population final

When dealing with a COPD patient the nurse realizes the client understands prevention techniques for infection control when he/she verbalizes.... A. I will change my toothbrush after every infection B. I don't have to change my oxygen cannula until it breaks C. Washing my hands once a day will suffice D. I can use the same straw every day for a month as long as it isn't broken

A. I will change my toothbrush after every infection infection control

The nurse is reviewing the record of a client with Crohn's disease. Which of the following stool characteristics should the nurse expect to note documented in the client's records? (Select all that apply) 1.Non-bloody diarrhea 2.Three to five stools per day 3.Diarrhea episodes increasing in frequency and severity over time 4.Increasing duration of diarrhea episodes over time 5. Chronic constipation 1. Stool constantly oozing from the rectum A. All options should be included B.1, 2, 3, 4 C.1, 5, 6 D.2, 4. 6 E.1, 3, 6

B.1, 2, 3, 4

A nurse is conducting health screening for osteoporosis. The nurse would interpret that which of the following clients is at greatest risk for developing this disorder? A) A 36-year-old man who has asthma B) A 25-year-old man who jogs C) A sedentary 65-year-old woman who smokes cigarettes D) A 70-year-old man who consumes excess alcohol

C) A sedentary 65-year-old woman who smokes cigarettes prevention

Organs cannot be donated by: A) People with lung disease B) People with no medical insurance C) People with certain known infectious diseases such as HIV D) People over the age 65

C) People with certain known infectious diseases such as HIV assessment

The nurse is caring for clients on the medical unit. A client is admitted with a diagnosis of deep vein thrombosis. Admission orders include heparin 2000 units/hr in 5% dextrose in water. The nurse should have which of the following available: A) Propranolol (Inderol) B) Protamine zinc C) Protamine sulfate D) Vitamin K

C) Protamine sulfate pharm

The client has had a cataract removed. The nurse's discharge teaching should include which of the following: A) Keep the head aligned straight B) Utilize bright lights in the home C) Use an eye shield at night D) Change the eye patch as needed

C) Use an eye shield at night teach

A nurse is showing a young student nurse the appropriate way to conduct an assessment using an otoscope on an elderly male client. Indicate in which order the nurse should conduct assessment of this client: 1. Choose the largest speculum that will fit comfortably. 2. Pull the pinna up and back to straighten the S-shape of the canal. 3. Tilt the clients head slightly away from you toward the opposite shoulder. 4. Hold the otoscope and use the dorsum of your hand along the person's cheek to steady the otoscope. A. 1, 2, 3, 4 B. 2, 1, 4, 3 C. 1, 3, 2, 4 D. 4, 3, 2, 1

C. 1, 3, 2, 4 Choose the largest speculum that will fit comfortably. , Tilt the clients head slightly away from you toward the opposite shoulder., Pull the pinna up and back to straighten the S-shape of the canal., Hold the otoscope and use the dorsum of your hand along the person's cheek to steady the otoscope.)

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? A) Bradycardia B) Numbness in the legs C) Nausea and vomiting D) A rigid, board-like abdomen

D) A rigid, board-like abdomen assessment

The potential for injury during an attack of Meniere's disease is great. The nurse should instruct the client to take which immediate action when experiencing vertigo? A. "Place your head between your knees" B. "Concentrate on rhythmic deep breathing" C. "Close your eyes tightly" D. "Assume a reclining or flat position"

D. "Assume a reclining or flat position" safety

A clinic nurse is providing instructions to a client with a diagnosis of conjunctivitis. Which statement by the client indicates a need for further instruction? A. "I should apply warm compresses before instilling the antibiotic drops if purulent drainage is present in my eye." B. "I can use saline eye irrigations before instilling antibiotics in my eye if drainage is present." C. "If I have any eye discomfort, I can use the eye analgesic ointment that my physician has prescribed." D. "Sharing washcloths and towels is acceptable because this condition is not contagious."

D. "Sharing washcloths and towels is acceptable because this condition is not contagious." safety

The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states the he or she will: a. Expose the face to cold and drafts b. Massage the face with a gentle upward motion c. Perform facial exercises d. Wrinkle the forehead, blow out the cheeks, and whistle

a. Expose the face to cold and drafts

The nurse has given the male client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: a. Exposure to cold and drafts b. Massage the face with gentle upward motion c. Perform facial exposures d. Wrinkle the forehead, blow out the cheeks, and whistle

a. Exposure to cold and drafts prevention

The nurse assesses a client for hyperlipidemia. Normal lipid levels are best evidenced by which laboratory values? a. HDL 40, LDL 90 b. HDL 45, LDL 175 c. HDL 45, LDL 160 d. HDL 35, LDL 130

a. HDL 40, LDL 90 assessment

A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms? a. Inadequate tissue perfusion leading to nerve damage. b. Fluid overload leading to compression of nerve tissue. c. Sensation distortion due to psychiatric disturbance. d. Inflammation of the skin on the hands and feet.

a. Inadequate tissue perfusion leading to nerve damage. assessment

Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? select all that apply a. It results when oxygen demand is greater than oxygen supply b. It is characterized by pain that often occurs during rest c. It is a result of tissue hypoxia d. It is characterized by cramping and weakness

a. It results when oxygen demand is greater than oxygen supply c. It is a result of tissue hypoxia d. It is characterized by cramping and weakness

The nurse is teaching a client with gastroesophageal reflux disease (GERD) about dietary and lifestyle modifications. Which of the following information should the nurse include in the teaching? Select all that apply. a. Maintain a high-protein, low-fat diet. b. Avoid snacks between meals. c. Sleep with the head of the bed elevated. d. Stay upright for 2 to 3 hours after eating. e. Decrease daily intake of sodium.

a. Maintain a high-protein, low-fat diet. c. Sleep with the head of the bed elevated. d. Stay upright for 2 to 3 hours after eating.

A nurse is discussing treatment options for retinal detachment with a client. Which of the following are options? Select all that apply a. Observation b. Sealing breaks c. Vitrectomy d. Injections

a. Observation b. Sealing breaks c. Vitrectomy

A client has been recently diagnosed with COPD, which of the following can be delegated to the UAP: a. Record the O2 Stat vital b. Teach the client how to use the Tripod position c. Assess the respiratory system d. Explain discharge planning

a. Record the O2 Stat vital management of care

Which of the following should the nurse do to prevent infection in an immunosuppressed client who just received an organ transplant? a. Remove invasive lines early when possible b. Wear gloves only when performing sterile procedures c. Wash hands for 3 seconds before putting on gloves d. Leave invasive lines in the patient as long as possible

a. Remove invasive lines early when possible infection control

A nurse providing primary prevention in the control of COPD would most likely refer the patient to which of the following: a. Smoking Cessation Program b. Alcohol and Drug Abuse Program c. Ask the Doctor d. Over the Counter Medications

a. Smoking Cessation Program prevention

A benefit of getting an organ from a living donor is: a. There's a smaller chance of rejection if the organ is received from a living person. b. The living donor's organs are younger than a deceased person. c. A deceased persons organs won't work d. The deceased person's organs will always be rejected

a. There's a smaller chance of rejection if the organ is received from a living person. prevention

A client has been diagnosed with GERD. She is going to start her first round of medication therapy. Which of the following medications should the nurse teach the client to use first? a. Tums b. Prilosec OTC c. Pepcid AC d. Surgery

a. Tums priority

a client is being cared for after post op following a hysterectomy. which of the following is not an acceptable action on the part of the nurse? a. encouraging the client to refrain from ambulating b. having the client wear TED hose c. restricting food/fluids if the client is experiencing nausea d. perfroming regular dressing changes on the abdomen/perineum

a. encouraging the client to refraing from abulating safety

the nurse evaluates the effectiveness of drug therapy in a client w/ hyperlipidemia. effective therapy is best evidenced by which laboratory values? a. hdl 40, ldl 90 b. hdl 45, ldl 160 c. hdl 45, ldl175 d. hdl 35, ldl 130

a. hdl 40, ldl 90 assessment

when assessing conjuctiva of a 7 yom, the nurse records redness of the child's left eye. The nurse then decides to a. initiate contact precautions b. give the patient an eye patch c. teach the pt infection control measures d. request an MRI from the doctor on call

a. initiate contact precautions assessment

the most effective measure the nurse can use to prevent wound infection when changing a clients dressing after coronary artery bypass surgery is to: a. observe careful hand-washing procedures b. clean the incision area w/an antiseptic c. use prepackaged sterile dressings to cover the incision d. place soiled dressing in a waterproof bag before disposing of them

a. observe careful hand-washing procedures infection control

the nurse is teaching about irritable bowel syndrome (IBS). which of the following would be most important to include? a. reinforcing the need for a balance diet b. encouraging the client to drink 16oz of fluid w/each meal c. telling the client to eat a diet low in fiber d. instructing the client to limit his intake of fruits & veggies

a. reinforcing the need for a balanced diet client teaching

the client w/longstanding myasthenia gravis is admitted to the acute care unit after having been diagnosed & treated for cholinergic crisis. which of the following warning signs of cholinergic crisis will the nurse teach the family? select all that apply a. respiratory distress b. tachycardia c. vertigo d. sever muscle weakness

a. respiratory distress c. vertigo d. severe muscle weakness

the client w/ myasthenia gravis is prescribed the cholinesterase inhibitor, neostigmine (prostigmin). which data indicate the medication is effective a. the client is able to feed self independently b. the client is able to blink eyes w/o tearing c. the client denies any nausea or vomiting when eating d. the client denies any pain when performing ROM exercises

a. the client is able to feed self independently Prevention: health promotion & maintenance, reduction of risk potential

