Physiological Adaptation
A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include A. inability to perform active movement and pain with passive movement. B. inability to perform passive movement and pain with active movement. C. body-wide decrease in bone mass. D. a growth in and around the bone tissue.
A. inability to perform active movement and pain with passive movement.
A client reports occasional numbness in the fingers and lips. Which dietary choices should the nurse encourage the client eat? A. milk products B. chicken broth C. bananas D. wheat breads
A. milk products
The nurse should inform a client with Ménière's disease that before an attack of the disease, the client may experience: A. a severe headache B. nausea C. blurred vision D. a feeling of inner ear fullness
D. a feeling of inner ear fullness
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention? A. serving small portions of bland food B. withholding fluids for the first 4 to 6 hours after chemotherapy administration C. encouraging rhythmic breathing exercises D. administering metoclopramide and dexamethasone as ordered
D. administering metoclopramide and dexamethasone as ordered
The nurse is assessing a client who has a long history of uncontrolled hypertension. The nurse should assess the client for damage in which area of the eye? A. cornea B. iris C. sclera D. retina
D. retina
The client asks the nurse, "How did I get this urinary tract infection?" What should the nurse tell the client causes cystitis? A. an ascending infection from the urethra B. an infection elsewhere in the body C. congenital strictures in the urethra D. urinary stasis in the urinary bladder
A. an ascending infection from the urethra
A nurse is caring for a client with a spinal cord injury. The client is experiencing blurred vision and has a blood pressure of 204/102 mm Hg. What should the nurse do first? A. check the client's bladder for distention B. control the environment by turning the lights off and decreasing stimulation for the client C. position the client on the left side D. administer pain medications
A. check the client's bladder for distention
The parent of a toddler with nephrotic syndrome asks the nurse what can be done about the child's swollen eyes. Which is the best measure that the nurse should suggest? A. elevate the head of the child's bed B. apply cool compresses to the child's eye C. limit the child's television watching D. apply eye drops every 8 hrs
A. elevate the head of the child's bed
For a client with rib fractures and a pneumothorax, the health care provider (HCP) prescribes morphine sulfate, 1 to 2 mg/h, given IV as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which finding indicates the goal has been met? A. pain rating of 0 on a scale of 0-10 by the client B. respiratory rate of 26 bpm C. decreased client anxiety D. PaO2 of 70 mm Hg
A. pain rating of 0 on a scale of 0-10 by the client
Following a modified radical mastectomy, a client has an incisional drainage tube attached to Hemovac suction. The nurse determines that the suction is effective when what occurs? A. There is an increased collateral lymphatic flow toward the operative area. B. No adhesions are formed between the skin and chest wall in the operative area. C. Accumulated serum and blood in the operative area are removed. D. The intrathoracic pressure is decreased, and the client breathes easier.
C. Accumulated serum and blood in the operative area are removed.
A client who is 16 hours postoperative rates pain as 7 out of 10, has a respiratory rate of 28 breaths/min, and an arterial blood gas (ABG) result of pH 7.47, CO2 33 mm Hg (4.39 kPa), and HCO3 26 mEq/L (26 mmol/L). Which action should the nurse take? A. Start oxygen at 2 L/min as prescribed. B. Notify the health care provider about the ABG results. C. Administer I.V. morphine sulfate 4 mg as prescribed D. Teach the client how to take slow, deep breaths.
C. Administer I.V. morphine sulfate 4 mg as prescribed
A parent brings an infant to the health clinic for a well-baby checkup. During the assessment, the nurse measures the head circumference of the child and notes that there has been a rapid increase in size. What action should the nurse take next? A. Obtain an order to administer a diuretic. B. Teach the parent how to protect the child's head. C. Assess for signs of increased intracranial pressure. D. Document that growth is occurring quickly.
C. Assess for signs of increased intracranial pressure.
A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement to the client would the nurse use to describe a healthy stoma? A. "At first, the stoma may bleed slightly when touched." B. "A burning sensation under the stoma faceplate is normal." C. "The stoma should appear dark and have a bluish hue." D. "The stoma should remain swollen distal to the abdomen."
A. "At first, the stoma may bleed slightly when touched."
After having trouble breastfeeding, a 6-week-old female infant exhibits dry, scaly skin and a protruding tongue. A diagnosis of congenital hypothyroidism is made. The mother asks the nurse why the child was not diagnosed with this condition at birth. What would be the nurse's best response? A. "Newborns generally receive enough thyroid hormone from the mother to get by the first few weeks." B. "Your baby had little need for thyroid hormone until she was 1 month old." C. "We couldn't reach you at home to give you the results of tests taken at birth." D. "We had the results of the newborn screen, but you didn't bring the baby in for the 2-week checkup."
