culture.

Which action would the nurse plan to take to prevent aspiration in a client who has just returned to the nursing unit after bronchoscopy? 1 Administer oxygen through a nasal cannula. 2 Have the client rest in the supine position. 3 Suction oral secretions at frequent intervals. 4 Withhold food until the gag reflex returns.

Which blood collection tube does the nurse use to collect the blood sample for a coagulation test? 1 A tube with a gray stopper 2 A tube with a yellow stopper 3 A tube with a lavender stopper 4 A tube with a light blue stopper

Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion? 1 Choking 2 Redness 3 Gagging 4 Cyanosis

Which daily diet recommendation would the nurse reinforce with a client who has arthritis? 1 Wheat germ and yeast 2 Yogurt and blackstrap molasses 3 Multiple vitamin supplements in large doses 4 Foods from a variety of food groups

Which information about a client who is scheduled for magnetic resonance imaging (MRI) of the chest would be most important for the nurse to report to the health care provider before the procedure? 1 Client reports being claustrophobic. 2 Client has shellfish and iodine allergies. 3 Client has multiple facial and body piercings. 4 Client has surgical clips in place after craniotomy.

Which organ relies almost exclusively on glucose for energy? 1) Liver 2) Heart 3) Pancreas 4) Brain

Which phrase describes a hydrocolloid dressing? 1 A seaweed derivative that is highly absorptive 2 Premoistened gauze placed over a granulating wound 3 A debriding enzyme that is used to remove necrotic tissue 4 A dressing that forms a gel that interacts with the wound surface

Which principle would be considered when caring for a client with a closed wound drainage system? 1 Gravity causes fluids to flow down a pressure gradient. 2 Fluid flow rate is determined by the diameter of the lumen. 3 Siphoning causes fluids to flow from one level to a lower level. 4 Fluids flow from an area of higher pressure to one of lower pressure.

While caring for a client with a portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. Which nursing intervention would the nurse do next? 1 Circle the drainage on the dressing. 2 Irrigate the suction tube with sterile saline. 3 Clean the drainage port with an alcohol wipe. 4 Compress the container before closing the port.

While obtaining a blood sample via a venipuncture, for which reason would the nurse not leave the tourniquet on for a long period of time? 1 To minimize the risk of hemolysis 2 To minimize the risk of infection 3 To minimize the risk of hemorrhage 4 To minimize the risk of hemoconcentration

The nurse is collecting a sample of gastric contents to determine the pH for a patient who is on enteral feeding through a nasogastric (NG) tube. Arrange the actions performed by the nurse in the correct order. 1 Compare the color on the test strip to the color chart provided by the manufacturer. 2 Discard gloves and wash hands 3 Slowly pull the plunger back to obtain at least I ml. of aspirate(5 to 10 ml is ideal 4 Apply a drop of aspirate to the pH test paper, following the manufacturers instructions 5 Wash hands thoroughly and put on gloves, 6 Connect a 50- to 60-ml. syringe to the NG or nasotracheal (NT) tube

5 6 3 4 1 2

The nurse is ambulating Mr. Sanchez, who had a bowel resection yesterday. Suddenly, Mr. Sanchez states, "It feels like I've popped open." The nurse observes that the abdominal incision has opened 3 inches and a small section of the bowel is protruding. In addition to calling the physician immediately, the nurse would do which of the following? A. Place the patient supine in bed, knees flexed, and cover the wound with sterile gauze soaked with sterile saline B. Position the patient prone to put pressure on the area, and instruct him not to cough. C. Place the patient supine in bed, legs flat, and cover the wound with dry, sterile dressings. D. Position the patient in Trendelenburg's position, knees flexed, and cover the wound with an occlusive dressing

The nurse is caring for a patient who has diabetes. The patient reports compliance with the medical regime. Which test result indicates to the nurse that the patient has not been compliant with the treatment plan? a. Hemoglobin A1c 16% b. Random blood sugar (RBS) 112 mg/dL c. Lactate dehydrogenase (LDH) 55 units/L d. Erythrocyte sedimentation rate (ESR) 14 mm/hr

The nurse is caring for a patient who has undergone a cystoscopy. Which action will the nurse take when the patient expresses concern about passing pink-colored urine? a. Explain to the patient that it is a normal finding. b. Send the patient's urine sample for examination. c. Administer the prescribed antibiotic to the patient. d. Notify the health care provider immediately.

