old & new tophat q

On the third post-operative day after a subtotal gastrectomy, a client reports having severe abdominal pain. the nurse palpates the client's abdomen and determines rigidity. What should be the nurse's first action? A Administer the prescribed proton pump inhibitor. B Assist the client ambulate. C Encourage the use of incentive spirometry. D Obtain the client's vital signs.

D Obtain the client's vital signs.

A client with liver failure is experiencing jaundice. Which lab result provides evidence of this finding? A bilirubin 5 mg/dL (0-1.4 mg/dL) B creatinine 1 mg/dL (0.5-1.5 mg/dL) C hemoglobin 18 g/dL (12-16 g/dL) D red blood cell count 3.8 K/CMM (4.2-5.4 K/CMM)

a

The nurse is caring for a client experiencing an exacerbation of multiple sclerosis. The client has been receiving corticosteroids to treat the disorder. The nurse notes the client is experiencing fatigue and weak leg muscles. Which complication of corticosteroids does the nurse suspect the client is experiencing? A hyperglycemia B hypokalemia C mood changes D weight gain

b

The nurse is caring for a client who recently returned from surgery. The client's arterial blood gas results are: pH 7.33, CO2 48, HCO3 20. What intervention should nurse the implement based on these values? A Assist to bathroom to empty bladder. B Encourage to take more frequent breaths. C Have take slow deep breaths in a paper bag. D Offer fluids to increase fluid intake.

b

The nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. What common response does the nurse expect to identify during this phase of burn recovery? An increase in: A hematocrit level B serum potassium level C serum sodium level D urinary output

d

The nurse is caring of a client who had a total hip replacement two days ago after years of experiencing osteoarthritis. Which laboratory finding should the nurse notify the health care provider immediately? A BUN 5 (5-25 mg/dL) B Estimated sedimentation rate 98 (1-20 mm/hour) C Hemoglobin 11 (12-16 g/dL) D Sodium 118 (135-153 mEq/L)

d

The nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion? A Deep respirations and abdominal pain B Diaphoresis and altered mental state C Erythema toxicum rash and pruitis D Nervousness and tachycardia

A Deep respirations and abdominal pain

A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane? A Dominant hand B Left hand C Right hand D Stronger hand

B

The nurse is assessing the client who has had a rapid loss of gastric secretions from a nasogastric tube (NG) connected to intermittent suction. The client's arterial blood gases reflect the client is experiencing metabolic alkalosis. What assessment findings would the nurse expect this client to exhibit? A Anxious behavior B Decreased GI motility C Hypotonic reflexes D Rapid, shallow respirations

B Decreased GI motility

A client with gastroesophageal reflux disease (GERD) reports having difficulty sleeping at night. What should the nurse instruct the client to do? A Drink a glass of milk before retiring. B Elevate the head of the bed on blocks. C Eliminate carbohydrates from the diet. D Take antacids, such as sodium bicarbonate.

B Elevate the head of the bed on blocks.

The nurse administers two units of salt-poor albumin to a client with portal hypertension and ascites. How should the nurse explain the purpose of this infusion to the client? A Diverts blood away from the liver temporarily B Elevates the circulating blood volume C Increases protein stores D Provides necessary nutrients

B Elevates the circulating blood volume

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? A Hyperkalemia and poor skin turgor B Hyponatremia and decreased urine output C Increased blood urea nitrogen (BUN) and hypotension D Polyuria and increased specific gravity of urine

B Hyponatremia and decreased urine output

A client is admitted with acute pancreatitis. The nurse plans on implementing the health care provider's orders. Which order is most important for the nurse to implement first? A Initiate an intravenous infusion of D5NS at 125 mL/hour. B Insert a nasogastric tube and connect to intermittent suction. C Place anti-embolism stockings on both legs. D Start the prophylactic intravenous antibiotic.

B Insert a nasogastric tube and connect to intermittent suction.

A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom? A anorexia B clay-colored stools C fatigue D yellow urine

B clay-colored stools

A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. which diet can the nurse expect will be prescribed for this client based upon the assessment? A high protein B moderate protein C no protein D strict protein restriction

B moderate protein

A client is experiencing constipation and asks the nurse what can be done to prevent it. Which choice of cold breakfast cereal indicates the client understood the nurse's teaching? A corn flakes B fruit-flavored frosted corn and oats C shredded wheat D toasted rice

C shredded wheat

The nurse is reviewing vital signs of assigned clients. Which client does the nurse need to see first? The client with: A a cerebral contusion with a temperature of 98.7 degrees F, pulse 50 b/minute, respirations 20 b/minute, and blood pressure 176/58 mmHg. B atherosclerosis with a temperature of 97.7 degrees F, pulse 60 b/minute, respirations 18 b/minute, and blood pressure 138/88 mmHg. C diabetes mellitus with a temperature of 97.6 degrees F, pulse 110 b/minute, respirations 18 b/minute, and blood pressure 90/60 mmHg. D pneumonia with a temperature of 101.8 degrees F, pulse 104 b/minute, respirations 25 b/minute, and blood pressure 150/78 mmHg.