A. "Newborns generally receive enough thyroid hormone from the mother to get by the first few weeks."
A 15-month-old client is being discharged after treatment for severe otitis media and bacterial meningitis. Which statement by the caregivers indicates effective discharge teaching? A. "We'll go to the physician if our child pulls on the ears or won't lie down." B. "We're just so glad this is all behind us." C. "We should have gone to the physician sooner. Next time, we will." D. "We'll take our child to the physician's office every week until everything is okay."
A. "We'll go to the physician if our child pulls on the ears or won't lie down."
The nurse is teaching the client with an ileal conduit how to prevent a urinary tract infection. Which measure would be most effective? A. Maintain a daily fluid intake of 2,000 to 3,000 mL. B. Use sterile technique to change the appliance. C. Avoid people with respiratory tract infections. D. Irrigate the stoma daily.
A. Maintain a daily fluid intake of 2,000 to 3,000 mL.
Which item must the nurse consider when positioning a client for tracheal suctioning? A. Position in a semi-Fowler's position. B. Maintain the head in a hyperextended position. C. Position in low-Fowler's position. D. Ensure that the client's neck is flexed.
A. Position in a semi-Fowler's position.
A client who has apnea during sleep would require which of the following interventions? Select all that apply. A. Refer to primary healthcare provider B. Assess sleep routine/hours C. Teach client pursed-lip breathing D. Restrict family members from sleeping in the room E. Have client keep a sleep diary
A. Refer to primary healthcare provider B. Assess sleep routine/hours E. Have client keep a sleep diary
A client with aortic stenosis tells the nurse, "I have been feeling so tired lately that I take a nap in my recliner every afternoon." On assessment, the nurse notes apical heart sounds 2 cm left of the midclavicular line, crackles in lower lung fields during respiration, blood pressure 110/90 mm Hg, and weight gain of 2.5 kg (5.5 lb) in 24 hours. Which assessment requires further action? A. weight gain of 2.5 kg (5.5 lb) in 24 hours B. crackles in lower lung fields during inspiration C. blood pressure 110/90 mm Hg D. apical heart sounds 2 cm to the left of midclavicular line
A. weight gain of 2.5 kg (5.5 lb) in 24 hours
After the nurse teaches the parent of an infant with pyloric stenosis about the condition, which cause, if stated by the parent, indicates effective teaching? A. "a result of giving the baby more formula than is necessary" B. "an enlarged muscle below the stomach" C. "a telescoping of the large bowel into the smaller bowel" D. "a genetically smaller stomach than normal"
B. "an enlarged muscle below the stomach"
A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply. A. Alert the client to resume food and fluids when the client's voice returns. B. Assess for hemoptysis and frank bleeding. C. Withhold food and fluids until the client's gag reflex returns. D. Keep the client flat for at least 2 hours. E. Provide sips of water to moisten the client's mouth. F. Monitor the client's vital signs.
B. Assess for hemoptysis and frank bleeding. C. Withhold food and fluids until the client's gag reflex returns. F. Monitor the client's vital signs.
Which nursing diagnosis takes highest priority for a client with hyperthyroidism? A. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing B. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess C. Disturbed body image related to weight gain and edema D. Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess
B. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? A. The appendix may develop gangrene and rupture, especially in a middle-aged client. B. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. C. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage. D. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture.
B. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
A client is admitted to the pediatric unit with a diagnosis of celiac disease. What finding would the nurse expect in this client? A. a concave abdomen B. a protuberant abdomen C. a palpable abdominal mass D. bulges in the groin area
B. a protuberant abdomen
What is a priority for the nurse developing a plan with a client admitted to the hospital with an acute exacerbation of rheumatoid arthritis? A. continuing to work on a positive self image because joint deformities are common in this disease B. achieving a controlled level of pain and fatigue throughout the day. C. always performing activities of daily living independently D. accepting and working toward understanding long-term chronic illness