The nurse is caring for a patient who is scheduled for a needle aspiration and biopsy to rule out cancer. Which Nursing diagnosis is appropriate and important for this patient? a. Anxiety related to potential for cancer diagnosis depending on biopsy results b. Impaired health maintenance related to delayed insurance coverage for procedure c. Powerlessness related to lengthy wait for diagnosis d. Ineffective coping related to patient stated she is a little nervous about the test results

The nurse is caring for a patient who will be undergoing bone marrow biopsy. Which statement by the patient indicates that additional teaching is needed? a. "I will count the ceiling tiles when the doctor inserts the numbing medicine." b. "I will take acetaminophen later today if the site becomes uncomfortable." c. "I will squeeze your hand to help calm my fears about the test." d. "I will keep the biopsy site clean and dry for the next 24 hours."

Which prescribed action would the nurse perform first when caring for a client with hemodynamically stable sepsis who complains of abdominal pain? a. Draw peripheral blood cultures from two different sites. b. Administer levofloxacin 500 mg intravenously over 30 minutes. c. Administer 1 L intravenous bolus of Ringer's lactate over 30 minutes. d. Take the client to x-ray for an abdominal computed tomography (CT) scan.

The nurse is caring for a patient who is undergoing a liver biopsy. Which interventions will be included in the patient's care plan for the diagnosis of risk for infection: r/t invasive diagnostic procedure? (Select all that apply.) a. Monitor for and report redness, warmth, discharge, or fever promptly to the physician. b. Carefully maintain the sterile field during the biopsy procedure. c. Teach patient how to care for the biopsy site when procedure is completed. d. Provide a supportive, caring presence to minimize patient anxiety. e. Provide information about the pathophysiology and treatment options for liver cancer. f. Consider using healing touch and other mind-body-spirit interventions.

a b c

The nurse is caring for a patient who is anemic. Which CBC test results demonstrate that the patient's treatment plan is effective and the anemia is resolving? (Select all that apply.) a. Red blood cell count (RBC) 5.8 million/mm3 b. Hematocrit (HCT) 25% c. Hemoglobin (HGB) 14 g/dL d. White blood cell count (WBC) 4500/mm3 e. Platelet count (PLT) 255,000/mm3

a c

The nurse is caring for an elderly patient who has residual weakness on the right side as the result of a cerebrovascular accident (stroke). The nurse is correct in reporting dysphagia when the patient exhibits which symptoms? (Select all that apply.) A Incomplete lip closure B Presence of a normal gag reflex C A change in voice quality after eating D Difficulty speaking, with a slow, weak voice E Abnormal movements of the mouth, tongue, and lips

a c e

The nurse is caring for a patient who has been having abdominal pain. The doctor suspects that the patient may have an abdominal aortic aneurysm. Which tests would confirm the doctor's suspicion? (Select all that apply.) a. Magnetic resonance imaging (MRI) scan b. Needle aspiration with biopsy c. Fiberoptic endoscopy d. Computed tomography (CT) scan e. Flexible sigmoidoscopy f. Thoracentesis

a d

The nurse is caring for a patient who needs to collect a 24-hour urine specimen at home. Which steps of specimen collection may be delegated to the assistant? (Select all that apply.) a. Label the urine container and lab slips with the patient's name and information. b. Assess the patient's ability to collect the specimen as required. c. Explain the procedure to the patient. d. Obtain the urine container from the utility room or laboratory. e. Transport the specimen to the laboratory once it is collected. f. Ensure that the correct test is ordered and collected.