A a cerebral contusion with a temperature of 98.7 degrees F, pulse 50 b/minute, respirations 20 b/minute, and blood pressure 176/58 mmHg.

Upon hearing report on four clients on a medical-surgical unit, the nurse contemplates which client to assess first. Considering the report provided, client should the nurse assess first? The client with: A a fiberglass cast to the left lower extremity and complaining of extreme pain not relieved by a dose of hydromorphone IV received 30 minutes prior. B an open cholecystectomy that occurred two days prior with large amounts of greenish-brown drainage into the t-tube collection bag. C chronic renal failure that has a potassium level of 5.8 mEq/L and is scheduled for dialysis within the hour. D emphysema receiving oxygen at 2 L/minute; however, has a oxygen saturation level of 89%.

A a fiberglass cast to the left lower extremity and complaining of extreme pain not relieved by a dose of hydromorphone IV received 30 minutes prior.

The nurse is teaching a client about the results of the lipid panel. The client's total cholesterol is 189 mg/dL (<200 mg/dl), triglycerides are 125 mg/dL (<150 mg/dL), LDL is 90 mg/dL (<100 mg/dL) and the HDL is 100 mg/dL (>60 mg/dL). What should the nurse tell the client about these values? "Your results: A are within normal values." B indicate you need to reduce fatty food consumption." C show you ate a fatty food before the blood sample was obtained." D your health care provider will likely prescribe a lipid lowering agent."

a

When assessing a client, the nurse notes the client's blood pressure is 78/42 mmHg, pulse is 126 b/minute, respiration is 32 b/minute, and body temperature is 99.4 degrees F. The client's skin is cool and clammy. Which intervention is PRIORITY for the nurse to implement? A Administer oxygen B Check the client's level of consciousness C Connect a continuous blood pressure monitor D Obtain an electrocardiogram (EKG)

a

client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and complains of right-sided chest pain. What action should the nurse do first? A Administer oxygen using a face mask B Encourage the use of incentive spirometer C Obtain vital signs D Perform an electrocardiogram (ECG)

a

fter gastrointestinal surgery, a client's condition improves and a regular diet is prescribed. Which food included on a regular diet, generally is best tolerated with little discomfort? A baked fish B bran cereal C fresh fruit D whole milk

a

A client is admitted to the hospital for medical treatment of bronchopneumonia. What test result should the nurse examine to help determine the effectiveness of the client's therapy? A bronchoscopy B culture and sensitivity of sputum C pulmonary function tests D pulse oximetry

b

The nurse is caring for a client suspected of experiencing sepsis. Which ordered laboratory test does the nurse recognize is NOT diagnostic of sepsis? A blood culture B electrolytes C lactate level D white blood cell count

b

After a transurethral prostatectomy (TURP), a client returns to the post-anesthesia care unit (PACU) with a three-way indwelling urinary catheter with continuous bladder irrigation. What nursing action is the priority? A Encouraging fluids by mouth once the gag reflex returns B Maintaining the client in a semi-Fowler's position C Monitoring for signs of confusion D Observing the suprapubic dressing for drainage

c

The nurse is caring for a client in the emergency department with complaints of influenza. The client has a history of a seizure disorder that is treated with phenytoin. The nurse receives the client's results on the phenytoin serum level and the results are 5 mcg/mL. Which action should the nurse implement? A Ask why the client is not taking the prescribed phentoin. B Initiate intravenous access with a 18 g angiocath. C Institute seizure precautions. D Verify the dose and frequency of the client's prescription.

