pn2 final
A client is receiving an IV infusion of heparin sodium at 1100 units/hr. The drug concentration is 25000 units/500 mL. What is the rate the nurse should infuse the medication?
22
A client has hypokalemia. What question be the nurse obtains the most information on a possible cause? A. "Do you use sugar substitutes? "B. "Do you use diuretics or laxatives? "C. "Do you have any kidney disease? "D. "Have your bowel habits changed recently?"
"Do you use diuretics or laxatives?
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." B. "I will call the provider to get a prescription for discontinuing the IV heparin today." C. "Both heparin and warfarin work together to dissolve the clots." D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay
"Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level.
The nurse is caring for a client who is experiencing a seizure that is continuing after 5 minutes. What is the nurse's priority action? A. Establish a large-bore catheter and start 0.9% sodium chloride. B. Start the patient on 2L of oxygen via nasal cannula. C. Establish airway D. Guide the client to prevent injury during convulsions.
. Establish airway
The nurse assess a client who has Guillain — Barre syndrome. Which clinical manifestation does the nurse expect to find in this client? A. Progressive ascending weakness and paresthesia B. Ophthalmoplegia and diplopia C. Weakness of the face, jaw, and sternocleidomastoid muscles D. Progressive weakness without sensory involvement
. Progressive ascending weakness and paresthesia
A client is to receive 1 unit of packed red blood cells over 4 hours. There is 325 ml in the infusion bag. The IV administration infusion set delivers 15 gtts/min. At what flow rate (drops/min) should the nurse run the infusion? 11
11
A nurse is calculating the client's intake for the 7-3 shift. 1 cup of coffee, 4 oz OJ, 4 oz broth, 4 oz diet soda. 20 ounces x 30ml
600mL
A nurse is documenting the plan of care for a client who has type 1 diabetes mellitus that has remained unstable despite conventional insulin therapy. The provider has explained to the client that the new plane will incorporate a long-acting insulin preparation. The nurse anticipates seeing a prescription for the addition of which of the following insulin preparations? A. Glargine B. Aspart C. Lispro D. Glulisine
A. Glargine
Which client is at greatest risk for atherosclerosis? A. A 65-year-old client who is obese with LDL of 188. B. A 43-year-old male with a family history of heart disease and a cholesterol of 158. C. A 56-year-old male with a HDL of 60 who takes atorvastatin. D. A 43-year-old female with mitral valve prolapse who quit smoking ten years ago
A. A 65-year-old client who is obese with LDL of 188.
The nurse is assigned to care for a group of clients. Upon revieing the clients records the nurse determines which client is most likely at risk for a fluid volume deficit? A. A client with ileostomy. B. A client with heart failure C. A client receiving frequent wound irrigations D. A client on long term corticosteroids
A. A client with ileostomy.
The nurse is assessing a client with anemia. Which clinical manifestation does the nurse expect to see in this client? A. Dyspnea with activity B. Hypertension C. Bradycardia D. Warm, flushed skin
A. Dyspnea with activity
A nurse is assessing a client who has systemic lupus systemic erythematosus. Which of the following should the nurse expect? ( SATA) A. Elevated temperature during exacerbation B. Elevated Creatinine C. Butterfly rash D. Subcutaneous nodules E. Joint Inflammation
A. Elevated temperature during exacerbation B. Elevated Creatinine C. Butterfly rash E. Joint Inflammation
A client returned to the nursing unit after a prostatectomy. Which activities does the nurse delegate to the unlicensed assistive personnel? (SATA) A. Encourage the client to get out of bed and use the chair B. Assessing the client for new onset of pain C. Irrigating the catheter with normal saline for blood clots D. Demonstrate how to use incentive spirometer E. Measuring and recording output from the indwelling catheter
A. Encourage the client to get out of bed and use the chair D. Demonstrate how to use incentive spirometer E. Measuring and recording output from the indwelling catheter
A nurse is instructing a client diagnosed with type 2 diabetes mellitus on diagnostic tests used to evaluate how well the control disorders has been managed. The nurse should instruct the client on which of the following diagnostic tests that will provide this intervention? A. Glycosylated hemoglobin B. Two-hour oral glucose test C. Fasting Plasma test D. Random plasma test
A. Glycosylated hemoglobin
A client is having a sudden and sever anaphylactic reaction to a medication. The nurse immediately stops the medication and calls a rapid response. The clients blood pressure is 80/52, HR 120 BPM and oxygen saturation 87%. Audible wheezing is noted, along with facial redness and swelling. Which initial treatment should be administered first? A. IM epinephrine B. Nebulized inhaler C. IV diphenhydramine D. IV normal saline bolus
A. IM epinephrine
A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions is the highest priority for the nurse to take? A. Review the client's electrolyte values. B. Check the client's perianal skin integrity. C. Investigate the client's emotional concerns. D. Obtain a dietary history from the client.