Which of the following can a living donor donate? (Select all that apply) a.) A kidney b.) A lobe of the spleen c.) A lobe of the lung d.) A lobe of the liver e.) A lobe of the pancreas

a.) A kidney c.) A lobe of the lung d.) A lobe of the liver

The physician prescribes cholestyramine (Questran) for a client with hyperlipidemia. Which instructions should the nurse include in the client's teaching plan? a.) Increase your intake of fiber and fluid b.) Take medication before you go to bed c.) Check your pulse before taking the medications d.) Contact your doctor if your skin or sclera turn yellow

a.) Increase your intake of fiber and fluid teaching

a client has been diagnosed w/ acute angle-closure glaucoma. what medications/therapies would be appropriate for this emergency? a. cholinergic agents b. hyperosmotic agents c. laser surgery to create an opening in the iris d. all of the above

d. all of the above (cholinergic agents, hyperosmotic agents, laser surgery to create an opening in the iris) pharmacological & parenteral therapies

In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the physician's orders, expecting which type of eye drops to be prescribed? a. a miotic agent b. a thiazide diuretic c. can osmotic diuretic d. an mydriatic medication

d. an mydriatic medication management of care

A 5-year-old child was recently diagnosed with having bacterial conjunctivitis in both eyes. The nurse is teaching the mother the best way to prevent the spread of infection to the child's siblings. The best way to prevent the spread of infection is: a) wash both eyes with soap and water frequently b) use regular eye drops 3 times per day until the infection clears c) apply antibiotic eye drops as prescribed, wash hands frequently, and keep the child from touching the eyes until the infection has cleared d) do nothing because this infection is not contagious at all so there is nothing to worry about

safety

The nurse evaluates the effectiveness of drug therapy in a client with hyperlipidemia. Effective therapy is best evidenced by which laboratory values? A. HDL 45; LDL 160 B. HDL 35; LDL 130 C. HDL 40; LDL 90 D. HDL 45; LDL 175

C. HDL 40; LDL 90 assessment

What nursing interventions promote adequate bowel functions for the aging populations? (Select all that apply) 1) increase fiber and bulk in diet 2) provide adequate hydration 3) encourage irregular exercise 4) promote eating large meals frequently 5) determine the "normal" GI functioning for each individual

1) increase fiber and bulk in diet 2) provide adequate hydration 5) determine the "normal" GI functioning for each individual

A patient with Diverticulitis is experiencing diarrhea and is running back and forth between the bathroom. He is a risk for falls. 1. Assign a UAP to assist the client to the commode 2. Check on the client every 30 min. 3. Give the client Pepto-Bismol 4. Assure the client it will subside soon

1. Assign a UAP to assist the client to the commode safety

A nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen's test on the client. Number the following steps in order of priority for performing the Allen's Test: 1. Assess the color of the extremity distal to the pressure point 2. Explain the procedure to the client. 3. Document the findings. 4. Apply pressure over the ulnar and radial arteries 5. Release pressure from the ulnar artery 6. Ask the client to open and close the hand repeatedly

2, 4, 6, 5, 1, 3

The nurse has reported for her shift. After receiving morning report, which of the following patients should the nurse visit first? 1. A 26 yo M who is complaining of stomach cramps 2. A 10 yo F who just received a transplant and is running a fever 3. A transplant recipient who has no complaints 4. A 12 yo F who just received a transplant and is hungry

2. A 10 yo F who just received a transplant and is running a fever priority

To prevent gastroesophageal reflux in a patient with hiatal hernia, nurse Bryan should provide which discharge instruction? 1. Lie down after meal to promote digestion 2. Avoid coffee and alcohol beverages 3. Take antacids with meals 4. Limit fluid intake with meals

2. Avoid coffee and alcohol beverages prevention

What dietary information is it helpful to record when treating diarrhea in children with Irritable Bowel Syndrome? (Select all that apply.) 1. Measure the percentage of addition high fiber in the diet 2. Measure the fluid intake, including popsicles and ice chips 3. Weigh client daily 4. Record hours of sleep

2. Measure the fluid intake, including popsicles and ice chips 3. Weigh client daily

The patient who has had surgery this morning for cataracts is now going home. Discharge instructions include that the patient should (select all that apply): 1. sleep on the operated side. 2. use stool softeners. 3. avoid bending over. 4. not lift anything heavier than 5 pounds. 5. not wear an eye shield at night.

2. use stool softeners. 3. avoid bending over. 4. not lift anything heavier than 5 pounds.

Contact precautions are initiated for any client with a transplant. Which patient would it be ok to place in the same room with a transplant patient? 1. A patient who just got confirmed HIV + 2. A patient with MRSA 3. A patient with C. DIF 4. A patient recovering from an MI

4. A patient recovering from an MI infection control

Which medication would not be prescribed for a patient with GERD? 1.Maalox 2. Prilosec 3. Pepcid 4. Asprin

4. Asprin pharm

The nurse is performing an abdominal assessment. Put these techniques in sequence: 1. Observe contour of the abdomen 2. Find borders of the liver and spleen 3. Check for rebound tenderness 4. Obtain subjective data from patient 5. Auscultate bowel sounds

??? 4,1,5,2,3

The nurse plans care for a client with acute glaucoma who reports severe pain in the eyes and rainbow colors (halos) around lights. Which action should the nurse take first? A) Administer pain medication B) Explain to the client that with reduction in intraocular pressure, pain and other symptoms will subside C) Provide preoperative teachings to the client D) Assess the client's visual signs

A) Administer pain medication management of care

A client recently diagnosed with irritable bowel syndrome (IBS) is receiving teaching from the nurse. Which of these statements by the client would indicate that teaching has been effective (IBS)? Select all that apply. A. "IBS can cause episodes of diarrhea." B. "IBS can cause episodes of constipation." C. "IBS can cause structural damage to bowel over time." D. "Symptoms can be exacerbated by stress." E. "Symptoms can be exacerbated by certain foods."

A. "IBS can cause episodes of diarrhea." B. "IBS can cause episodes of constipation." D. "Symptoms can be exacerbated by stress." E. "Symptoms can be exacerbated by certain foods."

A nurse is making a home visit to a 12 year old girl who had a liver transplant 4 years ago. Which pet below is one that the little girl cannot have in the home: A. A cat. B. A fish. C. A snail. D. A spider

A. A cat. safety

A 65-year-old male has hearing loss and a sensation of fullness in both ears. The nurse examines his ears with the understanding that a common cause of hearing loss in older adults is related to: A. Accumulation of cerumen in the external canal. B. Accumulation of cerumen in the internal canal. C. External otitis D. Exostosis

A. Accumulation of cerumen in the external canal. prevention

A nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment the nurse notes that the client is severely dysphagic. Which of the following would be included in the care plan for the client? Select all that Apply. A. Assess swallowing ability frequently B. Provide oral hygiene after each meal C. Allow the client sufficient time to eat D. Maintain a suction machine at the bedside E. Provide a full liquid diet for ease in swallowing

A. Assess swallowing ability frequently B. Provide oral hygiene after each meal C. Allow the client sufficient time to eat D. Maintain a suction machine at the bedside

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implantation. Which home care measures will the nurse include in the plan? Select all that apply. A. Avoid activities that require bending over B. Contact the surgeon if eye scratchiness occurs C. Place an eye shield on the surgical eye at bedtime D. Episodes of sudden severe pain in the eye are expected E. Take acetaminophen (Tylenol) for minor eye discomfort

A. Avoid activities that require bending over C. Place an eye shield on the surgical eye at bedtime E. Take acetaminophen (Tylenol) for minor eye discomfort

A patient in a routine checkup mentions a relative who suddenly died as a result of an untreated and unknown asthma attack. She is worried about her own risk for COPD diseases. Which of the following represent modifiable risk factors (select all that apply) A. Half a pack per day smoker B. Family history of chronic bronchitis C. Industrial work environment with small particulate dust D. Multiple indoor pets E. Personal history of pneumonia 2x bilaterally

A. Half a pack per day smoker C. Industrial work environment with small particulate dust D. Multiple indoor pets

A female client with chronic obstructive pulmonary disease (COPD) takes anhydrous theophylline, 200 mg P.O. every 8 hours. During a routine clinic visit, the client asks the nurse how the drug works. What is the mechanism of action of anhydrous theophylline in treating a nonreversible obstructive airway disease such as COPD? A. It makes the central respiratory center more sensitive to carbon dioxide and stimulates the respiratory drive. B. It inhibits the enzyme phosphodiesterase, decreasing degradation of cyclic adenosine monophosphate, a bronchodilator. C. It stimulates adenosine receptors, causing bronchodilation. D. It alters diaphragm movement, increasing chest expansion and enhancing the lung's capacity for gas exchange.

