NURS 402 - Exam 4
A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching? A. History of smoking B. Obesity C. History of hypertension D. Race
D
Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Absent bowel sounds b. Loud gurgles c. High-pitched gurgles d. Frequent clicking sounds
A
A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup; 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
1720 mL
An adult patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect? a. Recent weight gain b. Elevated urine ketones c. Poor skin turgor d. Decreased blood pressure
A
A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? (Select all that apply.) A. After each medication B. Before aspirating gastric contents C. When the flow of the medication by gravity slows D. Prior to administering each medication E. After giving multiple medications
A,D,E
What should the nurse include when teaching an adult patient to prevent the recurrence of kidney stones? a. Using a filter to strain all urine b. Drinking 3000 mL of fluid each day c. Avoiding dietary sources of calcium d. Choosing diuretic fluids such as coffee
B
A patient has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The apical pulse is 100 beats/min. b. The patient reports a sore throat. c. The patient is very drowsy. d. The oral temperature is 101.4° F.
D
After the nurse teaches the patient with stage 1 hypertension about diet modifications, which diet choice indicates that the teaching has been most effective? a. The patient restricts intake of chicken and fish. b. The patient avoids eating nuts or nut butters. c. The patient has two cups of coffee in the morning. d. The patient drinks low-fat milk with each meal.
D
An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. After the nurse notifies the health care provider, what should the nurse do next? a. Elevate the leg above the level of the heart. b. Assist the patient in gently exercising the leg. c. Apply a compression stocking to the leg. d. Keep the patient in bed in the supine position.
D
A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over 24 hr using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
35 mL/hr
A nurse is caring for a client who has deep-vein thrombosis and is receiving IV fluid that contains 10,000 units of heparin in 500 mL infusing at 1,000 units/hr. When calculating the client's intake and output, how much should the nurse document as intake from this infusion in an 8-hr shift? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
400 ml
A 46-yr-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge? a. Elastic compression stockings should be applied before getting out of bed. b. Taking an aspirin daily will help prevent clots from forming around venous valves. c. Exercise, such as walking or jogging, can cause recurrence of varicosities. d. Sitting at the work counter, rather than standing, is recommended.
A
A 58-yr-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which patient problem is present, based on these findings? a. Excess fluid volume b. Poor perfusion c. Inadequate nutrition d. Activity intolerance
A
A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers? A. The left second intercostal space B. The right second intercostal space C. The left fifth intercostal space D. The left fifth intercostal space at the midclavicular line
A
A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? A. Assess the apical pulse for a full minute. B. Assess the apical pulse with a Doppler device. C. Assess the pedal pulses for a full minute. D. Assess the pedal pulses with a Doppler device.
A
Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension? a. 128/76 mm Hg b. 98/56 mm Hg c. 128/92 mm Hg d. 142/78 mm Hg
A
A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? A. Urinary tract infection B. Urinary incontinence C. Urinary frequency D. Urinary retention
A
A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have? A. Grape juice B. Lemon sherbet C. Milkshake D. Vanilla ice cream
A
A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider? A. Urine output of 175 mL in the past 8 hr B. Urine output of 2,200 mL in the past 24 hr C. First-voided urine in the morning has a strong odor D. Urine is cloudy after sitting in the urinal for 6 hr
A
A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? A. Obtain a pair of slipper-socks for the client. B. Rub the client's feet briskly for several minutes. C. Increase the client's oral fluid intake. D. Place a moist heating pad under the client's feet.
A
A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching? A. Yogurt B. Popsicle C. Gelatin D. Broth
A
A patient who has just been started on enteral nutrition of full-strength formula at 100 mL/hr has 6 liquid stools the first day. Which action should the nurse plan to take? a. Slow the infusion rate of the feeding. b. Check gastric residual volumes more often. c. Change the enteral feeding system and formula every 8 hours. d. Discontinue administration of water through the feeding tube.
A
A transesophageal echocardiogram (TEE) is planned for a patient hospitalized with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first? a. Place the patient on NPO status. b. Start O2 per nasal cannula. c. Give lorazepam (Ativan) 1 mg IV. d. Start an IV line.
A
A young adult with extensive facial injuries from a motor vehicle crash is receiving continuous enteral nutrition through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care? a. Flush the tube with 30 mL of water every 4 hours. b. Obtain a daily abdominal radiograph to verify tube placement. c. Crush and mix medications in with the feeding formula. d. Keep the patient positioned lying on the left side.
A
Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this drug when the patient reveals a history of: a. asthma. b. peptic ulcer disease. c. myocardial infarction (MI). d. daily alcohol use.