c

The nurse is caring for a client suspected of experiencing sepsis. The nurse notes the client's blood pressure is 88/58 mmHg, pulse is 122 b/minute, respiration is 28 b/minute, and body temperature is 103.2 degrees F. The client's skin is cool and clammy and the client is experiencing lethargy. Which health provider order should the nurse implement FIRST? A Administer the prescribed antibiotic B Administer the prescribed antipyretic C Initiate the intravenous fluid infusion D Obtain two sets of blood cultures

c

The nurse is caring for a client who had a brain attack (stroke) five days prior. The client is experiencing paralysis of the dominant upper and lower extremity. Which action by the nurse is most important for the nurse to implement? A Add a thickening agent to the liquids B Keep the head of the bed at 30 degrees at all times C Provide passive range of motion to the affected joints D Teach how to use a communication board

c

The nurse is caring for a client who is receiving mechanical ventilation on the biPap mode. The nurse realizes this client's mechanical ventilation operates in which manner? A Allows the client to breathe at own rate and depth between programmed ventilations. B Delivers timed ventilations in response to multiple variables or the absence of respiration. C Delivers pressure controlled ventilations allowing unrestricted spontaneous ventilations. D Provides positive end expiratory ventilations at a set depth and rate.

c

The nurse is caring for a client who recently returned from surgery. The client's arterial blood gas results are: pH 7.33, CO2 48, HCO3 20. What should the nurse determine regarding compensation based on these results? A non-compensated B fully compensated C partially compensated

c

The nurse is caring for a client with a medical history that includes diabetes mellitus type II and hypertension. The nurse recognizes which anti-hypertensive agent is responsible for the client having developed a dry, non-productive cough? A amlodipine B hydrochlorothiazide C lisinopril D metoprolol

c

The health care provider prescribes a low-fat, two gram sodium diet for a client with hypertension. Which rationale does the nurse understand is the physiology of this diet? A Causes fluid to move toward the interstitial compartment B Chemically stimulates the loop of Henle C Diminishes the client's thirst response D Prevents reabsorption of water into the distal tubules

d

The nurse is caring for a client suspected of experiencing sepsis. Which health care provider order should the nurse implement FIRST? A Administer the prescribed antibiotic B Initiate the intravenous fluid infusion C Monitor the client's oxygen saturation D Obtain two sets of blood cultures

d

The nurse is caring for a client who had surgery earlier in the day to repair a right hip fracture. The client asks how the incentive spirometry works to prevent pneumonia. Which response by the nurse is most accurate? A "Blowing air out forcibly keeps small air sacs within the lungs open and free of bacteria." B "Exercising the muscles along the rib cage improves the body's ability to take deep breaths and blow out fluid and contaminants from the lungs." C "Moving the ball up several times a day helps move the antibiotic to the blood and then to the lung tissue to prevent pneumonia." D "Taking deep breaths helps prevent fluid from filling into the part of the airways where pneumonia develops."

d

The nurse is caring for a client who is receiving biotherapy (immunotherapy) for the treatment of non-Hodgkin's lymphoma. The medication carries a risk of the development of pneumonitis. The client is experiencing dyspnea. When assessing the client's breath sounds, which area of the lung should the nurse FIRST assess? Right and left of the: A upper sternum B mid-sternum C lower sternum D lower lobes

d

A spouse of a client with pulmonary tuberculosis (TB) receives a tuberculin skin test. The nurse reads the test and identifies an area of induration greater than 10 mm. What does this result indicate to the nurse? A Additional tests are necessary B No further action is required C Repeating the skin test is indicated D Results are positive, indicating infection

A

A client who had a total knee replacement the day prior is experiencing pain and edema to the affected knee after participating in physical therapy. The nurse administered the prescribed analgesic prior to the physical therapy. Which measure should the nurse implement to provide comfort and reduce swelling of the affected knee? A Administer the scheduled antibiotic. B Apply ice to the affected knee. C Assist the client up to a chair. D Gently place the knee in a flexed position.

Apply ice to the affected knee.

A client is receiving bumetanide for the treatment of heart failure. The client takes hydrochlorothiazide for the treatment of hypertension. When teaching the client about the adverse effects of these two drugs, which instruction should the nurse include in the education? A Reduce intake of foods high in potassium such as apricots, bananas, and potatoes. B Report any muscle weakness or muscle cramping to the health care provider. C Stop taking the bumetanide once it is easier to breathe and walk long distances. D Take the bumetanide two hours prior to the hydrochlorothiazide.

B Report any muscle weakness or muscle cramping to the health care provider.