a d e

The nurse is preparing a patient for an esophagogastroduodenoscopy (EGD). Which statements by the patient indicate that the patient has understood the nurse's teaching? (Select all that apply.) A "The doctor will be able to view my stomach during the test." B "I will be able to have something to drink immediately after the test." C "There are no risks involved with this test." D "The doctor will be able to see whether there is an ulcer in my stomach E "I will be NPO for 8 hours before the test"

a d e

A client reports a loss of 20 pounds (9 kg) in 3 months and black, tarry stools. A colonoscopy is scheduled. Which instructions would the nurse give to prepare the client for this test? a. The nurse instructs the client that a bland diet will be prescribed for the night before the test. b. The nurse tells the client not to eat or drink anything the morning of the test. c. The nurse administers an oil-retention enema just before the test. d. The nurse explains that the pretest laxative will cause diarrhea after the test.

Mr. Smith had a small basal cell carcinoma lesion removed from his back. The plastic surgeon removed an area of skin 3 inches (7.5 cm) in diameter and ½ inch (1.2 cm) deep around and under the lesion and left the wound open to heal. The wound will heal by: A. primary intention. B. secondary intention. C. third intention. D. tertiary intention

The nurse is caring for a patient with diabetes who will be doing fingerstick blood glucose testing at home. What is the best way for the nurse to ensure that the patient can perform the procedure correctly? a. Quiz the patient on the steps of the procedure. b. Have the patient perform the procedure in front of the nurse. c. Ask the patient if he has any questions about the test. d. Use terminology that the patient can easily understand.

The nurse is working at a health fair and providing information about reducing the risk of heart disease. A male asks what his ideal numbers should be for cholesterol and triglycerides. Which of the following is correct? A Total cholesterol: >200 mg/dL B HDL: >45 mg/dL C LDL: >100 mg/dL D Triglycerides: >160 mg/dL

The patient states that she has been taking Coumadin, an anticoagulant, for several years. The nurse notices several bruised areas on her arms. Which of the following laboratory results is clinically significant? A Platelets: 450,000 B Prothrombin time: 24.2 seconds C Activated partial thromboplastin time: 30 seconds D Fibrinogen:350 mg/dL

The physician has prescribed enemas for Mr. Gray until the return is clear. The nurse is to use a hypertonic solution. The nurse would question the order if Mr. Gray had which of the following conditions? A. Constipation B. Chronically elevated BUN and creatinine C. Peptic ulcer disease D. Multiple sclerosis

Which of the following is a complication of wound healing? A. Three centimeters of sanguineous fluid on a surgical dressing B. Hypotension and increased pain at the surgical site C. Presence of beefy red tissue in the center of a closing wound D. Low-grade temperature

A young adult female is considering becoming pregnant and is not taking any multivitamins. Which instruction would best help reduce the potential for the development of neural tube defects in the fetus? A Discuss taking selenium supplements with meals. B Stress the importance of prenatal exercise. C Recommend folic acid dietary supplements. D Inquire about the patient's diet and birth control method.

What nursing intervention would be most beneficial to implement in an effort to prevent aspiration by a patient receiving tube feedings? A Check the pH of stomach contents before starting each feeding B Hold prescribed medications until after each feeding. C Elevate the head of the patient's bed at least 45 degrees D Slow the delivery of the tube feeding to 15 mL/hour.

Which client finding would the nurse document as a pulse deficit? a. Blood pressure of 130/70 mm Hg indicating pulse deficit of 60 b. Capillary refill greater than 3 seconds indicating pulse deficit c. Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8 d. Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10

The nurse is caring for a patient who is to collect a 24-hour urine specimen. Which statement by the patient indicates that additional teaching is required? a. "I will keep the urine container on ice to keep it chilled until I bring it to the lab." b. "I will start the test over if I forget and urinate into the toilet during the testing time." c. "I will start the test tomorrow after I urinate first thing in the morning." d. "I will drink extra fluids so that the lab will have a large specimen to test."