A
Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. What should the nurse assess before administering the medication? a. Bowel sounds b. Level of consciousness (LOC) c. Blood glucose d. Blood urea nitrogen (BUN)
A
The nurse evaluates that discharge teaching about the management of a new permanent pacemaker has been effective when the patient states a. "I won't lift the arm on the pacemaker side until I see the health care provider." b. "I will notify the airlines when I make a reservation that I have a pacemaker." c. "It will be several weeks before I can return to my usual activities." d. "I will avoid cooking with a microwave oven or being near one in use."
A
The nurse obtains the following information from a patient newly diagnosed with elevated blood pressure. Which finding is most important to address with the patient? a. No regular physical exercise b. Drinks a beer with dinner every night c. Weight is 5 pounds above ideal weight d. Low dietary fiber intake
A
What finding should the nurse expect during the assessment of a young adult with infective endocarditis (IE)? a. A new regurgitant murmur b. Substernal chest pressure c. Involuntary muscle movement d. A pruritic rash on the chest
A
What should the nurse anticipate teaching a patient with a new report of heartburn? a. Proton pump inhibitors b. Endoscopy procedures c. A barium swallow d. Radionuclide tests
A
What should the nurse ask the patient about to determine possible causes of acute glomerulonephritis? a. Recent sore throat and fever b. History of high blood pressure c. History of kidney stones d. Recent bladder infection
A
When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse? a. Inversion of T waves on the electrocardiogram b. Sinus tachycardia at a rate of 110 beats/min c. Patient reports feeling tired d. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg
A
Which assessment finding for a patient receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? a. Serum potassium level of 3.0 mEq/L b. Orthostatic systolic BP decrease of 12 mm Hg c. Current blood pressure (BP) reading of 168/94 mm Hg d. Blood glucose level of 175 mg/dL
A
Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? a. Serum potassium of 2.9 mEq/L b. Blood glucose of 243 mg/dL c. Serum chloride of 92 mEq/L d. Serum sodium of 134 mEq/L
A
Which menu choice best indicates that the patient is implementing the nurse's suggestion to choose high-calorie, high-protein foods? a. Fried chicken with potatoes and gravy b. Beef noodle soup and canned corn c. Fresh fruit salad with yogurt topping d. Baked fish with applesauce
A
While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? A. A systolic murmur B. A third heart sound (S3) C. An expected heart sound D. A fourth heart sound (S4)
A
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? A. Impaired tissue perfusion B. Alteration in body image C. Alteration in activity tolerance D. Impaired skin integrity
A
A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? A. Steatorrhea B. Blood C. Bacteria D. Parasites
B
A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect? A. 6.0 B. 4.0 C. 7.0 D. 8.0
B
A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? (Select all that apply.) A. Broth B. Grape juice C. Nonfat milk D. Custard E. Lemon gelatin
A,B,E
A nurse is administering a cleansing enema to a client who reports mild cramping. The client asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take? A. Discontinue the enema. B. Slow the flow of enema solution briefly. C. Continue the enema and reassure the client. D. Pause the enema and administer oral pain medication.
B
A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema? A. 4+ B. 3+ C. 2+ D. 1+
B
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? A. Elevating her feet B. Massaging her legs C. Flexing her ankles D. Ambulating soon after surgery
B
A nurse is caring for a client who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this is being done to resolve which of the following conditions? A. Electrolyte imbalance B. Diarrhea C. Constipation D. Delayed gastric emptying
B
A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions? A. Atrial gallop B. Ventricular gallop C. Closure of the mitral valve D. Closure of pulmonic valve
B
A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take? A. Put on sterile gloves. B. Assist the client to the left Sims' position. C. Hang the enema container 60 cm (24 in) above the anus. D. Insert the tubing about 15 cm (6 in) into the anus.
B
A nurse is teaching with a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client? A. Transdermal patch B. Sublingual C. Suspended-release D. Topical ointment
B
A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take? A. Allow the AP to deliver the food tray to the client. B. Call the dietary department and ask for a kosher tray. C. Replace the nonfat milk with apple juice. D. Explain to the client that he needs the protein in the milk and the beef.
B
A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate? a. "Taking both blood thinners greatly reduces the risk for another clot to form." b. "Enoxaparin will work right away, but warfarin takes several days to begin preventing clots." c. "Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner." d. "Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming."
B
The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. Which laboratory test result should be most helpful in indicating myocardial damage? a. Myoglobin b. Troponins c. Creatine kinase-MB (CK-MB) d. Homocysteine (Hcy)
B
The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). Which patient statement indicates a need for additional teaching? a. "I should get a Medic Alert device stating that I take warfarin." b. "I should reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the warfarin." d. "I will check with my health care provider before I begin any new drugs."
B
The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD). Which patient statement indicates a need for further instruction? a. "I will buy loose clothes that do not bind across my legs or waist." b. "I will use a heating pad on my feet at night to increase the circulation." c. "I will change my position every hour and avoid long periods of sitting with my legs crossed." d. "I will walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week."