A. It makes the central respiratory center more sensitive to carbon dioxide and stimulates the respiratory drive.

The nurse should assess an older adult with macular degeneration for.... A. Loss of central vision B. Loss of peripheral vision C. Total blindness D. Blurring of vision

A. Loss of central vision assessment

When caring for a patient with lower GI problems who has just returned from surgery with a colostomy, which of the following should the nurse consider for controlling infection (select all that apply)? A. Maintain standard precautions and other precautions appropriately B. Assist with personal hygiene C. Allow patient to smoke in the room D. Consider end of life grief and loss issues E. Handle infectious drainage and secretions safely F. Obtain informed consent for treatments and surgical procedures

A. Maintain standard precautions and other precautions appropriately B. Assist with personal hygiene E. Handle infectious drainage and secretions safely

The client is diagnosed with Huntington's chorea. Which intervention should the nurse implement with the family? Select all that apply. A. Refer to Huntington's Chorea Foundation B. Explain the need for the client to wear football padding C. Discuss how to cope with the client's messiness D. Provide three (3) meals a day and no between-meal snacks E. Teach the family how to perform

A. Refer to Huntington's Chorea Foundation B. Explain the need for the client to wear football padding C. Discuss how to cope with the client's messiness management of care

A client has acute arterial occlusion. The physician has ordered IV heparin. Before stating the medication, the nurse should: A. Review the blood coagulation laboratory values B. Test the clients blood stools for occult blood C. Count the clients apical pulse for 1 minute D. Check the 24 hour urine output

A. Review the blood coagulation laboratory values management of care

The nurse is teaching a seminar on central nervous system infections to a group of local college students. Which of the following topics should be discussed during the information session? A. Vaccinations for meningococcal meningitis are recommended for military recruits and college students (groups at increased risk for invasive meningococcal meningitis). B. Administration of prophylactic rifampin (Rifadin) is recommended for everyone living in a college dorm. C. Vaccination against Japanese B encephalitis is recommended for all college students living in dorms. D. Delayed diagnosis and treatment of infections of the head, neck, and respiratory system are still effective.

A. Vaccinations for meningococcal meningitis are recommended for military recruits and college students (groups at increased risk for invasive meningococcal meningitis). infection control

A nurse is caring for a client who has come into the neurology clinic with complaints of persistent migraines. Which of the following suggestions would be appropriate for this client to follow in an attempt to decrease the incidence of migraines? (select all that apply) A. Wake up at the same time each morning B. Try a lactose free diet C. Exercise at least three times per week D. Reduce or eliminate red wine, cheese, alcohol, chocolate, and caffeine E. No smoking or caffeine after 3pm

A. Wake up at the same time each morning C. Exercise at least three times per week D. Reduce or eliminate red wine, cheese, alcohol, chocolate, and caffeine E. No smoking or caffeine after 3pm

The patient receiving mitoxantrone (Novantrone) for treatment of secondary progressive Multiple Sclerosis (MS) is closely monitored for: A. leukopenia and cardiac toxicity B. mood changes and fluid and electrolyte alterations C. renal insufficiency D. hypoxia

A. leukopenia and cardiac toxicity pharm

When administering eye drop medication is important that the nurse following standard precautions. Which of the following should be done? A. Dawn gown B. Wash hands and wear gloves C. Have patient shield unaffected eye D. Not take any precautions

B. Wash hands and wear gloves infection control

The nurse in an outpatient clinic is supervising student nurses administering influenza vaccinations. The nurse should question the administration of the vaccine to which of the following clients? A) A 45 YO male who is allergic to shellfish B) A 60 YO female who says she has a sore throat C) A 66 YO female who lives in a group home D) A 70 YO female who has CHF

B) A 60 YO female who says she has a sore throat

If a nurse for a client with duodenal ulcer finds the client diaphoretic, with knees drawn up to a hard, tender abdomen, the nurse should initially: A) Call the physician B) Assess for bowel sounds C) Give as-needed pain medication D) Insert an NG tube to suction

B) Assess for bowel sounds assessment

A client with Parkinson's disease is prescribed levodopa(L-dopa) therapy. Improvement in which of the following indicates effective therapy? A) Mood B) Build muscle C) Appetite D) Alertness

B) Build muscle pharm

A nurse should teach a client with migraine headaches being treated with sumatriptan (Imatrex) that the drug: A) Requires a break in its use every 4-6 months because of its side effects B) Reserves the pathological process of migraines by counteracting the effect of serotonin C) May be addicting if used over a long period of time, in which case it must be abruptly withdrawn D) Is to be used only to prevent the headaches, and ergotamine (Ergomar) should be used if a headache occurs

B) Reserves the pathological process of migraines by counteracting the effect of serotonin

A nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action? A) Notify the physician B) Stop the irrigation temporarily C) Increase the height of the irrigation D) Medicate for pain and resume the irrigation

B) Stop the irrigation temporarily assessment

As a home health nurse, you are making a visit to a newly diagnosed coronary artery disease client. After your initial assessments are completed, you decide to review dietary alterations that may be considered for this client. You are satisfied that your teaching is successful when your client makes which of the following statements? A. "I will reduce the total saturated fats in my cooking by using butter when I fry my meals." B. "I will add fiber to my diet by eating oatmeal for breakfast three times a week." C. "I will only eat canned vegetables, because they will not spoil as quickly." D. "I can drink as much regular pop as I want."

B. "I will add fiber to my diet by eating oatmeal for breakfast three times a week." teach

The client who has ulcerative colitis is scheduled for an ileostomy. When the client asks the nurse what to expect related to bowel function and care after surgery, what response should the nurse make? A. "You will be able to have some control over your bowel movements." B. "The stoma will require that you wear a collection device all the time." C. "After the stoma heals, you can irrigate your bowel so you will not have to wear a pouch." D. "The drainage will gradually become semisolid and formed."

B. "The stoma will require that you wear a collection device all the time." teach

A client with peripheral vascular disease returns to the surgical care unit after having femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this client: 1. Postoperative pain 2. Peripheral pulses 3. Urine output 4. Incision site A. 1, 2, 3, 4 B. 2, 4, 3, 1 C. 1, 4, 2, 3 D. 1, 2, 4, 3

B. 2, 4, 3, 1

A client undergoes a barium swallow fluoroscopy that confirms gastroesophageal reflux disease (GERD). Based on this diagnosis, the client should be instructed to take which actions? Select all that apply. 1. Follow a high-fat, low fiber diet. 2. Avoid caffeine and carbonated beverages. 3. Sleep with the head of the bed flat. 4. Stop smoking. 5. Take antacids 1 hour and 3 hours after meals. 6. Limit alcohol consumption to one drink per day. A. 1, 2, 3, 4, 5 B. 2, 4, 5 C. 1, 5, 6 D. 2, 5. 6 E. 1, 3, 5

B. 2, 4, 5

A registered nurse at a hospital has 4 patients and a team consisting of an LPN and a UAP. Which of these patients would the RN be appropriate in assigning to the UAP? A. The patient with new diagnosis of ALS that has questions about their disease process. B. A 78 year old female that has been ordered to have her vital signs checked every 2 hours C. A patient that needs discharge teaching. D. A patient that needs their scheduled PO meds.

B. A 78 year old female that has been ordered to have her vital signs checked every 2 hours management of care

The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnosis should receive priority? A. Alteration in comfort B. Alteration in mobility C. Alteration in skin integrity D. Alteration in O2 perfusion

B. Alteration in mobility priority

The nurse in charge formulates a diagnosis of Activity Intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include: A. Drinking more than 1,500 ml of fluid daily. B. Being overweight. C. Eating a high-protein snack at bedtime. D. Eating more than 3 large meals a day.