A. Review the client's electrolyte values
The nurse conducts a physical assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis? A. Severe, steady right lower quadrant pain B. Abdominal pain that started a day after vomiting began C. Abdominal pain that increases with knee flexion D. Marked peristalsis and hyperactive bowel sounds
A. Severe, steady right lower quadrant pain
An older adult client who has mature cataract in the right eye states " Now I have lost the sight in my right eye because I waited too long for treatment". How does the nurse best respond to the client? A. Surgery can still save the sight in your eye with removal of the cataract B. Yes, this type of blindness could have been prevented by earlier treatment C. It is fortunate you came for treatment in time to save the sight of your other eye D. Nothing you could have done would have made any difference
A. Surgery can still save the sight in your eye with removal of the cataract
A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a DVT (deep vein thrombosis)? (Select all that apply.) a. Assess legs for redness or swelling. b. Turn patient every 2 hours c. Administer ordered subcutaneous Heparin. d. Decrease fluid intake e.Massage the calves every day
Assess legs for redness or swelling Turn patient every 2 hours Administer ordered subcutaneous Heparin. Massage the calves every day
The nurse is caring for a client who was started on TPN two days previously. The client reports increased thirst, dry mouth, and voiding frequently. Which is the nurses most appropriate action? A. Weigh the client B. Assess the clients blood sugar C. Slow down the TPN infusion D. Assess the clients' vital signs
B. Assess the clients blood sugar
The nurse is changing the central line of a client receiving TPN and notes that the catheter insertion site appears reddened. The nurse should next assess what item? A. Expiration date on the bag B. Clients temperature C. Tightness of tubing connections D. Time of the last dressing change
B. Clients temperature
To delay the onset of microvascular and macrovascular complications in the diabetic client the nurse stresses what action? A. Restricting fluid intake B. Controlling hyperglycemia C. Preventing ketosis D. Preventing hypoglycemia
B. Controlling hyperglycemia
Phenazopyridine is prescribed for symptomatic relief of pain resulting from a lower urinary tract infection. The nurse should provide the client with information regarding this medication? A. Take the medication before meals B. A reddish orange discoloration of the urine may occur C. Take the medication at bedtime D. Discontinue the medication if headache occurs
B. A reddish orange discoloration of the urine may occur
The nurse suspects a client is experiencing an exacerbation of COPD when which of the following is assessed (SATA) A. Jugular vein distension B. Decrease oxygen saturation C. Peripheral Edema D. Sputum production E. Cough F. Dyspnea on exertion
B. Decrease oxygen saturation D. Sputum production E. Cough F. Dyspnea on exertion
Which teaching intervention is most appropriate for the client with Parkinson's disease? A. Isometric exercises B. Fall precautions C. Universal precautions D. Seizure precautions
B. Fall precautions
The client with heart failure has been prescribed intravenous nitroglycerin and furosemide for pulmonary edema. Which is the priority nursing intervention? A. Insert an indwelling urinary catheter. B. Monitor the client's blood pressure. C. Place the nitroglycerin under the client's tongue. D. Monitor the client's serum glucose level
B. Monitor the client's blood pressure
The nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which action is part of the plan or preparation and administration of the potassium? A. Obtaining an IV fusion pump B. Prepare the medication for bolus administration C. Monitoring urine output during administration D. Ensuring that the medication is diluted in the appropriate amount of normal saline.