B
The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? a. Serum potassium of 4.5 mEq/L b. Serum creatinine of 2.8 mg/dL c. Blood glucose level of 96 mg/dL d. Serum hemoglobin of 14.7 g/dL
B
Which action by a nurse caring for a patient after an implantable cardioverter-defibrillator (ICD) insertion indicates a need for more teaching about the care of patients with ICDs? a. The nurse helps the patient fill out the application for obtaining a Medic Alert device. b. The nurse encourages the patient to do active range-of-motion exercises for all extremities. c. The nurse administers amiodarone (Cordarone) to the patient. d. The nurse teaches the patient that sexual activity can be resumed when the incision is healed.
B
Which action by the patient with newly diagnosed Raynaud's phenomenon best demonstrates that the nurse's teaching about managing the condition has been effective? a. The patient avoids taking nonsteroidal anti-inflammatory drugs (NSAIDs). b. The patient exercises indoors during the winter months. c. The patient immerses hands in hot water when they turn pale. d. The patient takes pseudoephedrine (Sudafed) for cold symptoms.
B
Which group of drugs will the nurse plan to include when teaching a patient who has a new diagnosis of peripheral artery disease (PAD)? a. Anticoagulants b. Statins c. Thrombolytics d. Antibiotics
B
Which laboratory test result will the nurse review to determine the effects of therapy for a patient being treated for heart failure? a. Troponin b. B-type natriuretic peptide (BNP) c. Homocysteine (Hcy) d. Low-density lipoprotein (LDL)
B
A 20-yr-old patient has a mandatory electrocardiogram (ECG) before participating on a college soccer team. The patient is found to have sinus bradycardia, rate 52 and blood pressure (BP) 114/54 mm Hg. The student denies any health problems. What action by the nurse is appropriate? a. Tell the student to stop playing immediately if any dyspnea occurs. b. Refer the student to a cardiologist for further testing. c. Allow the student to participate on the soccer team. d. Obtain more detailed information about the student's family health history.
C
A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? A. Hypotension B. Numbness C. Shivering D. Reduced blood viscosity
C
A nurse is assessing a client who is receiving bolus enteral feedings. Which of the following laboratory values indicates the client needs a change in the formula? A. Hematocrit 42% B. Urine specific gravity 1.022 C. BUN 28 mg/dL D. Sodium 142 mEq/L
C
A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first? A. Auscultate B. Percuss C. Inspect D. Palpate
C
A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene? A. Chlorhexidine B. Povidone-iodine C. Nonantimicrobial soap D. Alcohol-based hand rub
C
A nurse is caring for a client who is postoperative and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take? A. Apply the stockings while the client is sitting in a chair. B. Remove the stockings once each day. C. Check the stockings for wrinkles. D. Measure the size of the client's foot.
C
A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan? A. Serve foods that have a hot/cold balance. B. Serve milk products separately from meals C. Request a meal tray without pork. D. Remove tea and coffee from meal trays.
C
A nurse is measuring a client for knee-high anti-embolic stockings to help prevent venous stasis. Which of the following actions should the nurse take? A. Measure from the heel to the gluteal fold. B. Measure the length of the feet. C. Measure from the heel to the popliteal space. D. Measure the ankle circumference.
C
A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make? A. "They protect your legs and heels from skin breakdown." B. They help keep you warm after your surgery." C. "They improve your circulation to keep blood from pooling in your legs." D. "They make it easier for you to do leg exercises after your surgery."
C
A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching? A. Bear down hard when defecating. B. Drink four to five glasses of water daily. C. Increase dietary intake of raw vegetables. D. Limit activity.
C
A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective? A. "My partner should cough while swallowing food." B. "My partner should place their food on the weaker side of their mouth when eating." C. "My partner should tilt their head forward when swallowing." D. "My partner should sit at a 30° angle while eating their meals."
C
A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though." What focused assessment should the nurse make? a. Ask about any skin color changes that occur in response to cold. b. Look for the presence of tortuous veins bilaterally on the legs. c. Palpate for the presence of dorsalis pedis and posterior tibial pulses. d. Assess for unilateral swelling, redness, and tenderness of either leg.
C
A patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level
C
After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? a. Q waves on ECG b. Elevated troponin c. Bilateral crackles d. Hyperglycemia
C
An older adult patient who has just arrived in the emergency department has a pulse deficit of 46 beats. The nurse should expect that the patient may require: a. emergent cardioversion. b. hourly blood pressure checks. c. electrocardiographic monitoring. d. cardiac catheterization.