B. achieving a controlled level of pain and fatigue throughout the day.
Which factor, if described by the parents of a child with cystic fibrosis (CF), indicates that the parents understand the underlying problem of the disease? A. reaction to the formation of antibodies against streptococcus B. an abnormality in the body's mucus-secreting glands C. formation of fibrous cysts in various body organs D. failure of the pancreatic ducts to develop properly
B. an abnormality in the body's mucus-secreting glands
An older adult client diagnosed with end-stage renal disease (ESRD) presents with fluid volume excess. Which nursing intervention is the priority? A. weigh the client B. assess the client's lung sounds C. assess the client's heart rate and blood pressure D. place the client on intake and output measurement
B. assess the client's lung sounds
A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson disease. Which assessment finding should the nurse anticipate? A. bilateral upper extremity weakness B. coughing when drinking liquids C. muscle flaccidity of the lower extremities D. tremors in the fingers that increase with purposeful movement
B. coughing when drinking liquids
A client has chronic open-angle glaucoma. What should the nurse ask the client about when conducting a focused assessment? A. eye pain B. decreasing peripheral vision C. colored light flashes D. excessive lacrimation
B. decreasing peripheral vision
A nurse should expect to find which defining characteristics in a client with a nursing diagnosis of Ineffective tissue perfusion (peripheral)? Select all that apply. A. skin pink in color B. edema C. skin temperature changes D. skin discoloration E. strong, bounding pulses F. normal sensation
B. edema C. skin temperature changes D. skin discoloration
Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment? A. absence of tissue ischemia over bony prominences B. free, easy movement of the joints C. external rotation of the hips at rest D. absence of paralytic footdrop
B. free, easy movement of the joints
The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect: A. normal breath sounds B. inspiratory and expiratory wheezing C. morning headaches D. increased forced expiratory volume
B. inspiratory and expiratory wheezing
The nurse is caring for a 5-year-old child who had a hernia repair 1 day ago. The child is vomiting, has a nasogastric (NG) tube to low intermittent suction, and has diarrhea. Which of the following laboratory results would be the immediate priority for the nurse to assess? A. chloride level B. potassium level C. magnesium level D. calcium level
B. potassium level
A young adult is admitted for elective nasal surgery for a deviated septum. Which sign would be an important indicator of bleeding even if the nasal drip pad remained dry and intact? A. rapid respiratory rate B. repeated swallowing C. presence of nausea D. feelings of anxiety
B. repeated swallowing
The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved? A. the blood pressure is 90/60 mm Hg B. the urine output is greater than 35 mL/h C. the body weight has increased D. the fluid intake is less than urinary output
B. the urine output is greater than 35 mL/h
The parents of a child with a serious head injury ask the nurse if the child is going to be all right. Which response by the nurse would be most appropriate? A. "Children usually recover rapidly from head injuries." B. "That is something you'll have to talk to the health care provider about." C. "It is hard to tell this early, but we will keep you informed of the progress." D. "Children usually do not do very well after head injuries like this."
C. "It is hard to tell this early, but we will keep you informed of the progress."
A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse? A. Connect the client to a new chest tube system. B. Clamp the chest tube and document the response. C. Further assess the client for reinflation of the lung. D. Increase the suction level of the chest tube.
C. Further assess the client for reinflation of the lung.
A client is to start chemotherapy to treat lung cancer. A venous access device has been placed to permit administration of chemotherapeutic medications. Three days later at the scheduled appointment to receive chemotherapy, the nurse assesses that the client is dyspneic and the skin is warm and pale. The vital signs are blood pressure 80/30 mm Hg, pulse 132 bpm, respirations 28 breaths/min, temperature 103°F (39.4°C), and oxygen saturation 84%. The central line insertion site is inflamed. After the nurse calls the rapid response team, what should the nurse do next? A. Place cold, wet compresses on the client's head. B. Obtain a portable ECG monitor. C. Insert a peripheral intravenous fluid line and infuse normal saline. D. Administer a prescribed antipyretic.
C. Insert a peripheral intravenous fluid line and infuse normal saline.
The nurse evaluates the effectiveness of the client's postoperative plan of care. Which outcome is expected for a client with an ileal conduit? A. The client verbalizes the understanding that physical activity must be curtailed. B. The client will place an aspirin in the drainage pouch to help control odor. C. The client will empty the drainage pouch frequently throughout the day. D. The client demonstrates how to catheterize the stoma.
C. The client will empty the drainage pouch frequently throughout the day.
When the nurse is assessing an infant with suspected inguinal hernia, which finding would be most concerning? A. The infant's diaper is wet with urine, and the abdomen is nontender. B. The inguinal swelling can be reduced, and the infant has a stool in the diaper. C. The inguinal swelling is reddened, and the abdomen is distended. D. The infant is irritable, and a thickened spermatic cord is palpable.
C. The inguinal swelling is reddened, and the abdomen is distended.
The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions? A. hypovolemic shock B. hospital-acquired pneumonia C. acute respiratory distress syndrome (ARDS) D. asthma
C. acute respiratory distress syndrome (ARDS)
What is the most common cause of hyperaldosteronism? A. deficient potassium intake B. a pituitary adenoma C. an adrenal adenoma D. excessive sodium intake
C. an adrenal adenoma
What should the nurse do first when admitting a toddler with croup? A. ensure adequate fluid intake B. monitor vital signs C. assess respiratory status D. place a tracheostomy set at the bedside
C. assess respiratory status
Which assessment finding puts a client at increased risk for epistaxis? A. use of a humidifier at night B. history of nasal surgery C. cocaine use D. hypotension
C. cocaine use
For a neurologically injured client, the nurse should assess motor strength by: A. asking the client to signal when feeling pressure applied to the feet. B. observing the client feed himself or herself. C. comparing equality of hand grasps. D. observing spontaneous movements.