B. Prepare the medication for bolus administration
A client with Alzheimer's disease is admitted to the hospital. Which psychosocial assessment is most important to the nurse to complete? A. Ability to recall past events B. Reaction to a change of environment C. Relationship with close family members D. Ability to perform calculations
B. Reaction to a change of environment
The nurse is caring for four clients with asthma. Which client does the nurse assess first? A. Client with a SaO2 level of 92% at rest B. Client whose expiratory phase is longer than inspiratory phase C. A client whose heart rate is 120 beats/min D. Client with barrel chest and clubbed fingers
C. A client whose heart rate is 120 beats/min
The nurse has completed an assessment on a client with decreased cardiac output. Which findings should be the highest priority? A. Weight gain of 1 kg in 3 days, blood pressure 130/80, mild dyspnea with exercise B. Blood pressure 110/62, atrial fibrillation with heart rate of 82, bibasilar crackles C. Confusion, urine output 15 mL over the last 2 hours, orthopnea D. O2 sat 92 on 2 L nasal cannula, respirations 20, 1+ edema
C. Confusion, urine output 15 mL over the last 2 hours, orthopnea
Which of the following would the nurse most likely assess in a client diagnosed with right sided heart failure? A. Cough with frothy blood-tinged sputum B. Syncope C. Distended neck veins D. Oliguria
C. Distended neck veins
A client presented to ER with decrease level of consciousness, polydipsia, hyperthermia, dry mucous membranes. Blood glucose result was critical high of 600 mg/dl and serum Na= 155, K= 6, and no serum ketones. The nurse determines the physician will diagnosis this client with which of the following conditions? A. Hypoglycemic Hypotonic Ketoacidosis. B. Diabetic ketoacidosis. C Hyperglycemic Hyperosmolar State (HHS/HHNK) D. Diabetic Insipidus
C. Hyperglycemic Hyperosmolar State (HHS/HHNK)
A client is admitted with a possible deep vein thrombosis. Nursing interventions should be implements for which of the following complications? A. Pneumonia B. Myocardial Infarction C. Pulmonary embolism D. Renal Failure
C. Pulmonary embolism
A client with chronic obstructive pulmonary disease (COPD) is admitted to the hospital. How can the nurse best participate the client to improve gas exchange? A. Resting in bed in a semi-fowlers position with the knees flexed B. Resting in bed with the head elevated to 45 to 60 degrees C. Sitting up at the bedside or in the chair and leaning slightly forward D. In the Trendelenburg position with several pillows behind the head
C. Sitting up at the bedside or in the chair and leaning slightly forward
A nurse is reviewing the labs for a newly admitted heart failure client and notes a serum potassium level of 5.8. Upon reviewing the clients' meds, the nurse realizes which of the following medications most likely contributed to this electrolyte imbalance? A. Hydrochlorothiazide B. Bumetanide C. Spironolactone D. Furosemide
C. Spironolactone
Which of the following conditions should the nurse recognize as a type II hypersensitivity reaction? A. Allergic rhinitis B. Positive purified protein derivative (PPD) test C. Transfusion with the improper blood type D. Serum sickness after receiving immunoglobulin
C. Transfusion with the improper blood type
A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response? A. Daily weight will help us make sure that you're eating properly. B. The hospital requires that all inpatients be weighted daily. C. Weight is one of the best indications that you are gaining or losing fluid. D. You need to lose weight to decrease your risk of heart failure.