During the assessment of an older adult patient, the nurse finds the patient is susceptible to developing a pressure injury. Which action would the nurse take to prevent a pressure injury for this patient? Select all that apply. One, some, or all responses may be correct. 1 Change the patient's position once every 2 hours. 2 Elevate the head of the bed to a 50-degree angle. 3 Prevent the patient's inner knees from pressing onto each other. 4 Avoid using pillows to elevate the patient's legs. 5 Avoid placing the patient in positions that increase stress on bony prominences.

1 3 5

When a client with chronic dyspnea is scheduled for computed tomography (CT) using contrast, which assessment information would the nurse communicate to the health care provider before the procedure? Select all that apply. One, some, or all responses may be correct. 1 Metformin taken today 2 Hematocrit 38% 3 Serum creatinine 2.1 mg d/L (185.6 umol/L) 4 Coronary artery disease history 5 Shellfish allergy 6 Respiratory rate 22 breaths per minute

1 3 5

A primary health care provider schedules a bone scan for a client with osteoporosis. Which nursing action is beneficial for the client? Select all that apply. One, some, or all responses may be correct. 1 Placing the client in the supine position 2 Verifying presence or absence of a shellfish allergy 3 Ensuring the client does not have metal on their clothing 4 Instructing the client to empty their bladder before the scan 5 Informing the client that the postprocedure headache resolves in 2 days

1 4

Which intervention could result in further tissue necrosis when the registered nurse (RN) delegates the tasks of caring for a client with pressure ulcers? 1 Cleaning of the wound by the RN 2 Performing irrigation of the wound by the patient care associate (PCA) 3 Administering of oral analgesics by the licensed practical nurse (LPN) 4 Repositioning the client every 1 to 2 hours by the licensed practical nurse (LPN)

Which blood level is commonly tested to help assess kidney function? 1) Hemoglobin 2) Potassium 3) Sodium 4) Creatinine

Which vitamin is essential for the synthesis of prothrombin by the liver? 1 B12 2 C 3 D 4 K

The nurse is caring for a patient who is to have a noncontrast MRI scan performed. Which assessment finding leads the nurse to report that the patient may not be able to have the test? a. The patient has an implanted insulin pump. b. The patient is breastfeeding her newborn infant. c. The patient is severely allergic to iodine and latex. d. The patient has profound hearing loss.

A 15-year-old female gymnast is hospitalized with the diagnosis of bulimia nervosa. Which data would the nurse anticipate finding in the patient's admission history and physical assessment? A Excessive intake of food, self-induced vomiting, and use of laxatives B Refusal to eat, body image disturbance, constipation, and amenorrhea C Excessive exercise, refusal to eat, poor muscle tone, and social isolation D Hair loss, BMI of 27, occasional use of diuretics, calorie intake 2200/day

According to the text calculations, which of the following patients is taking in the correct number of kcal to meet their total energy needs? Choose all that apply. A. Mr. Jones, who weighs 180 lb, is active, has a normal weight, and is taking in 3,240 kcal per day. B. Mrs. Sanchez, who weighs 220 lb, is sedentary, overweight, and taking in 1,000 kcal per day. C. Susan, who weighs 100 lb, is slightly underweight, plays soccer three times a week, and is taking in 1,500 kcal per day. D. Mr. Clark, who works a desk job, weighs 190 lb (a normal weight for his height), and is currently taking in 2,800 kcal per day.

Mr. Grant has just had a lumbar puncture. Which of the following notes would be important to document on his plan of care? A He is to lie flat for at least 4 hours B He should remain NPO for at least 4 hours. C The nurse should assess for signs of postprocedure hypertension. D The nurse should hold all sedatives and narcotics for at least 4

The nurse is caring for a patient who will be undergoing flexible sigmoidoscopy testing to screen for colon cancer. What goal will the nurse include in the patient's plan of care? a. Patient will verbalize understanding of preprocedure preparation to be completed at home the day before the test. b. Patient will feel comfortable about the upcoming test and have trust in the health care providers. c. Patient will learn common side effects of the medications used to prepare the GI tract for endoscopy testing. d. Patient will realize how important regular sigmoidoscopy testing is in the prevention of colon cancer.