C
The nurse is examining an adult patient. For what purpose would the nurse use palpation? a. Determining kidney function b. Assessing for ureteral peristalsis c. Checking for bladder distention d. Identifying renal artery bruits
C
The nurse will be teaching self-management to patients after gastric bypass surgery. Which information will the nurse plan to include? a. Choose high-fat foods for at least 30% of intake. b. Choose foods high in fiber to promote bowel function. c. Drink fluids between meals but not with meals. d. Developing flabby skin can be prevented by exercise.
C
Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective? a. The antistreptolysin-O (ASO) titer has decreased. b. The patient denies pain or burning with voiding. c. The periorbital and peripheral edema are resolved. d. The urine dipstick is negative for nitrites.
C
Which information about an 80-yr-old male patient at the senior center is of most concern to the nurse? A. Difficulty chewing food B. Occasional indigestion C. Unintended weight loss D. Decreased appetite
C
Which question should the nurse ask to assess a patient's dysuria? a. "Do you have blood in your urine?" b. "Do you have to urinate frequently?" c. "Do you have pain when you urinate?" d. "Do you have to urinate at night?"
C
Which statement to the nurse from a patient with jaundice indicates a need for teaching? A. "I take an antacid for indigestion several times a week" B. "I take a baby aspirin every day to prevent strokes." C. "I use acetaminophen (Tylenol) every 4 hours for pain." D. "I used cough syrup several times a day last week."
C
Which topic should the nurse include in teaching for a patient with a venous stasis ulcer on the lower leg? a. Methods of keeping the wound area dry b. Purpose of prophylactic antibiotic therapy c. Application of elastic compression stockings d. Need to increase carbohydrate intake
C
A 28-yr-old male patient has just been diagnosed with polycystic kidney disease. Which information should the nurse include in teaching during the first teaching session? a. Differences between hemodialysis and peritoneal dialysis b. Complications of renal transplantation c. Methods for treating severe chronic pain d. Options to consider for genetic counseling
D
A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse? A. Clamps the NG tube during auscultation B. Performs auscultation between meals C. Auscultates bowel sounds for 3 to 5 min D. Palpates the abdomen prior to performing auscultation.
D
A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly to the health care provider? a. The patient's abdomen appears bloated after the inflow. b. The patient has an outflow volume of 1800 mL. c. The patient has abdominal pain during the inflow phase. d. The patient's peritoneal effluent appears cloudy.
D
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? A. Creatine kinase B. Troponin C. Total bilirubin D. Albumin
D
A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? A. The client who has a tracheostomy tube attached to humidified oxygen B. The client who has an indwelling urinary catheter to gravity drainage C. The client who has a chest tube to water seal D. The client who has a nasogastric (NG) tube to suction
D
A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching? A. "I will wear gloves when removing food from the freezer." B. "I will try to anticipate and avoid stressful situations when possible." C. "I will complete the smoking cessation program I started." D. "I will take my medications at the first sign of an attack."
D
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? A. Mix the three medications together prior to administering. B. Dilute each medication with 10 mL of tap water. C. Maintain the head of the bed in a flat position for 30 min following medication administration. D. Flush the NG feeding tube with 30 mL of water immediately following medication administration
D
A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? A. Deflate the catheter balloon using a sterile syringe. B. Measure and document the urine in the drainage bag. C. Remove the tape or device securing the catheter to the client's thigh. D. Position the client supine.
D
A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching? A. "A weight loss program can decrease my LDL cholesterol level." B. "Exercising regularly will increase HDL cholesterol levels." C. "Adding foods containing omega-3 fatty acids to my diet can lower my risk." D. "Increasing my intake of foods containing trans-fatty acids can lower my risk."
D
How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis? a. Palpate along both sides of the lumbar vertebral column. b. Push fingers upward into the two lowest intercostal spaces. c. Percuss between the iliac crest and ribs at the midaxillary line. d. Strike a flat hand covering the costovertebral angle (CVA).
D
The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism of the left lower leg. Which action by the nurse is best? a. The patient's bed is placed in the Trendelenburg position. b. The bed is elevated at the knee and pillows are placed under both feet. c. Two pillows are positioned under the calf of the affected leg. d. One pillow is placed under the thighs and 2 pillows are under the lower legs.
D
To prevent recurrence of uric acid kidney stones, the nurse teaches the patient to avoid eating: a. legumes and dried fruit. b. milk and cheese. c. spinach and chocolate. d. sardines and liver.
D
Which information is most important for the nurse to include when teaching a patient newly diagnosed with hypertension? a. Most people are able to control BP through dietary changes. b. Increasing physical activity controls blood pressure (BP) for most people. c. Annual BP checks are needed to monitor treatment effectiveness. d. Hypertension is usually asymptomatic until target organ damage occurs.
D
Which item should the nurse offer to the patient restarting oral intake after being NPO due to nausea and vomiting? a. Cup of coffee with cream b. Bowl of hot chicken broth c. Glass of orange juice d. Dish of lemon gelatin
D