The nurse notes a client who experienced a cat bite to the left index finger now has increased edema, redness surrounding the puncture site, and a fever since admission the day prior. The nurse notifies the health care provider and receives orders. Which health care provider order should the nurse implement first? A Administer a tetanus toxoid injection. B Elevate the extremity above heart level C Initiate the added antibiotic prescribed D Provide acetaminophen to reduce the fever

C Initiate the added antibiotic prescribed

A nurse notes a pulse deficit when assessing the apical and peripheral pulses of a client. The nurse would suspect the possibility of which condition? A Acute myocardial infarction B Aortic stenosis C Right-sided heart failure D Premature ventricular contractions

Premature ventricular contractions

The nurse is teaching a client to provide self-care for a methicillin-resistant staphylococcus aureus skin infection. Which response by the client indicates the client understands the nurse's teaching? A "I need to put on sterile gloves prior to placing a dressing on the wound." B "I should apply an antibiotic ointment to wound bed before placing a dressing on it." C "I will place any dressings with drainage on them in a separate trash container than my other trash." D "I will wash the wound with a mild soap and warm water each time I change the dressing."

d

A client with pancreatitis is admitted to the medical unit. The nurse should be alert for what complication? A Hypoglycemia B Leg pain C Pancreatic tumor D Pleural effusion

D Pleural effusion

A client experiencing massive blood loss following a motor vehicle collision has a cardiac output of 2400 mL. The nurse realizes a major factor involved in this client's low cardiac is which factor? A Decreased preload B Increased afterload C Parasympathetic stimulation D Release of catecholamines

A Decreased preload

client had a colon resection with an anastomosis three days ago. The client complains of extreme pain. The nurse notes the left quadrant is edematous, tender to touch and firm. Which action should the nurse implement? A Call the health care provider B Give a soap suds enema C Give morphine sulfate as prescribed D Request a STAT portable abdominal x-ray

Call the health care provider

A client is admitted to the hospital with suspected liver disease and a needle biopsy of the liver is performed. After the procedure, the nurse should maintain the client in what position? A Dorsal recumbent B Right side-lying C Semi-Fowler D Supine

Right side-lying

The nurse is caring for a client with a history of hypertension. The client is non-responsive; however, had been alert and oriented earlier in the shift. The client's vital signs are 78/48 mmHg, 48 b/minute, 8 b/minute, 98.6 degrees F and 99% oxygen saturation. Which action should the nurse implement FIRST? A Apply oxygen at 2 liters per minute via nasal cannula B Assess when the client last received an antihypertensive agent C Notify the provider of the client's change in condition D Reassess the client's vital signs using manual assessment techniques

d

The nurse is preparing to discharge a client with acute kidney injury following dialysis. The client asks the nurse for the best method of determining fluid balance between dialysis treatments. Which response is MOST accurate for the nurse to provide? A "Assess for mouth dryness" B "Keep an accurate intake and output record daily" C "Note any edema in your ankles and legs." D "Weigh yourself daily in the same clothing."

d

The nurse is restarting an intravenous access following the infiltration of vancomycin. Which angiocath should the nurse select to insert? A 16 g 1 inch B 18 g 1 inch C 20 g 2 inch D 22 g 1 inch

d

The nurse is reviewing laboratory test values returned during the morning shift. Which value does the nurse realize needs to be called to the health care provider immediately? A blood urea nitrogen 45 mg/dL (2-25 mg/dL) B eosinophil count 10% (2-4%) C hematocrit 25% (37-47%) D sodium 116 mEq/L (135-153 mEq/L)

d

The nurse is caring post-operatively for a client who had right knee surgery performed earlier in the day. Which complication of the surgery does the nurse realize the client is LEAST likely to experience at this time? A atelectasis B diminished perfusion C urinary retention D wound infection

wound

A client diagnosed with a pituitary tumor. Which diagnostic test should be prescribed to rule out the probability of an aneurysm prior to surgery for tumor removal? A angiogram B computed tomography C magnetic resonance imaging D skull x-ray

A angiogram

A client is prescribed penicillin and a non-steroidal anti-inflammatory agent to treat a wound infection. Which assessment is most important for the nurse to implement due to the combination of these two agents? Signs of: A bruising. B dehydration. C hyperkalemia. D liver damage.

A bruising.

A client admitted following a myocardial infarction develops bilateral crackles, S3 heart sound, dependent edema, and diminished oxygen saturation, thirty-six hours after admission. The nurse suspects the possibility of which disorder? A Atrial fibrillation B Exacerbation of myocardial infarction C Heart failure D Post-operative pneumonia

C Heart failure

A client returns to the unit following a small bowel resection. The client has a nasogastric tube (NG) in place to intermittent suction. Which action should the nurse implement when the client complains of nausea and the NG tube is no longer draining any drainage into the collection device? A Assess the client's bowel sounds after turning off the suction. B Change the suction from intermittent to constant. C Irrigate the NG tube with 30 mL of normal saline. D Medicate the client with an antiemetic as prescribed.

C Irrigate the NG tube with 30 mL of normal saline.