C. comparing equality of hand grasps.
For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia? A. tingling in the toes B. cool skin temperature C. decreased deep tendon reflexes D. rapid pulse rate
C. decreased deep tendon reflexes
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must A. report fluctuations in the water-seal chamber. B. clamp the chest tube once every shift. C. encourage coughing and deep breathing. D. milk the chest tube every 2 hours.
C. encourage coughing and deep breathing.
Which condition should a nurse expect to find in a client diagnosed with hyperparathyroidism? A. hypophosphaturia B. hyperphosphatemia C. hypercalcemia D. hypocalcemia
C. hypercalcemia
The nurse is preparing to administer a suppository through a client's colostomy. What supplies will the nurse gather? Select all that apply. A. lotion B. soap and water C. lubricating jelly D. ostomy pouch E. gloves
C. lubricating jelly E. gloves
A client with peripheral artery disease has femoral-popliteal bypass surgery. What goal should the nurse establish with the client immediately after surgery? A. prevent infection B. provide education C. maintain circulation D. relieve pain
C. maintain circulation
Which statement indicates that the client with diabetes insipidus understands how to manage care? The client will: A. state dietary restrictions. B. exhibit serum glucose level within normal range. C. maintain normal fluid and electrolyte balance. D. select a diabetic diet correctly.
C. maintain normal fluid and electrolyte balance.
When educating a female client with gonorrhea, what should the nurse emphasize? In women, gonorrhea: A. is often marked by symptoms of dysuria or vaginal bleeding. B. can be treated but not cured. C. may not cause symptoms until serious complications occur. D. does not lead to serious complications.
C. may not cause symptoms until serious complications occur.
When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung's disease about how the stoma should normally appear, the nurse should include which description about the stoma's appearance in the teaching? A. turning almost purple in color B. becoming dark brown in 2 months C. staying deep red in color D. changing to several shades of pink
C. staying deep red in color
A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands the condition and how to control it? A. "I should be sure to limit my food and fluid intake when I'm not feeling well so my blood sugar doesn't go up." B. "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates." C. "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." D. "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual."
D. "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual."
A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond? A. "This form of muscular dystrophy is a relatively benign disease that progresses slowly." B. "You should ask your physician about that." C. "The strength of your arms and pelvic muscles will decrease gradually, but this should cause only slight disability." D. "You may experience progressive deterioration in all voluntary muscles."
D. "You may experience progressive deterioration in all voluntary muscles."
For a client with chronic obstructive pulmonary disease who has trouble raising respiratory secretions, which intervention would help reduce the tenacity of secretions? A. Ensure that the client's oxygen therapy is continuous. B. Take a diet history to determine if the client's diet is low in salt. C. Keep the client in a semi-sitting position as much as possible. D. Help the client maintain an adequate fluid intake.
D. Help the client maintain an adequate fluid intake.
After a laminectomy, a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80 mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20 breaths/min. What is the best nursing intervention? A. Reassure the client that this is a normal voiding pattern. B. Administer the prescribed analgesic, and repeat the client's vital signs in 20 minutes. C. Offer the client a warm compress, and observe for worsening discomfort. D. Perform a bladder scan, and obtain an order for urinary catheterization.
D. Perform a bladder scan, and obtain an order for urinary catheterization.
Following cardiac bypass surgery, the client has been referred to a cardiac rehabilitation exercise program. The client has type 1 diabetes and has bilateral leg discomfort with walking. The client is exercising using a stationary bicycle. The nurse should evaluate the client's response to exercise by assessing the presence of which condition? A. muscle atrophy B. Raynaud's disease C. transient ischemic attacks D. diabetic neuropathy
D. diabetic neuropathy
A mother tells a nurse that her child has been exposed to roseola. After the nurse teaches the mother about the illness, which finding, if stated by the mother as the most characteristic sign of roseola, indicates successful teaching? A. normal temperature followed by a low-grade fever B. cold-like signs and symptoms and a rash C. fever and sore throat D. high fever followed by a drop and then a rash
D. high fever followed by a drop and then a rash
A 4-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. The nurse should suspect that the child's I.V. fluid intake is excessive if assessment reveals A. nausea and vomiting B. gastric distention C. a temperature of 102 (38.9) D. worsening dyspnea
D. worsening dyspnea