The nurse is caring for a patient whose immune system is destroying red blood cells at a very rapid rate. Which test result will the nurse expect to see in the patient's chart as a result? a. Bilirubin level 4 mg/dL b. Platelet count 450,000/mm3 c. Serum uric acid level 1.7 mg/dL d. Partial thromboplastin time 45 seconds

The nurse is caring for a woman who has a cyst in her breast that was found at her recent mammogram. The physician wants to make sure that the cyst is not malignant. Which test will be used to determine this? a. Needle aspiration with biopsy b. Paracentesis c. Thoracentesis d. Fiberoptic endoscopy

Which action would be appropriate to implement when collecting a 24-hour urine test? a. Start the time of the test after discarding the first voiding. b. Discard the last voiding in the 24-hour period for the test. c. Insert a urinary retention catheter to promote the collection of urine. d. Strain the urine after each voiding before adding the urine to the container.

Which finding does the nurse expect when reviewing the mean corpuscular volume for patient with thalassemia major. a. 70 cells/mm b. 88 cells/mm c. 100 cells/mm d. 108 cells/mm?

Which finding indicates that a patient has a pseudomonal urinary tract infection? a. Bluish or greenish color of the urine b. Dark yellow to amber color of the urine c. Light yellow to amber color of the urine d. A very pale yellow color of the urine

Which laboratory test is important for the nurse to monitor when a client is admitted with acute coronary syndrome? a. Troponin b. Myoglobin c. Homocysteine d. Creatine kinase (CK)

Which of the following factors puts the patient at greatest risk for impaired skin integrity? A. Peripheral vascular disease B. Tanning once a week C. An 1,800-calorie diet D. A temperature of 101.5°F

The nurse is caring for a patient who is taking medication that is toxic to the liver. Which laboratory test results will be reviewed by the nurse to ensure that the patient's liver is tolerating the medication without damage to the organ? (Select all that apply.) a. Alanine aminotransferase (ALT) b. Alkaline phosphatase (ALP) c. Blood urea nitrogen (BUN) d. Anti-nuclear antibody (ANA) e. Erythrocyte sedimentation rate (ESR) f. Fibrin degradation products (FDP)

a b

A patient recovering from major abdominal surgery is to be progressed from a clear liquid diet to the next diet level. Which statement by the nurse would be most appropriate in this circumstance? A "You will progress from a clear liquid diet to a mechanical soft diet" B "If you can tolerate the clear liquid diet, your next meal will be a full liquid." C "You will receive a regular diet tray with anything you want at the next meal. D "It is important that you eat a pureed diet after you are able to tolerate the clear liquids.

A patient's urine specific gravity has been reported at 1.035. Which of the following nursing actions would be appropriate? A. Start an IV of normal saline at 150 mL per hour. B. Encourage the patient to increase fluid intake. C. Insert a straight catheter to assess for urinary retention. D. Obtain an order for fluid restriction from the physician

Identify the patient with the greatest risk for developing protein-calorie malnutrition. A patient: A. who is HIV positive B. with a fractured leg and pelvis from trauma who is running a fever of 101.5°F (38.6°C) C. weighing 300 lb who has entered the hospital for cardiac bypass surgery D. who is of Hispanic heritage

The nurse is caring for a patient who recently had a liver biopsy. To whom must the nurse give the results? a. The patient b. The patient's health care provider c. The patient's insurance provider d. The patient's spouse

Jan is an RN, and today she is working with Mary, the new nursing assistant. The nursing supervisor knows that Jan understands proper delegation in relationship to wound care when she asks Mary to: A. debride a clean wound healing by primary intention. B. evaluate how treatment is working for a decubitus ulcer. C. turn a comatose patient every 2 hours. D. irrigate an open wound using vigorous flushing

Mrs. Sanchez is awaiting surgery for a right hip fracture. The physician suspects that Mrs. Sanchez has a urinary tract infection. The nurse anticipates that the physician will order which of the following? A. Freshly voided urine specimen in the morning B. Clean-catch specimen C. Sterile urine specimen D. 24-hour urine collection