Six hours after major abdominal surgery, a client reports severe abdominal pain and feeling faint. The nurse identifies a thready, rapid pulse. The nurse checks the medication administration record (MAR) and determines the client can receive another injection of pain medication in an hour. Which is the most appropriate action by the nurse? A Explain to the client that it is too early to an an injection for pain. B Notify the healthcare provider about the client's symptoms. C Prepare the injection to administer it to the client early because of the severe pain. D Reposition the client for greater comfort and turn on the television as a distraction.

Notify the healthcare provider about the client's symptoms.

A client with malabsorption syndrome is admitted to the hospital for medical intervention. A subclavian catheter is inserted and the client is started on total parenteral nutrition (TPN). What should the nurse teach the client to prevent the most common complication of TPN? A Avoid disturbing the dressing B Keep the head as still as possible whenever moving C Monitor daily weights a the same time of day D Regulate the flow rate on the infusion pump as necessary

a

Six hours after major abdominal surgery, a client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states feels faint. The nurses assesses the client's medication administration record and determines the client can receive another injection of pain medication in an hour. What is the most appropriate action by the nurse? A Call the health care provider; report the client's symptoms; and obtain further orders.. B Explain to the client that is too early for another injection of pain medication. C Prepare the injection of pain medication and administer it in 30 minutes. D Reposition the client for greater comfort and turn on the television as a distraction.

a

A client is receiving dopamine at 2 mcg/kg/min continuous infusion to promote renal perfusion. The nurse needs to administer an intravenous dose of furosemide to the client. Which action should the nurse implement? A Administer the furosemide as a secondary infusion to the dopamine B Establish a second intravenous access and administer the furosemide through that line C Request from the health care provider that the furosemide be provided orally D Stop the dopamine temporarily and flush the line before and after administering the furosemide

b

The nurse is caring for a client who recently returned from surgery. The client's arterial blood gas results are: pH 7.33, CO2 48, HCO3 20. Which acid-base imbalance does the nurse recognize exists based on these values? A metabolic acidosis B metabolic alkalosis C respiratory acidosis D respiratory alkalosis

c

he nurse is evaluating the response a client has had to furosemide injections over the last 24 hours. Which response does the nurse recognize is the best indicator that the furosemide is having the desired therapeutic response? A Mucus membranes are pink but dry B The last 24 hour intake was 2560 mL with an output of 2640 mL C Urine output has increased from 40 mL/hour to 60 mL/hour D Weight has decreased from 174 pounds to 172 pounds

d

A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2 degrees F. the temperature was 99.2 degrees F when it was taken six hours ago. What is the priority nursing intervention in this case? A Administer the prescribed antipyretic and notify the primary health care provider. B Assess the amount and color of urine and obtain a specimen for urinalysis. C Note the consistency of respiratory secretions and obtain a specimen for culture. D Obtain the respirations, pulse, and blood pressure and recheck the temperature in one hour.

A

A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy (PEG) tube feeding. Which clinical finding indicates the client is unable to tolerate a continuation of the feeding? A Passage of flatus B Rapid inflow of the feeding C Rise of formula in the tube D Tenderness of epigastic area

C Rise of formula in the tube

An older client experiences a cerebral vascular accident (brain attack) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. Which abilities does the nurse explain will be affected? A Comprehending written words. B Recognizing familiar objects. C Stating wishes verbally. D Understanding verbal communication.

C Stating wishes verbally.

A nurse is caring for a client who has a portable wound suction device after abdominal surgery. What reason should the nurse give the client for emptying the device when it is half full? A Accurate measurement of drainage is facilitated. B Emptying the unit is safer when it is half full. C Fluid collecting in the unit exerts pressure into the wound. D The force of suction lessens as the fluid accumulates.

D

A client with a history of degenerative joint disease underwent a total knee replacement and was admitted to the unit from the postanesthesia care unit (PACU). To promote the client's comfort and optimal functioning, which action should the nurse implement first? A Keep lower extremities abducted while in bed. B Maintain semi-Fowler's position while the continuous passive motion (CPM) is in use. C Place the operative knee on a pillow to maintain flexion. D Use a compression dressing to promote knee extension.

D Use a compression dressing to promote knee extension.

A client underwent a laparoscopic cholecystectomy yesterday. The client is now complaining of "bloating and abdominal discomfort." The nurse tells the nursing student to ambulate the client. The nursing student asks why this is necessary. Which rationale provided by the nurse is most accurate? Ambulating the client will: A improve the drainage of bile and decrease abdominal pain. B improve the drainage of the biliary salts, thus decreasing pain. C improve the gastric motility, thus decreasing bloating. D increase the absorption of abdominal air, decreasing bloating.