C. Weight is one of the best indications that you are gaining or losing fluid.
The nurse is caring for a client who is administering insulin for diabetes for the first time. The nurse is instructing the client on mixing Humulin N and Humulin R in one syringe. Arrange the instructions in order. 1. withdraw the Humulin R. 2. wipe with alcohol and inject air (equal to units ordered) into the Humulin N insulin 3. wipe with alcohol and inject air (equal to units ordered) into the Humulin R insulin 4. gently roll both insulin between your hands 5. double-check the total number of units in the syringe 6. Withdraw Humulin N insulin A. 4,3,2,1,6,5 B. 4,2,3,6,1,5 C. 2,3,4,1,6,5 D. 4,2,3,1,6,5
D. 4,2,3,1,6,5
The home care nurse is about to administer intravenous medication to the client and reads in the chart that the peripherally inserted central catheter (PICC) line in the client's arm has been in place for four weeks. The PICC line is patent with a good blood return. The site is clean and free from manifestations of infiltration, irritation, and infection. What is the nurse's best action? A. Switch the medication to an oral route B. Discontinue the PICC line C. Notify the physician D. Administer the prescribed medication
D. Administer the prescribed medication
. A client who is experiencing an exacerbation of Crohn's disease should be monitored for which complication? A. Constipation B. Hyperkalemia C. Hypercalcemia D. Dehydration
D. Dehydration
A client is diagnosed with glaucoma and is prescribed medication to treat it. The nurse knows that which of the following best explains the purpose of the medication? A. This medication helps dry up excess secretions. B. This medication lowers extraocular pressure. C. It strengthens the muscles of the eye. D.This medication lowers intraocular pressure
D. This medication lowers intraocular pressure
Which arterial blood gas (ABG) values are expected with hyperventilation? A. pH, 7.32; PaCO2, 55 mm Hg B. pH, 7.45; PaCO2, 42 mm Hg C. pH, 7.48; PaCO2, 38 mm Hg D. pH, 7.55; PaCO2, 32 mm Hg
D. pH, 7.55; PaCO2, 32 mm Hg
A client is worried about contracting influenza. What is the nurse's best response to the client? A. Did you receive a flu vaccine this year? B. Flu in no longer a prevalent problem C. If you develop symptoms an antibiotic will cure you D. Current flu strains are generally mild
Did you receive a flu vaccine this year?
Which action should the nurse take when caring for a newly admitted client receiving a blood transfusion? A. Warm the blood prior to transfusion. B. Inform the client that the transfusion usually takes 6 hours. C. Instruct the client to report any itching, chest pain, or dyspnea D. Remain with the client for the first 60 minutes of the transfusion.
Instruct the client to report any itching, chest pain, or dyspnea
A nurse is caring for a client with a bowel obstruction with a nasogastric tube in place to low intermittent suctioning. The nurse would assess for which of the following conditions? A. Respiratory Alkalosis B. Respiratory Acidosis C. Metabolic Alkalosis D. Metabolic Acidosis
Metabolic Alkalosis
A 75-year-old diabetic client presents to the ER after collapsing in a local department store. The client has been fasting for days and testing had found ketones in the urine. Which acid base imbalance would the nurse expect assess in the client? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis
Metabolic acidosis
A client receiving continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result is most important to report to the health care provider? A. Sodium 154 B. Potassium 154 C. Magnesium 1.8 D. Calcium 7.8
Sodium 154
The laboratory values of a client who has diabetes mellitus include a fasting blood glucose level of 196mg/dl and hemoglobin AIC of 6.8. What are the nurses' interpretations of these findings? A. The lab values indicate that the client has poorly managed his or her disease. B. The values indicate that the client has managed his or her disease well. C. The client's glucose control for the past 24 hours has been poor, but the overall control is good D. The client's glucose control for the past 24 hours has been good, but the overall condition is poor
The client's glucose control for the past 24 hours has been poor, but the overall control is good
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? a. Check the client's vital signs. b. Request a dietitian consult. c. Suggest that the client rests before eating the meal. d. Request an order for an antiemetic
a. Check the client's vital signs.