The nurse is caring for a patient who has a bleeding gastric ulcer. How will the nurse expect the patient's stool to appear? a. Soft and formed with bright red streaks b. Watery with particles of undigested food c. Sticky and black d. Hard lumps that are difficult to pass

The nurse is caring for a patient who has multiple fractures from a skiing accident. To best facilitate bone growth, the nurse should encourage the patient to eat foods high in calcium and vitamin D. Which food selection by the client indicates an understanding of foods that are high in calcium? A. Orange juice B. Peanut butter C. Tofu D. Baked flounder

The nurse is caring for a patient who is having blood drawn as part of preoperative testing. Which step is the most important to ensure the safety of the patient and the nurse? a. Ensuring that the tourniquet is not left in place for too long b. Using the smallest possible needle for venipuncture c. Properly disposing of the needle after the specimen is obtained d. Making sure that all of the collection tubes are filled completely

The nurse would suspect an alteration in a patient's nutritional status if she notes which of the following? A. Fasting serum blood glucose of 87 mg/dL B. BUN of 16 mg/dL C. Serum albumin level of 1.8 g/dL D. Total white blood cell count of 6,000/mm3

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food items in a list provided to the client? A Tomato soup B Boiled shrimp C Instant oatmeal D Summer squash

Mrs. Jackson is a 58-year-old woman with no family history of colorectal cancer. Which of the following screening guidelines would you recommend? A Fecal occult blood testing every 5 years B Sigmoidoscopy every 10 years C Cystoscopy every 5 years D Colonoscopy every 10 years

The health care provider instructs the nurse to prepare a patient with a cardiac disorder for a magnetic resonance imaging (MRI) procedure. Which condition would the nurse check for in the patient's medical records? a. History of a heart attack b. History of bypass surgery c. History of a heart transplant d. History of a pacemaker insertior

The nurse is caring for a patient who has just undergone paracentesis. For which complication will the nurse carefully monitor? a. Collapse of the lung with shortness of breath b. Fecal impaction from retained barium in the colon c. Cerebrospinal fluid leak resulting in severe headache d. Perforation of the bowel resulting in abdominal infection

The nurse is caring for a patient who will be receiving iodine-based contrast medium for a CT scan. Which allergy should be reported to the technician and radiologist before the test is performed? a. Gluten and lactose b. Strawberries and blueberries c. Peanuts and cashews d. Shrimp and scallops

A client is having a lumbar puncture. In which position should the nurse place the client? 1. Lateral with head bent toward the chest and knees flexed onto the abdomen 2. Lying prone, with the knees drawn up toward the abdomen 3. Sitting bent over from the waist with legs extended 4. Supine with knees pulled toward the chest

A patient who underwent surgery for removal of a pituitary tumor develops a condition in which the kidneys are unable to conserve water and the quantity of urine voided increases. Which urine specific gravity would the nurse expect to find in the patient with this disorder? 1) 1.001 2) 1.010 3) 1.025 4) 1.030

The nurse is preparing to collect a throat culture from a client. What client response indicates to the nurse that teaching about this test has not been effective? 1. I need to hyperextend my neck. 2. I need to say ah.' 3. I will need to sit up. 4. The nurse will use a light.

The nurse is teaching a client with heart failure about diagnostic tests. Which test should the nurse emphasize in this teaching? 1. BNP 2. CBC 3. LDH 4. PKU

When inserting an indwelling urinary catheter in a male patient, the nurse cleanses the penis with an antiseptic wash. Which step should she take next? 1) Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant. 2) Ask the patient to bear down as though trying to void. 3) Slowly insert the end of the catheter into the urinary meatus. 4) Insert the catheter about 7 to 9 inches (17 to 22.5 cm) or until urine flows

The nurse is caring for a client who has just had a lumbar puncture. What should the nurse document about this clients procedure? Standard Text: Select all that apply. 1. Date and time performed 2. The physicians name 3. The clients ability to void after the procedure 4. The color, character, and amount of cerebrospinal fluid withdrawn 5. The clients status after the procedure