D increase the absorption of abdominal air, decreasing bloating.

How does Dr. Begley explain cancer remission? The cancer: A cells are most similar to the tissue cells. B cell numbers are lower than we can detect them. C has been cured and any recurrence is a new cancer. D has been eliminated in the body; although can recur.

b

The nurse is caring for a client experiencing the diuresis phase of acute kidney injury. Which complication should the nurse protect the client from experiencing? A atelectasis B orthostatic hypotension C renal calculi D urinary tract infection

b

A client's subclavian central venous pressure (CVP) reading has ranged from 2 to 5 mmHg over the last week. The client's vital signs have been stable. The client's urine output has ranged from 40 to 50 mL/hour since admission. The client is on oxygen therapy at 4 L/minute vial nasal cannula. The nurse would anticipate which prescription from the health care provider? A Increased diuretic prescription B Pulse oximetry C Removal of the CVP line D Urine culture and sensitivity

Removal of the CVP line

The nurse is caring for a client whose complete blood count shows: red blood cell 2.86 (4.2-5.4 M/uL), hemoglobin 9.8 g/dL (12-16 g/dL), hematocrit 28.8% (37-47%), MCV 100.4 (80-94 FL), and MCH 34.1 (27-31 PG). Which action should the nurse implement in response to these findings? A Ask about the client's daily alcohol intake B Encourage the client to eat foods higher in iron C Instruct the client to drink more fluids D Notify the health care provider that the client is hemorrhaging

a

The nurse is caring for a client with emphysema. The client is experiencing severe dyspnea that is preventing sleep. Which action by the nurse would be most therapeutic? A Assist the client to sit up and lean over a pillow placed on a bedside table with upper arms extended B Change the oxygen delivery device from nasal cannula to simple face mask at a rate no greater than 2 liters/minutes C Encourage the client to perform incentive spirometry 10 times every two hours D Request a stronger sleeping medication from the health care provider

a

The nurse is preparing to culture a wound suspected of being infected with methicillin-resistant staphylococcus aureas. Which action should the nurse implement in obtaining the wound culture? A Run the swab over the wound bed after removing any drainage. B Swab any drainage present within the wound. C Use a sterile rayon-tipped applicator to collect the specimen D Wear sterile gloves when collecting the culture.

a

A client is receiving piperacillin/tazobactam intravenously to treat pneumonia. Which finding does the nurse recognize is a common effect of the medication? A dry, non-productive cough B infusion site phlebitis C pleuritic chest pain D severe hypotension

b

A client with cancer of the stomach is admitted to the hospital and scheduled for a subtotal gastrectomy. The nurse is providing preoperative teaching. What should the nurse teach the client to do postoperatively to minimize the complication of dumping syndrome? A Ambulate after every meal B Eat in a semirecumbent position C Increase fluid intake when eating food D Remain on a diet low in fat

b

The nurse is caring for an older client diagnosed with non-Hodgkin's lymphoma. The client has received biological therapy over the last year. The client presents to the clinic with complaints of fever and chills. The CBC report shows a white blood count (WBC) of 1.9 K/CMM (4.8-10.8 K/CMM), hemoglobin of 10.8 g/dL (12-16 g/dL), and platelet count of 99 K/CMM (150-400 K/CMM). Which finding does the nurse recognize is the most serious? A Cough rhinitis and sore throat B Elevated body temperature, fatigue and shortness of breath C Fatigue, nausea and a skin rash to the upper arms D Headache, bruising to left arm, and dry skin

b

A client with type I diabetes mellitus is admitted to the hospital for major surgery. Before surgery, the client's insulin requirements are elevated but well-controlled. What insulin requirements will the nurse anticipate for this client postoperatively? A decrease B fluctuate C increase sharply D remain elevated

remain elevated

A nurse is caring for a client with chronic obstructive pulmonary disease. Which clinical finding supports the nurse's suspicion that the client is developing cor pulmonale? A lethargy progressing to coma B peripheral edema C productive coughing D twitching of the extremities

b

A nurse is caring for a client with dysuria. Which component of the urinalysis indicates the client is experiencing a urinary tract infection? A Erythrocytes microscopic B Nitrate positive C Protein positive D Urobilinogen 0.2

b

The nurse is evaluating the complete blood cell counts for four clients. The nurse recognizes which client has the highest risk of bleeding? Client with a: A hemoglobin of 11.4 g/dL (12.1-16/0 g/dL) B platelet level of 100 K/CMM (150-400 K/CMM). C mean cell volume (MCV) of 60 fL (80-94 fL). D white blood cell count of 3 K/CMM (4.8-10.8 K/CMM)

b

The nurse is preparing to administer two incompatible drugs via the intravenous (IV) route. Which action should the nurse implement in the administration of these medications? A Administer one at the highest point of the IV tubing and the other at the lowest point. B Administer the first drug and then flush the line with normal saline before administering the second drug. C Clarify the order with the health care provider and request one be change to a compatible drug. D Reschedule one of the drugs to a different administration time and notify the pharmacist.