B. Being overweight. teaching

A client with encephalitis is receiving morning care from the certified nursing assistant (CNA). The charge nurse observes the CNA do all of the following interventions. Which one requires action by the charge nurse? A. CNA checks that the bedrails are up before leaving the room to get linens B. CNA opens the blinds and turns on the lights to give the bed bath C. CNA enters the room without a mask D. CNA offers to get the client an additional juice for breakfast

B. CNA opens the blinds and turns on the lights to give the bed bath management of care

A new nurse who is working on a floor with multiple variations of COPD patients is asked to assess a recently admitted patient that has been referred to his floor on triage from the overcrowded ER. The admitting signs and symptoms (dyspnea, coughing, sputum production, fatigue, and activity intolerance) were similar to other COPD patients, but the nurse flatly declines this patient as she is a danger others. What item in the chart is praised by the nurse manager as a good catch by the nurse? A. History of medication seeking behavior B. Current medications including isoniazid and rifampin C. On a previous admission this patient was caught smoking in a bathroom D. Lack of insurance

B. Current medications including isoniazid and rifampin infection control

Which of the following lifestyle modifications should the nurse encourage the client with a hiatal hernia to include in activities of daily living? A. Daily aerobic exercise B. Eliminating smoking and alcohol use C. Balancing activity and rest D. Avoiding high stress situations

B. Eliminating smoking and alcohol use prevention

Which of the following actions is the first priority care for a client exhibiting signs and symptoms of coronary artery disease? A. Decrease anxiety B. Enhance myocardial oxygenation C. Administer sublingual nitroglycerin D. Educate the client about his symptoms

B. Enhance myocardial oxygenation priority

A registered nurse is planning assignments for the clients on a nursing unit. The registered nurse needs to assign clients to a UAP to help decrease her workload. Which of the following tasks would the registered nurse NOT assign to the UAP? A. Frequent cleaning of eye discharge for a client with Conjunctivitis. B. Frequent neurological assessments for a client with Bell's Palsy. C. Feeding and re-orientating the food on the plate of a client with temporary blindness from blunt trauma to both eyes. D. Assisting a Multiple Sclerosis client with a bath.

B. Frequent neurological assessments for a client with Bell's Palsy. management of care

A client complains that he experience pain and numbness when he types on a computer keyboard. Which action will help the nurse assess for Phalen's sign? A. Having the client hold both hands above his head with his arms straight for 30 seconds. B. Having the client hold both wrist in acute flexion, with the dorsal surfaces touching for 60 seconds. C. Tapping gently over the median nerve in the wrist. D. Having the client extend his wrist while the nurse provides assistance.

B. Having the client hold both wrist in acute flexion, with the dorsal surfaces touching for 60 seconds. assessment

The nurse is witnessing the client's signature on the informed surgical consent for an abdominal hysterectomy .It is important to ascertain that the client understands that with this surgical procedure she will have: A. Decreased libido B. Infertility C. Depression D. Weight gain

B. Infertility management of care

The physician prescribed Ergotamine tartrate (Gynergen) for a client with migraine headaches. The client askes the nurse why she has migraine headaches. What is the nurse's best response? A. Migraine headaches are believed to be caused by sustained contraction of muscles around the scalp and face. B. Migraine headaches are believed to be caused by the dilation of cranial arteries C. Migraine headaches are believed to be caused by irritations and inflammation of the openings of the sinuses. D. Migraine headaches are believed to be caused by temporary decrease in intracranial pressure

B. Migraine headaches are believed to be caused by the dilation of cranial arteries teaching

A nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. The nurse assesses for associated signs and symptoms by: A. observing for softening of the nails or nail beds B. Palpating for diminished or absent peripheral pulses C. Checking for a rash on the digits D. palpating for a rapid or irregular peripheral pulse.

B. Palpating for diminished or absent peripheral pulses assessment

A patient is under observation while a physician is trying to figure out what diagnoses the patient has. He has many symptoms of COPD. What are some signs and symptoms would you see in a patient with COPD. (Select all that apply) A. Low grade fever B. Pursed lip breathing C. Dyspnea D. Tripod positioning

B. Pursed lip breathing C. Dyspnea D. Tripod positioning

A client with a new liver transplant is due for required vaccinations for public school. Which of the following should NOT be given? A. Hepatitis B B. Varicella (chickenpox) C. MMR D. Tetanus

B. Varicella (chickenpox) infection control

The nurse has been assigned to a client who is hearing impaired and reads speech. Which of the following strategies should the nurse incorporate when communicating with the client? (Select all that apply) 1. Avoiding being silhouetted against a strong light. 2. Not blocking out the person's view of the speaker's mouth. 3. Facing the client when talking. 4. Having a bright light behind the client so the individual can see. 5. Ensuring the client is familiar with the subject material before discussing. 6. Talking to the client while performing other nursing procedures. A. All options should be included B. 2, 3, 4,6 C. 1,2,3,5 D. 2, 4. 6 E. 1, 3, 6

C. 1,2,3,5 1. Avoiding being silhouetted against a strong light. 2. Not blocking out the person's view of the speaker's mouth. 3. Facing the client when talking 5. Ensuring the client is familiar with the subject material before discussing.

A client with conjunctivitis has to administer an eye ointment for several days. Indicate the order the client should take to administer the ointment 1. Pull down the lower lid, creating a pocket 2. Wash hands 3. Place a thin ¼" strip of ointment into the conjunctival sac 4. Look up 5. Gently close eyes for several minutes A. 1, 2, 4, 5, 3 B. 4, 5, 2, 1, 3 C. 2, 4, 1, 3, 5 D. 2, 1, 3, 5, 4

C. 2, 4, 1, 3, 5

Based on key signs and symptoms, in which order will the stages of Alzheimer's progress? 1. Loss of speech, loss of appetite, total dependence on caregiver 2. Confusion, sleep disturbances, disorientation to time and place 3. Difficulty recognizing family members, difficulty performing ADL's A. 1,2,3 B. 3,2,1 C. 2,3,1 D. 2,1,3

C. 2,3,1

A client is admitted to the hospital that underwent a kidney transplant 6 months ago. There are only semi-private rooms available, which client would be most appropriate for this client to share a room with? A. A 20 year old client with 2nd degree burns over 50% of her body B. A 30 year old client with diabetes and an ulcer on his foot C. A 25 year old client with HIV D. A 60 year old client with Pneumonia

C. A 25 year old client with HIV infection control

A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: A. Pleural effusion. B. Pulmonary edema. C. Atelectasis. D. Oxygen toxicity

C. Atelectasis. assessment

A client at the family planning clinic is diagnosed with primary dysmenorrhea. Which of the following should be included in the nurse's teaching plan for non-pharmacological comfort measures? A. Initiation of oral contraception B. Application of cold to the abdomen C. Balanced meals and adequate rest D. Regular emotional counseling

C. Balanced meals and adequate rest prevention

The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care? A. Avoid overuse of the eyes B. Decrease the amount of salt in the diet. C. Eye medications will need to be administered for the client's entire life. D. Decrease fluid intake to control the intraocular pressure.

C. Eye medications will need to be administered for the client's entire life. teach

A nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse would expect to observe which of the following in the client? A. Twitching on the affected side of the face B. Ptosis of the eyelid C. Facial drooping D. Periorbital edema

C. Facial drooping assessment

A client is admitted to the emergency room with sneezing and coughing. The client is in the triage area, waiting to be seen by a physician. To prevent spread of infection to others in the area and to the health care staff, the nurse should do which of the following? A. Place the client in an isolation room B. Ask the others in the area to move away from the client C. Give the client a surgical mask to wear D. Ask the client to wash his hands before being examined

C. Give the client a surgical mask to wear safety

A client is put on the immunosuppressant medication cyclosporine after a liver transplant. What types of food should the client avoid while taking this medication? A. Milk B. Peanuts C. Grapefruit D. Red meat

C. Grapefruit pharm

When teaching a patient about risk factors for glaucoma, the nurse knows that more teaching is needed when the patient states: A. I have a higher chance of glaucoma because both my mother and grandfather had it B. I should ask my doctor of pharmacist about medications I'm taking because some medications can cause glaucoma C. I should be tested for glaucoma periodically because I have a history of sinus infections D. I'm at higher risk because of the accident I had when a firework hit me in the eye

C. I should be tested for glaucoma periodically because I have a history of sinus infections infection control

Which of the following best indicates that the client understands teaching about their diagnosis of Parkinson's disease? A. My condition is cause by a chronic, degenerative, progressive disease of the CNS characterized by the occurrence of spall patches of demyelination in the brain and spinal cord B. My condition is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dance-like movement and dementia C. My condition is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain D. My condition is a rare, transmissible, progressive fatal disease of the CNS characterized by spongiform degeneration of the gray matter of the brain

C. My condition is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain infection control

A sixty year old blind man has been admitted to your floor. As the nurse what is your primary responsibility? A. Let the other nurses know he is blind B. Tell the charge nurse your safety concerns C. Orient the patient to the room D. Keep the door open so you can watch the patient

C. Orient the patient to the room safety

The client arrives in the emergency room with a penetrating eye injury from wood chips while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? A. Remove the piece of wood using a sterile eye clamp. B. Apply an eye patch. C. Perform visual acuity tests. D. Irrigate the eye with sterile saline.