1 2 4 5

A client has just completed a bone marrow biopsy. What should the nurse document about the client at this time? Standard Text: Select all that apply. 1. Clients tolerance of the procedure 2. Bowel sounds 3. The site for bleeding 4. Status of deep tendon reflexes 5. Presence of pain and any pain medication received

1 3 5

A client is scheduled for a nuclear imaging test. What should the nurse instruct the client about this test? 1. It is the use of a magnetic field to produce an image of a body part or organ. 2. A radioisotope will be injected to determine organ functioning as being either hot or cold. 3. It produces a three-dimensional image of an organ. 4. It is more sensitive than an x-ray image

What is the responsibility of the nurse when collecting a specimen from a client? 1. Always accompany the client to collect a specimen. 2. Handle the specimen discreetly. 3. Clean technique should be used with all specimen collection. 4. Use day-old specimens

Which medication will the primary care provider will most likely prescribe to increase urine output in the patient admitted with congestive heart failure? 1) Digoxin 2) Furosemide 3) Lovastatin 4) Atorvastatin

The nurse is instructing a female client on how to cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity. What should the nurse instruct this client to do? Standard Text: Select all that apply. 1. Clean the perineal area using a circular motion. 2. Use all towelettes provided. 3. Use each towelette once, and discard. 4. Clean the perineal area from back to front. 5. Clean the perineal area from front to back.

2 3 5

A client is scheduled to have abdominal ascites fluid removed. What should the nurse instruct the client about this procedure? 1. A catheter will be inserted into the bladder. 2. A liver biopsy will be done. 3. An abdominal paracentesis will be done. 4. A thoracentesis will be done.

The nurse is preparing an enteral feeding for a patient who will be receiving intermittent feedings via nasogastric tube for the first time. The patient is conscious. Which of the following is the priority intervention before administering this feeding? 1) Observe whether the patient can speak. 2) Inject air into the feeding tube while auscultating the stomach. 3) Aspirate stomach contents and measure residual volume. 4) Obtain an x-ray of the chest and abdomen

The nurse is reviewing instructions provided to a client about an upcoming cystoscopy. Which client response indicates that no further teaching is required? 1. During the procedure the physician will take x-rays. 2. I will be awake for this procedure. 3. The doctor will be able to see my kidneys. 4. The scope is a lighted instrument inserted through the urethra.

Unlicensed assistive personnel (UAP) will be conducting a test on a clients urine. What should the nurse instruct the UAP about the test? Standard Text: Select all that apply. 1. Nothing, because the UAP can perform urine testing. 2. Remind the UAP to tell the client the results of the test. 3. Notify the physician with the results of the test. 4. Report the results of the test to the nurse. 5. Save the urine, in case the nurse wants to repeat the test

4 5

Which response would the nurse give when a client is admitted with chest pain and a family member asks about the purpose of the prescribed 12-lead electrocardiogram (ECG)? a. Indicates whether a heart attack is occurring b. Detects changes in the structures in the heart c. Shows whether the heart muscle is pumping d. Evaluates for prognosis after heart attack

While collecting a specimen for a throat culture, the nurse swabs quickly and does not place the swab in the center of the throat. Which rationale justifies this intervention? a. To prevent the patient from gagging b. To prevent any cross-contamination c. To obtain a large enough specimen d. To visualize the throat and oral cavity

A client is scheduled for a kidney ultrasound. Which instructions would be given by the nurse? Select all that apply. One, some, or all responses may be correct. a. "Drink plenty of fluids." b. "Eat foods rich in fiber." c. "Do not urinate before the examination." d. "Lie flat and perfectly still during the test." e. "A urinary catheter may be needed temporarily for the test."