b

client is admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA). What is the initial intervention the nurse should expect the primary healthcare provider to prescribe for this client? A Intravenous fluids B NPH Insulin C Potassium D Sodium polystyrene sulfonate

A Intravenous fluids

The nurse is caring for a client who has sustained blunt trauma to the forearm. The nurse assesses the client for which early sign of compartment syndrome? A Bounding radial pulse in the injured arm B Escalating pain in the fingers C Rapid capillary refill in the affected hand D Warm skin at the site of injury

B

A client is admitted to the hospital with a tentative diagnosis of Guillian-Barre syndrome and a nurse is obtaining the client's health history. Which question by the nurse will best elicit information that supports this diagnosis? A "Did you receive a head injury during the past year?" B "Have you experienced an infection recently?" C "Is there a history of this disorder in your family?" D "What medications have you taken in the last several months?"

B "Have you experienced an infection recently?"

A client is admitted to the hospital for medical management of acute pancreatitis. Which nursing action is most likely to reduce the pancreatic and gastric secretions of a client with pancreatitis? A Administering prescribed anticholinergic medication B Assisting the client into a semi-Fowler's position C Encouraging clear liquids D Obtaining a prescription for morphine

a

A nurse is caring for a client with the diagnosis of right ventricular failure. Which condition unrelated to cardiac disease does the nurse recognize is a major cause of right ventricular failure? A chronic obstructive pulmonary disease B hypovolemic shock C renal disease D severe systemic infection

a

The nurse is caring for a client with a medical history that includes diabetes mellitus type II and hypertension. The client asks the nurse why the health care provider has prescribed both metoprolol and lisinopril. Which response by the nurse is most accurate? A "Both drugs dilate blood vessels, which lowers the blood pressure, however the lisinopril also assists in lower blood sugar." B "Both drugs work on lowering blood pressure; however, it would take much higher doses of just one of these drugs." C "The lisinopril affects the way the kidneys control blood pressure and metoprolol affects the way the nervous system controls blood pressure." D "The metoprolol slows down the heart rate and the lisinopril dilates the blood vessels, which leads to both lowering the blood pressure."

c

A client has a paracentesis and the health care provider removes 1500 mL of fluid. What clinical finding is most important for the nurse to assess after this procedure? A dry mouth B hypertensive crisis C increased abdominal distention D tachycardia

d

new graduate nurse is preparing to administer ketorolac 30 mg IM under the supervision of a registered nurse preceptor. Which action by the new graduate nurse should the preceptor provide corrective feedback? A Injected the medication at a 90 degree angle B Injected the medication using a 22 g 1 1/2 inch needle C Pulled the skin to the right during injection and released during needle removal D Selected an injection site directly above an imaginary line between the right greater trochanter and the posterior iliac spine

d

A client experiencing a pleural effusion tells the nurse to explain why it is important to do incentive spirometry to keep the alveoli open. Which explanation by the nurse is most accurate? A "Due to the fluid in the lining of your pleural space, you are taking more shallow breaths which are reducing your ability to keep the alveoli open." B "The fluid in your pleural space can expand to the alveoli unless there is increased pressure in the alveoli to keep it away." C "There is fluid in your alveoli that is infected and decreasing your ability to naturally take deep breaths." D "Your alveoli are filled with fluid due to your pleural effusion, which is increasing your risk of pneumonia unless you keep them as open as possible."

A "Due to the fluid in the lining of your pleural space, you are taking more shallow breaths which are reducing your ability to keep the alveoli open."

The nurse has performed discharge teaching for a post-knee replacement client. After teaching the client about home administration of fondaparinux sodium SC, the nurse notes additional teaching is required when the client makes which statement? A "I must have my PT and PTT counts monitored while taking this medication." B "I must not expel the air from the syringe before I give the injection." C "I should avoid the use of aspirin while taking the medication." D "I should notify my doctor if I notice any unusual bleeding while taking this medication."

A "I must have my PT and PTT counts monitored while taking this medication."