C. Perform visual acuity tests teach

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse tells the client that: A. The medication will help dilate the eye to prevent pressure from occurring. B. The medication will relax the muscles of the eyes and prevent blurred vision C. The medication causes the pupil to constrict and will lower the pressure in the eye D. The medication will help block the responses that are sent to the muscles in the eye.

C. The medication causes the pupil to constrict and will lower the pressure in the eye pharm

A 75 year old male client has a history of macular degeneration. While he is in the hospital, the priority nursing goal will be: A. To provide education regarding community services for clients with adult macular degeneration (AMD). B. To provide health care related to monitoring his eye conditions C. To promote a safe, effective care environment D. To improve vision

C. To promote a safe, effective care environment priority

The nurse should instruct the client who has been diagnosed with vasospastic disorder (Raynaud's phenomenon) to: A. Immerse her hands in cold water during an episode B. Wear light garments when the temperature gets below 50 F C. Wear gloves when handling ice or frozen foods D. Live in a cold climate

C. Wear gloves when handling ice or frozen foods teach

What is the immediate post-hysterectomy priority nursing action? A. Assist with sitz baths three times daily. B. Provide a high-protein diet. C. Teach the client exercises to strengthen the abdomen. D. Observe the client for decreased urine output.

D. Observe the client for decreased urine output priority

A patient with COPD has textbook symptoms of the disease. Which of the following would more than likely be observed? 1. Changes in breathing patterns 2. Bruising all over the lower extremities 3. Decreased breath sounds 4. Activity intolerance 5. Left sided weakness 6. Poor nutrition A. 1-4, 6 B. all of the above C. 1, 2, 5 D. 1, 3, 4, 6 E. 1, 6

D. 1, 3, 4, 6

You are assigned a client with conjunctivitis. When preparing to give the meds for your patient, you realize you must apply ophthalmic antibiotic ointment. Indicate which order signifies the proper procedure for administration and infection control: 1. Administer eye ointment 2. Don gloves. 3. Assist pt to high-Fowler's position with head slightly tilted back. 4. Cleanse the edges of eyelids from inner to outer if needed. 5. Pull down eyelid with non-dominant hand to expose the conjuctival sac. 6. Ask patient to gently close eyes and move them around. A. 1, 2, 3, 4, 6, 5 B. 2, 4, 3, 1, 5, 6 C. 2, 3, 4, 1, 5, 6 D. 3, 2, 4, 5, 1, 6

D. 3, 2, 4, 5, 1, 6

The newly graduated nurse has just started her first day on the Respiratory care Unit. The nurse's assignment consists of the following 4 clients. Prioritize in order from the highest to lowest. In which order would the nurse assess the clients? 1. An 85 yo with emphysema ready to leave and needs discharging information 2. A 60 yo with asthma who was just given medication 15 minutes ago. 3. A 35 yo client with COPD who complains of chest pain and is starting to become a bit cyanotic 4. A 56 yo with emphysema who is scheduled for a bronchodilator, with no acute Respiratory distress A. 4,2,1,3 B. 3,1,4,2 C. 2,4,3,1 D. 3,2,4,1

D. 3,2,4,1

The ER nurse has several patients arrive nearly simultaneously. Which of these represents the priority case? A. An 86 year female old brought in from a long term care facility with mental status change and confusion B. A 45 year old overweight male with chest pain following exercise C. A 14 year old female with a displaced upper arm fracture D. A 25 year old male with mild persistent asthma with an episode that has not responded to the rescue inhaler

D. A 25 year old male with mild persistent asthma with an episode that has not responded to the rescue inhaler priority

A nurse is assessing clients at a health fair. Which client is at greatest risk for coronary artery disease? A. A 32-year-old female with a mitral valve prolapse who quit smoking 10 years ago B. A 43-year-old male with a family history of CAD and cholesterol level of 158 C. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor) D. A 65-year-old female who is obese with an LDL of188

D. A 65-year-old female who is obese with an LDL of188 prevention

A nurse is conducting health screening for osteoporosis. Which of the following clients is at greatest risk of developing this disorder? A. A 25-year-old woman who jogs B. A 36-year-old man who has asthma C. A 70-year-old man who consumes excess alcohol D. A sedentary 65-year-old woman who smokes cigarettes

D. A sedentary 65-year-old woman who smokes cigarettes prevention

A fatigued patient admitted for exacerbation of asthma states he gets dizzy when walking to the bathroom. The nurse should: A. Put all four side rails up on the bed. B. Ask the UAP to place restraints on the client's upper extremities. C. Request that the client's roommate put the call light on when the client is attempting to get out of bed. D. Check on the client at regular intervals to ascertain the need to use the bathroom.

D. Check on the client at regular intervals to ascertain the need to use the bathroom. safety

When assessing the lower extremities of a client with PVD, the nurse notes bilateral ankle edema. The edema is related to: A. Competent venous valves. B. Decreased blood volume. C. Increase in muscular activity. D. Increased venous pressure.

D. Increased venous pressure. assessment

A transplant client with aspergillus is admitted to the ICU unit for treatment, what is the drug that should be ordered to treat this mold? A. Nitroglycerin B. Haldol C. Amphotericin D. Insulin

D. Insulin pharm

A patient who has received a heart transplant has developed bradycardia post-op. The nurse should epect to use which medication to treat this condition? A. Procainamide B. Adenosine C. Atropine D. Isoproterenol

D. Isoproterenol pharm

A patient who has received a heart transplant has developed bradycardia post-op. The nurse should expect to use which medication to treat this condition? A. Procainamide B. Adenosine C. Atropine D. Isoproterenol

D. Isoproterenol pharm

A common treatment regiment for which of the following conditions lowers the immune system and the patients increase risk of infection: A. ALS B. Bell's Palsy C. Myasthenia Gravis D. Multiple Sclerosis

D. Multiple Sclerosis infection control

When evaluating the extent of Parkinson's disease, a nurse observes for which of the following conditions? A. Bulging eyeballs B. Diminished distal sensation C. Increased dopamine levels D. Muscle rigidity

D. Muscle rigidity assessment

A client is postoperative for an abdominal hysterectomy. What is a priority nursing action in the immediate postoperative period? A. Assist with sitz baths three times a day B. Provide a high protein diet C. Teach the client exercise to strengthen the abdomen D. Observe the client for decreased urine output

D. Observe the client for decreased urine output priority

A nurse is taking a history on an older adult male. The client has a past medical history of erectile dysfunction, hypertension, and angina. The client has recently been tested for prostate cancer, and his results were negative. The client currently takes aspirin, isordil and tenormin each day. Having taken the history, which of the following medications should the nurse expect the physician to order for this client? A. Viagra B. Cialis C. Levitra D. Papaverine

D. Papaverine pharm

Carol has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? A. To observe the type and amount of nasogastric tube drainage B. Monitor the client for nausea or other complications C. Irrigate the nasogastric tube with the ordered irrigant D. Perform nostril and mouth care

D. Perform nostril and mouth care management of care

A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient. A. Let others know about the patient's deficits B. Communicate with your supervisor your concerns about the patient's deficits C. Continuously update the patient on the social environment D. Provide a secure environment for the patient

D. Provide a secure environment for the patient safety

A nurse manager is planning assignments for a registered nurse and two unlicensed assisted personnel. Which of the following is an appropriate assignment for one of the UAP's? A. Perform the Snellen test on a client. B. Observe drainage from the conjunctival lining of a client C. Document the results of a Snellen Test. D. Reinforce an eye bandage for a post-op client.

D. Reinforce an eye bandage for a post-op client management of care

The nurse is performing a physical assessment on a 20-year-old African-American client with hemolytic anemia. Which area would be the best location for the nurse to assess skin color? A. Sclera of the eyes B. Soles of the feet C. Palms of the hands D. Roof of the mouth

D. Roof of the mouth assessment

Which of the following drugs would be best to give to a client to treat a peptic ulcer? A. Tegretol B. Remicade C. Centrax D. Tagamet

D. Tagamet pharm

The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: A. Eating large, well-balanced meals B. Doing muscle-strengthening exercises C. Doing all chores early in the day while less fatigued D. Taking medications on time to maintain therapeutic blood levels

D. Taking medications on time to maintain therapeutic blood levels safety

The client with a recent liver transplant asks the nurse how long he will have to take an immunosuppressant. Which response is correct? A. 5 years B. 10 years C. 1 year D. The rest of his life

D. The rest of his life prewvention

A client who had a heart transplant is in reverse isolation postoperatively. Which of the following explanations for this is correct? A. To protect the client from his own bacteria. B. To protect the hospital staff from the client C. To protect the other patients on the nursing unit D. To protect the client from outside infections from others

D. To protect the client from outside infections from others safety

The nurse should instruct a patient who has been diagnosed with a vasospastic disorder (Raynaud's phenomenon) to: A. Immerse her hands in cold water during an episode. B. Wear lights garment when the temperature gets below 50 degrees F. C. Live in a cold climate. D. Wear gloves when handling ice and frozen foods.