a c d

When a client with chronic dyspnea is scheduled tor computed tomograpny (C 1) using contrast, which assessment information would the nurse communicate to the health care provider before the procedure? Select all that apply. One, some, or all responses may be correct. a. Metformin taken today b. Hematocrit 38% c. Serum creatinine 2.1 mg d/L (185.6 umol/L) d. Coronary artery disease history e. Shellfish allergy f. Respiratory rate 22 breaths per minute

a c e

A primary health care provider schedules a bone scan for a client with osteoporosis. Which nursing action is beneficial for the client? Select all that apply. One, some, or all responses may be correct. a. Placing the client in the supine position b. Verifying presence or absence of a shellfish allergy c. Ensuring the client does not have metal on their clothing d. Instructing the client to empty their bladder before the scan e. Informing the client that the post procedure headache resolves in 2 days

a d

Which nursing action would be included in the plan of care when a client is admitted with thrombocytopenia? Select all that apply. One, some, or all responses may be correct. a. Avoid intramuscular injections. b. Institute neutropenic precautions. c. Monitor the white blood cell (WBC) count. d. Administer prescribed anticoagulants. e. Examine the skin for ecchymotic areas.

a e

The registered nurse is evaluating the performance of a student nurse who is collecting a urine sample through an indwelling Foley catheter. Which action made by the student nurse needs correction? a. The student nurse empties any urine that is present in the tubing into the drainage bag. b. The student nurse inserts a blunt needleless cannula at g90-degree angle into the port. c. The student nurse places a waterproof pad under the catheter close to the injection port. d. The student nurse removes the clamp from the catheter tubing after obtaining the urine sample.

Which of the following subjective data gathered from the client would indicate a risk for constipation? A. Use of vitamin C and caffeine B. Taking Maalox often for heartburn C. Drinking 1,500 mL of water during the day D. Eating yogurt for breakfast and taking a magnesium supplement

A patient's cholesterol level is 240 mg/dL. Which complication does the nurse expect in the patient? Select all that apply. One, some, or all responses may be correct. a. Chronic anemia b. Hyperlipidemia c. Atherosclerosis d. Nephrotic syndrome e. Acquired immunodeficiency syndrome (AIDS)

b c d

When performing a focused assessment on a client with a possible diagnosis of iron deficiency anemia, which locations would the nurse examine? Select all that apply. One, some, or all responses may be correct. a. Sclera b. Nail beds c. Conjunctivae d. Palms of hands e. Bony prominences

b c d

Which result does the nurse expect to find in the laboratory report of a patient who has a biliary tract obstruction? Select all that apply. One, some, or all responses may be correct. a. Increased albumin levels b. Increased bilirubin levels c. Increased serum creatinine levels d. Increased serum alkaline phosphatase levels e. Increased serum alanine aminotransferase levels

b d e

After reviewing the lipid profile results for a patient, the nurse concludes that the patient has a borderline risk of developing cardiovascular disease. Which triglyceride level in the patient's report supports the nurse's conclusion? a. 120 mg/dL b. 140 mg/dL c. 180 mg/dL d. 200 mg/dL

The physician prescribes a test for occult blood to be done on Mrs. Petrowski's stool. The result has come back negative. To be sure you do not have a false negative reading, which information do you need to ask Mrs. Petrowski? Whether she has been A. using iron preparations B. eating red meat in the past 3 days C. taking vitamin C D. taking the diuretic, furosemide

Which prescribed diagnostic test would the nurse expect to confirm a tentative urinary tract infection diagnosis in a client recovering from deep, partial-thickness burns who develops chills, fever, flank pain, and malaise? a. Cystoscopy and bilirubin level b. Specific gravity and pH of the urine c. Urinalysis and urine culture and sensitivity d. Creatinine clearance and albumin/globulin (A/G) ratio

The nurse is caring for an elderly patient with dementia. Which laboratory finding indicates to the nurse that that patient is often forgetting to eat meals? a. Serum bilirubin 0.4 mg/dL b. PLT (platelet count) 425,000/mm3 c. Serum cholesterol 175 mg/dL d. Albumin 1.4 g/dL

Which condition would the nurse instruct a client to report immediately to the health care provider? a. Pelvic pain immediately after colposcopy b. Rectal bleeding for 48 hours after prostate biopsy c. Light vaginal bleeding for 24 hours after a hysterosalpingogram d. Body temperature of 102°F (38.9°C) 48 hours after cervical biopsy

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