The nurse is concerned that a client with a gastrostomy feeding tube is developing a complication. Which of the following are considered complications associated with this type of feeding tube? (Select all that apply.) a. Nausea b. Vomiting c. Leg cramps d. Abdominal distention e. Aspiration f. Diarrhea
a. Nausea b. Vomiting d. Abdominal distention e. Aspiration
A nurse suspects anaphylaxis when caring for a client following the initial administration of an intravenous infusion of an antibiotic. Which of the following would the nurse likely assess in this client? (Select all that apply). a. Bradycardia b. Itchiness c. Edema/swelling d. Hypotension e. Tachycardia f. Hypertension
b. Itchiness c. Edema/swelling d. Hypotension e. Tachycardia
The nurse is discharging home a client at risk for venous thromboembolism on enoxaparin sodium. What instruction is a priority for the nurse to provide to this client? a. "You must have your aPTT checked every 72 hours." b. "Massage the injection site after the heparin is injected." c. "You must have your PT/INR checked every 2 weeks." d. "Notify your health care provider if your stools appear tarry."
d. "Notify your health care provider if your stools appear tarry."
A client is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which arterial blood gas (ABG) lab value would the nurse expect to see with this client? a. pH 7.29; PaCO2 32; HCO3 18 b. pH 7.47; PaCO2 45; HCO3 28 c. pH 7.33; PaCO2 49; HCO3 29 d. pH 7.46; PaCO2 34; HCO3 23
pH 7.29; PaCO2 32; HCO3 18
A client is experiencing a loss of central vision nut not a loss of peripheral vision. The nurse realizes the client should be evaluated for which condition? A. Macular degeneration B. Nystagmus C. Detached retina syndrome D. Conjunctivitis
A. Macular degeneration
A client is prescribed lidocaine to infuse at 5mcg/kg/min. The drug concentration available is 500 mg in 250 ml dextrose 5% water. The clients weight is 80 kg What is the flow rate in ml hr. 12
12
A client diagnosed with type 1 diabetes mellitus administers a dose of NPH insulin at 7:00 am. At which of the following times would this client most likely exhibit hypoglycemia? A. 1400 B.0800 C.1000 D. 0900
1400
A client is admitted with a diagnosis of DKA. An insulin drip is initiated with 50 units of insulin in 100 ml of normal saline solution administered via an infusion mump at 30 mL/Hr. The nurse determines that the client is receiving how many units of insulin each hour?
15
The provider ordered normal saline with 20 mEq of KCL to infuse at 50mL/hr. A 500 mL bag has been hung at 0800. What time does the nurse anticipate needing to hang the second bag of IV fluids? 1800
1800
The nurse is notifying the health care provider via telephone of a change in the condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. 1. Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatment twice daily. Oxygen is prescribed at 2 L nasal cannula. 2. I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon 3. I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. 4. Hello, My name is Nurse Jones from Unit D. 5. Respirations are now 32 breaths/ minute. The pulse oximeter is 89% on 2L nasal cannula. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. A. 4,5,2,1,3 B. 4,2,1,5,3 C. 4,1,2,5,3 D. 4,5,1,2,3
4,2,1,5,3
The nurse assesses for which clinical manifestations in a client with suspected diabetic ketoacidosis? A. Increased rate and depth of respirations. B. Extremity tremors followed by seizure activity. C. Oral temperature of 102°F (38.9°C) D. Severe hypertension
A. Increased rate and depth of respirations.
Which action by the nurse is most effective to prevent becoming exposed to the Human Immunodeficiency Virus? A. Always use Standard Precautions with all clients in the workplace. B. Place clients who are HIV positive in Contact Precautions. C. Utilize sterile gloves for all procedures D. Convert parenteral medications to an oral form for clients who are HIV positive
A. Always use Standard Precautions with all clients in the workplace.
A nurse is assessing a client with mechanical bowel obstruction who reports intermittent abdominal pain. An hour later, the client reports constant abdominal pain. Which is the nurse's priority action? A. Assess the client's bowel sounds B. Administer intravenous opioid medications C. Insert a nasogastric tube for decompression D. Position the client knee to chest
A. Assess the client's bowel sounds
A client being treated for a spinal cord injury needs immediate ventilator support. The nurse realizes that this client's level of injury is most likely: A. C3. B. C6. C. T3. D. L3.