A client with cancer of the colon is admitted to the hospital for a hemicolectomy. What does the nurse expect the preoperative plan of care to include? A Administering cleansing enemas and then neomycin. B A high-protein and high-carbohydrate regular diet for two days preoperatively. C Giving oil-retention enemas daily for two days preoperatively. D Having a nasogastric esophageal compression tube at the bedside.

A Administering cleansing enemas and then neomycin.

A client receiving chemotherapy administration has a platelet count of 35,000 mm3. What should the nurse include in the client's plan of care? A Instruct the client to avoid a daily flossing routine. B Request the health care provider to prescribe a saline enema. C Notify the health care provider immediately. D Wash fresh fruit thoroughly before consuming it.

A Instruct the client to avoid a daily flossing routine.

A client has had two weeks of bile drainage from a T-tube following the client's cholecystectomy. To monitor for a lack of fat-soluble vitamins, the nurse should observe for what symptom? A easy bruising B excessive jaundice C muscle twitching D tingling of the fingers

A easy bruising

A nurse is caring for an older client who had an open reduction internal fixation of a fractured hip. Which clinical finding requires the nurse to notify the health care provider? A Complaints of right-sided chest pain 6 days postoperatively B Fatigue in the leg on the unaffected side 5 days postoperatively C Lack of a productive cough 2 days postoperatively D Rectal temperature of 100.2 degrees F 3 days postoperatively

a

The nurse is caring for a client admitted with acute pancreatitis. Which finding does the nurse recognize is most ominous? A absent bowel sounds B diminished breath sounds C distended abdomen D hyperglycemia

a

The nurse is caring for a client on the post-recovery care unit (PACU) following an laparoscopic cholecystectomy. The nurse notes the client's abdomen is soft and non-distended; however, the client's bowel sounds are absent. Once the client awakens, what question is priority for the nurse to ask? A "Are you experiencing any nausea? B "Are you having any pain?" C "Can you wiggle your toes?" D "Do you know where you are?"

a

The nurse is caring for a client who recently returned from the post-anesthesia care unit (PACU). The client's vital signs are: 132/86 mmHg, 52 beats/minute, and 12 breaths/minute. Which assessment should the nurse implement first? A body temperature B incision site C level of consciousness D oxygen saturation

a

The nurse is reviewing the prothrombin time (PT) and INR values for a client receiving warfarin. The nurse notes that the client's PT is 24 seconds (10-12 seconds) with an INR of 2.5 (2-3). Which interpretation would the nurse determine from these results? The warfarin dose: A is at a therapeutic level. B is at a subtherapeutic level for this client. C is at a toxic level for this client. D needs to be withheld and the provider notified.

a

What reason does Dr. Begley give for why older persons are more likely to have cancer? A Cancers take a long time to develop to a stage where they can be detected. B Their body systems do not function as well as younger ones. C Their tissue cells are older and die at a faster rate than in their youth. D They are exposed to carcinogens during a time when their cells are older.

a

The nurse recognizes that the streptomycin a client with tuberculosis is receiving can cause damage to the eighth cranial nerve. Which assessment should the nurse implement to test this cranial nerve? A extraocular eye movements B hearing acuity C pupil responsiveness D swallowing ability

b

Which reason does Dr. Begley explain makes it most difficult for us to cure cancer? Cancer: A cells in the early phase of development do not look like tissue cells. B develops long before we are able to detect it. C grows faster than treatments can effectively treat it. D mutate rapidly making treatments obsolete soon after released.

b

The nurse is caring for a client experiencing a methacillin-resistant staphylococcus aureus skin infection. Which medication should the nurse question prior to administering? A clindamycin B hydrocodone/acetaminophen C prednisone D vancomycin

c

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gasiness and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk? A applesauce B eggs C potatoes D yogurt

d

A client's complete blood count results are available for review from this morning's lab draws. Which value does the nurse realize needs to be called to the health care provider immediately? A hemoglobin 11.2 g/dL (12-16 g/dL) B mean cell volume 120 fL (80-94 fL) C platelets 458 K/CMM (150-400 K/CMM) D white blood count 14.8 K/CMM (4.8-10.8 K/CMM)

d

A new graduate nurse under the supervision of a registered nurse preceptor is preparing to administer enoxaparin 40 mg SC to a client receiving the medication to prevent venous thrombosis. Which action by the new graduate nurse should the preceptor provide corrective feedback? A Cleaned the site with an alcohol swab using a circular motion B Injected the air bubble present in the packaging of the medication C Selected the right anterolateral abdominal skin fold site for injection D Swabbed the injection site using a rubbing motion after injection

d