D. Wear gloves when handling ice and frozen foods. infection control

A nurse is caring for a patient with protruding hemorrhoids. The patient expresses concern about pain and the risk for infection. Which statement made by the nurse, addressing the prevention of infection, is correct? E. "You cannot clean it because of where it is located." F. "You should clean it every morning, night and after each time you use the bathroom." G. "It's just hemorrhoids; there is no need to worry." H. "To prevent infection do not use any over the counter ointment for pain."

F. "You should clean it every morning, night and after each time you use the bathroom." infection control

A client with a suspected duodenal ulcer is tested for H. pylori. Which medication, noted in the client history, could produce a false negative result in the test? a. Ampicillin b. Digoxin (Lanoxin) c. Propoxyphene napsylate (Darvocet) d. Ibuprofen (Advil)

a. Ampicillin pharm

The physician orders slidenafil (Viagra) for a male client with erectile dysfunction. The nurse should teach the client about the common side effects of this drug. Select all that apply. a) Flushing b) Headache c) dyspepsia d) constipation e) hypertension

a) Flushing b) Headache c) dyspepsia teaching

What effect does anxiety produce that makes it particularly important for the nurse to allay the anxiety of a client with heart failure? a) Increases the cardiac workload b) Interferes with usual respirations c) Produces an elevations in temperature d) Decreases the amount of O2 used

a) Increases the cardiac workload assessment

A client admitted to an acute care facility with pneumonia is receiving supplemental oxygen, 2 liters/minute via nasal cannula. The client's history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these history findings, the nurse closely monitors the oxygen flow and the client's respiratory status. Which complication may arise if the client receives a high oxygen concentration? a. Apnea b. Angina pain c. Respiratory alkalosis d. Metabolic alkalosis

a. Apnea assessment

The nurse has just gotten on shift for the day and has received her patients. Which patient should she be more concerned about seeing first? a) a 56 year old man with glaucoma on fall precautions trying to get out of bed b) an 87 year old woman just admitted with dementia and a penetrating object in her eye c) a 60 year old woman with a possible detached retina d) a 65 year old man who just had eye surgery due to eye trauma

a) a 56 year old man with glaucoma on fall precautions trying to get out of bed priority

A registered nurse employed on the medical surgical floor is making assignments for the day. There are four clients to be assigned and there is one registered nurse and two licensed practical nurses on the floor. Which patient should be assigned to the registered nurse? a) a client who has achalasia and just returned from a procedure to dilate the lower esophagus and cardiac sphincter b) the client who needs a small amount of assistance with ADLs c) a client who is visually impaired and needs help with eating lunch d) the client with a gastric ulcer who is stable and reports a pain level of 2/10

a) a client who has achalasia and just returned from a procedure to dilate the lower esophagus and cardiac sphincter management of care

In order to maintain and prevent organ rejection of a newly transplanted lung in a 45-year-old female, the nurse in the ICU might expect to see what type of medication ordered? a) immunosuppressant b) antidepressants c) antipsychotic d) antihistamines

a) immunosuppressant

A nurse is educating an adolescent on the correct use of a metered dose inhaler. In which order should the nurse teach the patient? 1. Rinse mouth with water. 2. Exhale slowly and deeply. 3. Hold breath for 10 seconds before exhaling slowly. 4. Inhale deeply for 3-5 seconds while pressing down the canister. a. 2, 4,3,1 b. 4,3,2,1 c. 1,4,3,2 d. 1,2,3,4

a. 2, 4,3,1

A patient is Post-Op and needs to receive Oxygen treatment. In what order would the nurse administer the oxygen? 1. Set up System 2. Wash hands 3. Assembled equipment 4. Performed completion actions 5. Place oxygen delivery device on client 6. Reassess client and system a. 2,3,1,5,6,4 b. 3,1,2,4,5,6 c. 2,1,4,6,5,3 d. 6,5,4,3,2,1

a. 2,3,1,5,6,4

When evaluating a client treated for uterine prolapsed, the nurse knows that the patient needs further treatment when the patient presents with: a. A dragging sensation in the pelvis or back b. Non-painful menstrual cycles c. Increased urge to urinate d. A craving for grapefruit

a. A dragging sensation in the pelvis or back eval of care

When assessing a client with COPD, the nurse monitors which of the following lab results: a. ABGs b. CKMB c. Thrombin Time d. Troponin

a. ABGs assessment

The nurse is caring for an infant who is admitted with bacterial meningitis. What is the first priority when providing nurse care for this child? a. Administer ordered antibiotics as soon as possible b. Keep the room quiet and dim c. Explain all procedures to the parents d. Begin low-flow oxygen via mask

a. Administer ordered antibiotics as soon as possible priority

Which of the following are common causes of primary and secondary impotence? (select all that apply) a. Adolescent vascular trauma b. Low B12 levels c. Psychiatric problems d. Medication e. Psychological distress

a. Adolescent vascular trauma c. Psychiatric problems d. Medication e. Psychological distress

A home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self care management. Which statement, if made by the client, indicated a need for further instruction? a) "I need to be sure not to go barefoot around the house." b) "I need to be sure that I elevate my leg above my heart level for at least an hour every day." c) "If I cut my toenails, I need to be sure that I cut them straight across." d) "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes."

b) "I need to be sure that I elevate my leg above my heart level for at least an hour every day." teach

A client with a prolapsed uterus is scheduled for a vaginoplasty. Preoperatively the nurse should: a) Encourage ambulation b) Apply moist compresses c) Elevate the foot of the bed d) Support the prolapsed uterus

b) Apply moist compresses prevention

A nurse is reviewing the drugs prescribed for a patient with a peptic ulcer. Which of the following poses a safety risk to the patient? a. Antibiotics b. NSAIDs c. Proton Pump Inhibitor d. H2- receptor blocker

b. NSAIDs safety

A client with migraine headaches and a history of angina asks the nurse why the physician does not prescribe one of the new medications for migraine, such as the Sumatriptan drugs Imitrex and Zomig. The nurse responds: a) the drugs would be too expensive for you b) Sumatriptan is contraindicated in clients with angina c) Sumatriptan is only used for the prophylactic treatment of migraines d) Sumatriptan is only used for migraines with an aura

b) Sumatriptan is contraindicated in clients with angina pharm

Which statement indicates that a client needs additional teaching after cataract surgery? a. "I'll avoid eating until the nausea subsides." b. "I can't wait to pick up my granddaughter." c. "I'll avoid bending over to tie my shoelaces." d. "I'll avoid touching the dropper to my eye when using my eyedrops."

b. "I can't wait to pick up my granddaughter." teaching

You are teaching a client diagnosed with chronic open angle glaucoma how to administer their eye drops, Pilocarpine HCl. Teaching is a success when the client states: a. "The eye drops are used to cause pupil dilation and help decrease pressure in the eye" b. "Vision may be blurred 1 to 2 hours after administration of pilocarpine" c. "Nausea, vomiting, and diarrhea are normal side effects of the medication" d. "Dark environments should not be a problem while I am using my eye drops"

b. "Vision may be blurred 1 to 2 hours after administration of pilocarpine"

The nurse is caring for client who underwent surgical repair of a detached retinal of the right eye. Which of the following interventions should the nurse perform? Select all that apply. a. Place the client in a prone position b. Approach the client from the left side c. Encourage deep breathing and coughing d. Discourage bending down e. Orient the client to his environment f. Administer the client to a stool softener

b. Approach the client from the left side d. Discourage bending down e. Orient the client to his environment f. Administer the client to a stool softener

In a patient with long-term emphysema, the nurse might expect to see which condition when inspecting the nails? a. A rapid blanch test b. Clubbing c. Koilonychias d. Paronychia

b. Clubbing assessment

The nurse evaluates the effectiveness of drug therapy in a patient with hyperlipidemia. Effective therapy is best evidenced by which laboratory values? a. HDL 45, LDL 160 b. HDL 40, LDL 90 c. HDL 45, LDL 175 d. HDL 35, LDL 130

b. HDL 40, LDL 90 labs

When preparing a male client, age 51, 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. 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. c. The appendix may develop gangrene and rupture, especially in a middle-aged client. d. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage

b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. infection control

A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching? a. Take the medication with milk b. Report chest pain. c. Remain upright after taking for 30 minutes. d. Allow 6 weeks for optimal effects.