A. C3
The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client? A. Muscle weakness that worsens with use and improves with rest. B. Muscle rigidity C. Hyperactive deep tendon reflexes D. Impaired stereognosis
A. Muscle weakness that worsens with use and improves with rest.
The nurse is assessing a client admitted to hr. cardiac unit. What statement made by the client alerts the nurse to the priority of right-sided heart failure? A. My shoes fit tight lately B. I will sleep with four pillows at night C. I have trouble catching my breath D. I wake coughing every night
A. My shoes fit tight lately
A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations specific to hyperglycemia A. Polydipsia B. Polyuria C. Cool, clammy skin D. Blurred or double vision E. Dry skin
A. Polydipsia B. Polyuria
A nurse is assessing a male client who has a new diagnosis of peripheral artery occlusion. Which of the following findings should the nurse expect to find on the affected extremity? (Select all that apply) A. Presbyopia B. Pallor C. Paralysis D. Pulseless E. Petechia F. Paresthesia
A. Presbyopia B. Pallor C. Paralysis D. Pulseless F. Paresthesia
A client with renal failure who has been taking aluminum hydroxide/magnesium hydroxide suspension at home for indigestion is drowsy and has decreased deep tendon reflexes. Which action should the nurse take first? A. Review magnesium level on client's chart B. Notify HCP C. Withhold the next scheduled dose of aluminum/magnesium hydroxide D. Check the clients most recent potassium levels
A. Review magnesium level on client's chart
The nurse is caring for a client who is about to have immunotherapy initiated due to severe allergies. Knowing that this patient is being exposed to a known allergen, what intervention does the nurse implement to provide for client safety this allergy treatment? A. Stay with the client and ensure that emergency equipment is in the room. B. Pretreat the skin area to be tested with a cortisone-based cream. C. Apply oxygen by mask or nasal cannula before injecting the test agent. D. Cover the examination table and pillow with plastic or an ultrafine mesh
A. Stay with the client and ensure that emergency equipment is in the room
Which of the following assessment techniques can the nurse us to determine if a client is experiencing hypocalcemia? (SATA) A. Trousseau's Sign B. Chvostek's sign C. Auscultation of the lungs D. Allen's Test E. Palpation of the neck F. Check the chart to evaluate recent lab values
A. Trousseau's Sign B. Chvostek's sign F. Check the chart to evaluate recent lab values
A nurse is caring for a client and observes that the client's urine is 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. Renal calculi D. Urinary retention
A. Urinary tract infection
A client appears dyspneic; nut the oxygen saturation is 97%. What action by the nurse is best? A. Tell the client to take slow, deep breaths B. Assess for other manifestations of hypoxia C. Obtain a new oximeter from the supply department D. Change the sensor on the pulse oximeter
B. Assess for other manifestations of hypoxia
5. The nurse is caring for a client who is experiencing a seizure that is continuing after 5 minutes. What is the nurse's priority action? A. Establish a large-bore catheter and start 0.9% sodium chloride. B. Start the patient on 2L of oxygen via nasal cannula. C. Establish airway D. Guide the client to prevent injury during convulsions
C. Establish airway
A nurse admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous status ulcer? A. Explore the client's family history of peripheral vascular disease B. Note the presence or absence of pain at the ulcer site C. Inquire about the presence or absence of claudication D. Ask if the client has had a recent infection
C. Inquire about the presence or absence of claudication
A nurse is teaching a group of nursing students about dissecting abdominal aortic aneurysm. Which of the following statements should the nurse include in the teaching? A. Has a high survival rate. B. Can be treated in the outpatient setting. C. It is a medical emergency requiring immediate treatment. D. Palpating the abdomen is the best way to assess
C. It is a medical emergency requiring immediate treatment.
91. The nurse is performing an assessment on a client diagnosed of left-sided heart failure. Which assessment component would elicit specific information regarding the left sided heart condition? A. Assessing for peripheral and sacral edema B. Palpating for organomegaly C. Listen to lung sounds. D. Assessing for jugular vein distension
C. Listen to lung sounds.
A client is receiving TPN. Which of the following routes is not appropriate for the type of nutrition administration? A. Central Venous Line B. Peripherally inserted central catheter line C. PERCUTANEOUS ENDOSCOPIC GASTRONOMY (PEG tube) D. Subclavian Line
C. PERCUTANEOUS ENDOSCOPIC GASTRONOMY (PEG tube)
A client comes into the emergency department with an acute shortness of breath and a cough that produces pink, frothy sputum admission assessment reveals crackles and wheezes. A blood pressure of 85/46 mm Hg, and heart rate of 122 bpm and a respiratory rate of 38 breaths per minute. The client's medical history included diabetes (DM) hypertension (HTN) and heart failure. Which of following disorders should the nurse suspect? A. Pulmonary hypertension B. Pulmonary embolism C. Pulmonary edema D. Pneumothorax
C. Pulmonary edema
The nurse is caring for a client with Parkinson's disease. Which intervention does the nurse implement to prevent aspiration related respiratory complications in the client? a. Keep an oral airway at the bedside. b. Ensure fluid intake of at least 3 L/day. c. Teach the client pursed lip breathing techniques. d. Maintain the head of the bed at least 30 degrees or greater.
d. Maintain the head of the bed at least 30 degrees or greater.
A client has the following ABG 7.30, HCO 22 PaC02 86. Which intervention by the nurse takes priority? A. Provide oxygen B. Administer bronchodilators C. Administer mucolytics D.Assess the airway
D. Assess the airway
A client diagnosed with heart failure is prescribed furosemide. Which of the following should this client be monitored for because of this medication? SATA A. Hypoglycemia B. Hyperkalemia C. Rebound fluid volume overload D. Hyponatremia E. Dehydration F. Hypernatremia
D. Hyponatremia E. Dehydration
The nurse is teaching a client who is newly diagnosed with epilepsy. Which statement by the client indicates a need for further teaching concerning the drug regimen? A. I will not drink alcoholic beverages. B. I will let my doctor know about all my prescriptions. C. I will wear a medical bracelet. D. I can skip a couple of pills if they make me ill
D. I can skip a couple of pills if they make me ill
A client with macular degeneration would like to watch television. Where does the nurse place the television for best visualization of the screen? A. As close to the client's face as possible B. As far away as possible, with low lights C. Directly in front of the client D. In the client's peripheral view
D. In the client's peripheral view
A nurse is planning care for a client who has acute dysphagia. Which of the following nursing interventions should be included in the plan of care? A. Providing a straw for consumption of liquid B. Encouraging larger bites C. Placing the client in at least Semi-Fowlers position during meals D. Instructing the client to throw head back when swallowing
D. Instructing the client to throw head back when swallowing
A client with benign prostate hyperplasia asks why his enlarged prostate is causing difficulty with urination. Which is the nurses most accurate response? A. It destroys nerves, decreasing awareness of a full bladder B. It presses on the kidneys, decreasing urine formation C. It secretes acids that weaken the bladder, causing dribbling D. It compresses the urethra, blocking the flow of urine
D. It compresses the urethra, blocking the flow of urine
The nurse is discussing an elderly client's diet and nutritional status with the hospital dietician. The nurse knows this client is at risk for which complication? A. Obesity B. A blood disorder C. Sodium Imbalance D. Malnutrition
D. Malnutrition
Intravenous heparin therapy is prescribed for a client. While implementing this prescription. The nurse ensures which medications is available on the nursing unit? A. Potassium Chloride B. Vitamin K C. Aminocaproic acid D. Protamine Sulfate
D. Protamine Sulfate
The nurse writes the nursing problem of "fluid volume excess" Which intervention should the nurse include in the plan of care? A. Change the IV fluid from 0.9 % normal saline to dextrose 5% water B. Monitor blood glucose levels C. Prepare the client forhempgialysis D. Restrict the client's sodium in the diet
D. Restrict the client's sodium in the diet
A client receiving a dose of red blood cells begins to report chest pain and lower back pain. Which action does the nurse take first? A. Reposition the client on the right side B. Administer morphine sulfate 1 MG IV C. Assess the level of pain D.Stop the transfusion
D. Stop the transfusion
Which assessment data obtained by the home care nurse suggests that an older client may be dehydrated? A. The nurse observes nonpitting bilateral ankle edema B. The client has dry, scaly skin on bilateral upper and lower extremities C. The client states that he gets up three or more tunes during the night to urinate D. The client states he feels lightheaded when he gets out of bed or stands up.