b. Report chest pain. teach

Which of the following responses should the nurse offer to a client who asks why he's having a vagotomy to treat his ulcer? a. To repair a hole in the stomach b. To reduce the ability of the stomach to produce acid c. To prevent the stomach from sliding into the chest d. To remove a potentially malignant lesion in the stomach

b. To reduce the ability of the stomach to produce acid

the nurse is preparing a discharge teaching plan for the male client who had umbilical hernia repair. what should the nurse include in the plan a. irrigating the drain b. avoiding coughing c. maintaining bed rest d. restricting pain medication

b. avoiding coughing management of care

In establishing a plan of care for a client with multiple sclerosis (MS), the nurse recognizes that which of the following is the long term goal? a. prevent progression of the disease b. enable the client to retain as much as independence as possible c. return client to previous level of functioning d. prevent client from becoming wheelchair dependent

b. enable the client to retain as much independence as possible prevention: health promotion & maintenance, reduction of risk potential

a client recovering from a cadaver kidney transplant is demonstrating signs of dysfunction. what can be done to assist the client a. discontinue antibiotic therapy b. monitor strict intake & output w/daily weights c. prepare to surgically remove the transplanted kidney & place client on hemodialysis d. restrict fluids

b. monitor strict intake & output w/daily weights safety

a client is taking sildenafil (viagra) po for erectile dysfunction. the nurse should instruct the client about which of the following a. sildenafil, viagra, may be taken more than 1 time/day b. the health care provider should be notified promptly if the client experiences sudden or diminished vision c. sildenafil, viagra, offers protection against some STDs d. sildenafil, viagra, does not requrire sexual stimulation to work

b. the health care provider should be notified promptly if the client experiences sudden or diminished vision pharmacological & parenteral therapies

the nurse is developing a plan of care for a client w/ crohn's disease who is receiving total parenteral nutrition, tpn. which of the following interventions would the nurse include? select all that apply a. monitoring vital signs once a shift b. weighing the client daily c. changing central venous line dressing daily d. monitor the iv infusion rate hourly e. instruct the parents about the need to administer the antibiotics for the full course of therapy

b. weighing the client daily d. monitor the iv infusion rate hourly e. instruct the parents about the need to administer the antibiotics for the full course of therapy

A nurse is caring for a client with moderate hearing and vision loss. The client has fallen three times since her last visit. Upon visiting the client's home, the nurse notes that the client has lot of clutter inside the house. Of the following the nurse would do all of the following except? a.) Providing adequate lighting b.) Placing a rug in the middle of the hall leading to the client's bedroom c.) Removing objects that could cause the client to slip d.) Providing no slip socks for the client to move around in

b.) Placing a rug in the middle of the hall leading to the client's bedroom safety

A relapse in MS is an indicator of worsening neurological symptoms. Many factors can contribute to this including infections. Which interventions can the nurse practice to lower the chance of infections? a.) Keep Foley catheters in for longer than ordered b.) Practice hand hygiene c.) Position client in semi-fowlers every night before bed d.) Administer IV antibiotic prophylaxis treatments

b.) Practice hand hygiene infection control

A 79-year-old client is admitted to the hospital with painful abdominal spasms and sever diarrhea of 2 days duration. The order of physical skills the nurse should follow when performing an admitting examination of this client should be: 1) inspection 2) palpation 3) auscultation 4) percussion a) 1, 2, 3, 4 b) 4, 2, 3, 2 c) 1, 3, 4, 2 d) 3, 1, 2, 4

c) 1, 3, 4, 2

the nurse is assessing coping in a female pt that had a liver transplant 5 months ago. which assessment is most important to report to the physician? a. the pt is expressing fears of organ rejection even though the lab values are normal b. the pt is concerned about facial hair that has appeared since starting on steroids c. the pt is withdrawn & only sleeping for 3 hrs/night due to posttraumatic stress d. the pt is expressing concern w/the ability to pay for medications & follow up health care

c. the pt is withdrawn & only sleeping for 3 hrs/night due to posttraumatic stress priority setting

a client admitted w/complaints of severe lower abdominal pain, cramping, and diarrhea is diagnosed as having diverticulitis. what are the nutritional needs of this client throughout recovery (order from acute phase to maintenance phase) 1. npo 2. high-fiber diet w/bulk-forming laxatives 3. no fiber 4. graduate to liquids a. 1,2,3,4 b. 4,3,2,1 c. 1,4,3,2 d. 2,3,1,4

c. 1,4,3,2 (npo, graduate to liquids, no fiber, high-fiber diet w/bulk-forming laxatives)

in treating different visual disorders it is important to administer eyedrops/ointments appropriately. list the following actions in order of how you would perform them. 1. wash hands & put on gloves 2. have client keep eyes closed for several minutes 3. press nasolacrimal canthus 4. evert lower lid 5. apply medication in the conjunctival sac a. 1,2,3,4,5 b. 5,4,3,2,1 c. 1,4,5,3,2 d. 5,1,2,3,4

c. 1,4,5,3,2 (wash hands & put on gloves, evert lower lid, apply medication in the conjunctival sac, press nasolacrimal canthus, have client keep eyes closed for several minutes)

the home health nurse is assigned the following clients. which client should be seen first a. 38yom diagnosed w/ MS who refused to have a gastrostomy feeding b. 22yof newly diagnosed w/MS who is deciding whether her fiance should be told before the wedding c. 40yom diagnosed w/ MS who called the office to tell the nurse that life is not worth living anymore d. 50yof diagnosed w/relapsing remitting MS who needs a subq flu injection

c. 40yom diagnosed w/ MS who called the office to tell the nurse that life is not worth living anymore priority setting

Medical management of the client with acute diverticulitis should include which of the following treatments? a.) Reduce fluid intake b.) Increased fiber in the diet c.) Administration of antibiotics d.) Exercises to increase intra-abdominal pressure

c.) Administration of antibiotics management of care

Which of the following people would be the best candidate to receive an organ transplant? a. A 30 year old with end stage liver failure and current alcohol abuse, who has promised to enter rehab and not drink if she can start over. b. A 40 year old with end stage renal failure who needs a kidney due to the financial concerns of continuing dialysis. c. A 50 year old with end stage renal failure and a history of melanoma that was removed 5 years ago and has not recurred d. A 60 year old with end stage liver failure who is receiving treatment for Hepatitis C and the disease seems to be responding to treatment.

c. A 50 year old with end stage renal failure and a history of melanoma that was removed 5 years ago and has not recurred priority

A client with primary sclerosing cholangitis has received a liver transplant. The nurse should give priority to assessing the client for complications. Which findings are associated with an acute rejection of the new liver? a. Increased jaundice and prolonged prothrombin time b. Fever and foul smelling bile drainage c. Abdominal distention and clay colored stools d. Increased uric acid, increased creatine

c. Abdominal distention and clay colored stools

Which of the following is true concerning headaches? a. The absence of phonophobia is characteristic in migraines b. Tension headaches can be treated but not prevented c. Alcohol & daytime napping may cause cluster migraines d. Nuchal rigidity is associated with estrogen withdrawal headaches

c. Alcohol & daytime napping may cause cluster migraines

A patient who has been diagnosed with Raynaud's disease complains of cold and stiffness in the fingers. Which is not an effective way for the patient to manage these symptom? a. Keep warm b. Smoking cessation c. Decrease exercise d. Control stress

c. Decrease exercise management of care

Gastroesphageal reflux disease (GERD) weakens the lower esophageal sphincter, predisposing older persons to risk for impaired swallowing. In managing the symptoms associated with GERD, the nurse should assign the highest priority to which of the following interventions? a. Decrease daily intake of vegetables and water, and ambulate frequently. b. Drink coffee diluted with milk at each meal, and remain in an upright position for 30 minutes. c. Eat small, frequent meals, and remain in an upright position for at least 30 minutes after eating. d. Avoid over-the-counter drugs that have antacids in them.

c. Eat small, frequent meals, and remain in an upright position for at least 30 minutes after eating priority