D. The client states he feels lightheaded when he gets out of bed or stands up.
The nurse is caring for a client post spinal cord injury. What interventions will the nurse provide to minimize the risk of autonomic dysreflexia? A. Ensure the client is wearing tight, compressing clothing. B. Minimize moving the client to prevent further injury. C. Limit bladder catheterization to once every 12 hours. D.Ensure strict adherence to a bowel retraining program
D.Ensure strict adherence to a bowel retraining program
The nurse reviews the ABG results of a client and notes the following: pH 7.45, PaCO2 30, HCO3 20. The nurse analyzes these results as indicating which condition? A. Metabolic acidosis uncompensated B. Metabolic acidosis fully compensated C. Respiratory acidosis uncompensated D.Respiratory alkalosis Fully compensated
D.Respiratory alkalosis Fully compensated
A client with diabetes mellites is prescribed to take insulin glargine once daily and regular insulin four times daily. How will the nurse teach the client to take these two medications when the first dose of regular insulin should be given at the same time of day as the insulin glargine dose. A. First draw up the dose of regular insulin and then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together. B. First draw up the dose of insulin glargine and then draw up the dose of regular insulin in the same syringe, mix and inject the two insulins together. C. Draw up and inject the insulin glargine first, wait an hour and then draw up and inject the dose of regular insulin. D. Draw up and inject the insulin glargine fist and then draw up and inject the dose of regular insulin in a separate syringe
Draw up and inject the insulin glargine fist and then draw up and inject the dose of regular insulin in a separate syringe
A client with diabetes mellitus has hot dry skin; rapid and deep respirations; and fruity odor to his breath. The charge nurse observes a newly graduated registered nurse performing all the following tasks. Which action requires that the charge nurse intervene immediately? A. Checking the client's fingernail for glucose level B. Assessing Clients Vital signs every 15 minutes C. Encouraging the client to drink 4 oz of orange juice D. Checking the clients order for sliding scale insulin
Encouraging the client to drink 4 oz of orange juice
A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiration rate is 36 and he appears very restless. The nurse anticipates which of the following values to be outside the expected reference range if the client is experiencing respiratory alkalosis. A. Bicarbonate B. PaO2 C. Sodium D. PaCO2
PaCO2
A client brought to the emergency department states that he has accidentally been taking two times has prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? A. Prepare to draw a sample for type and crossmatch and transfuse the client. B. Prepare to draw a sample for an activated patial thromboplastin (aPTT) C. Prepare to draw a sample for of PT/INR D. Prepare to administer an antidote
Prepare to draw a sample for of PT/INR
A client is admitted to the emergency room with a respiratory rate of 6/min. Arterial blood gasses (ABGs) have been drawn and reveal to following values: pH 7.22, PaCO2 68, HCO3 26, PaO2 74. Which of the following is an appropriate analysis of these ABGs? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis
Respiratory acidosis
The nurse assesses a client with pneumonia and notes no audible lung sounds on the left side and decreased lung expansion. What is the nurse's initial action? a. Have the client cough and deep breathe. b. Assess oxygen saturation and notify the health care provider. c. Perform an arterial blood gas analysis. d. Increase oxygen flow to 10 L/min
b. Assess oxygen saturation and notify the health care provider.
A client is suspected of having an abdominal aortic aneurysm. Which question is the highest priority for the nurse to ask first? A. Do you get frequent headaches B. Do you have any abdominal or back pain? C. Have you ever had any blood in your urine? D. Have you had bowel movements that looked black or tarry?
b. Do you have any abdominal or back pain?
A client receiving care for a spinal cord injury complains of a pounding headache, flushed skin, cardiac dysrhythmias and has a blood pressure of 220/125 mmHg. What is the first action the nurse should take? a. Administer medication as ordered. b. Position the client on the left side. c. Turn off the lights and decrease the noise in the room. d. Check the bladder for distension.
d. Check the bladder for distension.