A patient battling fibromyalgia suffers from chronic fatigue because of painful, sleepless nights. What medication is approved by the FDA for treatment of fibromyalgia? a. Motrin b. Percocet c. Lyrica d. Oxycontin

c. Lyrica pharm

A client receives a dose of edrophonium (Tensilon) intravenously. The client shows improvement in muscle strength for a period of time following the injection. The nurse interprets this finding as compatible with a. Multiple sclerosis b. Amyotrophic lateral sclerosis c. Myasthenia gravis d. Muscular dystrophy

c. Myasthenia gravis pharm

A nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Teaching for this client will include which of the following statements? a. Drive only when feelings of dizziness have not been experienced for several hours b. Go to the bedroom and lie down when vertigo is experienced c. Remove throw rugs and clutter in the home d. Turn the head slowly when spoken to

c. Remove throw rugs and clutter in the home teaching

The nurse is interviewing a slightly overweight 43-year-old man with mild emphysema and borderline hypertension. He admits to smoking a pack of cigarettes per day. When developing a teaching plan, which of the following should receive highest priority to help decrease respiratory complications? a. Weight reduction b. Decreasing salt intake c. Smoking cessation d. Decreasing caffeine intake

c. Smoking cessation priority

When planning collaborative care for a patient with irritable bowel syndrome the nurse understands that healthcare interventions may include all of the following except: a. Instruction of coping strategies and stress management techniques b. Management of symptoms that can include pain, constipation, and diarrhea c. Surgery to repair perforated bowel or hemorrhage d. Instruction in diet alterations

c. Surgery to repair perforated bowel or hemorrhage management of care

the client diagnosed w/parkinson's disease is being discharged. which statement made by the significant other indicates an understanding of the discharge instructions a. all of my spouses emotions will slow down now just like his body movements b. my spouse may experience hallucinations until the medication starts working c. i will schedule appointments late in the morning after his morning bath d. it is fine if we don't follow a strict medication schedule on weekends

c. i will schedule appointments late in the morning after his morning bath client teaching

the nurse is assigned 8 pts on the medical oncology floor. under the nurse are 2 UAPs & one LPN. the nurse delegates much of the daily hygiene care to the UAPs and all of the following medication administration to the LPN except: a. PO beta blockers b. anti-constipation suppositories c. iv phenergan d. subcutaneous lovenox

c. iv phenergan management of care

the nurse is assessing coping in a female pt that had a liver transplant 5 months ago. which assessment is most importnat to report to physician a. the pt is expressing frears of organ rejection b. the pt is concerned about facial hair that has appeared since starting on steroids c. the pt is w/drawn & only sleeping for 3 hrs/night due to post-traumatic stress d. the pt is expressing concern w/the ability to pay for medications & follow up health care

c. the pt is w/drawn & only sleeping for 3 hrs/night due to post-traumatic stress assessment

A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times? a.) Before meals b.) With meals c.) At bedtime d.) When pain occurs

c.) At bedtime pharmacological & parenteral therapies

The night nurse has four patients. Which of these patients will be safe to see last? a.) The client with COPD showing signs of altered mental status b.) The client with terminal cancer who wants pain meds c.) The client who suffered a traumatic eye injury that left him blind 3 years ago that wants to go to the bathroom. d.) The diabetic client whose blood glucose level is 275

c.) The client who suffered a traumatic eye injury that left him blind 3 years ago that wants to go to the bathroom. priority setting

When asking a client with a history of liver transplantation about their diet, which statement should concern the nurse most? a) "I like to eat bacon and eggs for breakfast." b) "Tuna sandwiches and potato chips for lunch." c) "When I feel like giving myself a treat I eat a candy bar." d) "I sometimes eat a grapefruit as a late night snack."

d) "I sometimes eat a grapefruit as a late night snack." teach

A floor nurse is starting her shift and must prioritize the needs of her patients. Which patient should be seen first? a) 52yom with chronic bronchitis hospitalized with a broken femur. b) 62 yof with emphysema participating in a sleep study. c) 30yom pack a day smoker under observations for neck injuries resulting from a minor vehicle accident. d) 12 yof admitted from the ED with status asthmaticus.

d) 12 yof admitted from the ED with status asthmaticus. priorit

Eight hours after an abdominal hysterectomy, the client has not voided and says, "I don't think I can urinate." The nurse should first: a) inform the surgeon of a possible urethral tear b) administer pain medications c) increase the client's fluid intake d) assess the bladder

d) assess the bladder assessment

Which of the following approaches to chronic pain management, such as a patient with fibromyalgia, is the most effective? a) CAM management b) psychological management c) pharmacological management d) multidisciplinary management

d) multidisciplinary management eval

The potential for injury during an attack of Meniere's disease is great. The nurse should instruct the client to take which immediate action when experiencing vertigo? a. "Place your head between your knees." b. "Concentrate on rhythmic deep breathing." c. "Close your eyes tightly." d. "Assume a reclining or flat position."

d. "Assume a reclining or flat position." prevention

The postmenopausal client reveals it has been several years since her last gynecological examination and states, "oh, I don't need exams anymore. I am beyond having children." Which statement should be the nurse's response? a. "As long as you are not sexually active, you don't have to worry." b. "You should be taking hormone replacement therapy now." c. "You are beyond bearing children. How does that make you feel?" d. "Here are situations other than pregnancy that should be checked."

d. "Here are situations other than pregnancy that should be checked." health promotion

A client with dementia is admitted to the hospital. Indicate in which order the nurse should conduct assessment of this client. 1. Slow onset 2. Personality changes 3. Confusion 4. Memory loss 5. Risk factors a. 1,2,3,4,5 b. 2,4,5,3,1 c. 1,5,4,2,3 d. 1,2,4,3,5

d. 1,2,4,3,5 (Slow onset, Personality changes, Memory loss, Confusion, Risk factors)

The ER nurse has had several patients arrive to the hospital simultaneously. Which of these clients represents the nurse's first priority. a. 5 year old client complaining of inner ear pain b. 72 year old female complaining of worsening cloudy vision with history of cataracts c. 83 year old male who claims he has a decrease in his ability to hear d. 23 year old male who was struck in the eye with a baseball and has complete loss of vision in right eye and bleeding.

d. 23 year old male who was struck in the eye with a baseball and has complete loss of vision in right eye and bleeding. priority

A newly hired nurse at a busy ENT's office is asked to keep an eye on things while the doctors and staff eat lunch. Which of the following indicate a need to call the doctor immediately? a. A 68 year-old man who had eye surgery two days ago and still has some bruising b. A 35 year-old woman with a small cut on her upper eyelid c. A 15 year-old boy who got an eraser stuck in his nose during a dare d. A 52 year-old man with atherosclerosis who recently changed his aspirin dosage and complains of tinnitus

d. A 52 year-old man with atherosclerosis who recently changed his aspirin dosage and complains of tinnitus

10. A patient is suffering from frequent episodes of tinnitus. What are some non-pharmacological interventions the nurse could suggest for the patient to try in order to alleviate these episodes? a. Mask sounds with music or background sound during sleep b. Keep earplugs nearby for when noises are loud c. Contact the American Tinnitus Association d. All of the above e. A and B only

d. All of the above (Mask sounds with music or background sound during sleep, Keep earplugs nearby for when noises are loud, Contact the American Tinnitus Association)

The nurse is assigning tasks to the unlicensed assistive personnel (UAP) for a client with an abdominal hysterectomy on the first postoperative day. Which of the following cannot be delegated to the UAP? a. Taking vital signs b. Recording intake and output c. Giving perineal care d. Assessing the incision site.

d. Assessing the incision site. management of care

Client's following a kidney transplant should do all the following except: a. Avoid prolonged periods of sitting b. Recognize the signs and symptoms of infection and rejection c. Avoid contact sports d. Avoid eating meat

d. Avoid eating meat safety

It is most critical to keep a high index of suspicion for which infection in the transplant recipient? a. ingrown hair b. burns c. asthma d. Candidiasis

d. Candidiasis priority

A female client complains of periorbital arching, tearing, blurred vision, and photophobia in her right eye. Opthalmologic examination reveals a small, irregular, nonreactive, pupil- a condition resulting from acute iris inflammation (iritis). As part of the client's therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? a. Parasympathomimetic agent b. Sympatholytic agent c. Adrenergic blocker d. Cholinergic blocker

d. Cholinergic blocker pharm

A client has just returned to the floor from having bowel surgery. What would be the best technique to use to prevent the client's ileostomy from becoming infected? a. Place client on a high fiber diet immediately b. Remove dressing one day post-op for ileostomy to heal c. Empty the pouch when its full d. Clean the skin around the stoma with warm water and soap often.

d. Clean the skin around the stoma with warm water and soap often. infection control

The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected? a. Normal breath sounds b. Prolonged expiration c. Normal chest movement d. Coarse crackles and rhonchi

d. Coarse crackles and rhonchi

A 50-year-old male has been taking aspirin regularly for 6 months to prevent a heart attack. He informs the nurse that he has noticed a constant "ringing" in both ears. How should the nurse respond to the client's comment? a. Tell the client that "ringing" in the ears is associated with the aging process. b. Inform the client he needs a Weber test done. c. Schedule the client for audiometric testing. d. Explain to the client that the "ringing" may be related to the aspirin he has been taking for his heart.

d. Explain to the client that the "ringing" may be related to the aspirin he has been taking for his heart. pharm

The physician has ordered chest physiotherapy for a client with chronic obstructive lung disease. When performing chest physiotherapy the nurse should give priority to: a. Covering the client's chest with a towel. b. Placing the client in a prone position. c. Beginning percussion in the lower lobes. d. Making sure that the client's face is visible.

d. Making sure that the client's face is visible. safety

The nurse is caring for a client with diagnosis of Multiple sclerosis. The client is concerned about the recurrent exacerbations and fatigue. The nurse suggests which of the following interventions to help at home? a. Ask the client's mother for help with the children in the evening. b. Limit activities and take morning and afternoon naps. c. Indentify where assistive devices can be obtained at reasonable prices. d. Space activities throughout the day with opportunities for rest.

d. Space activities throughout the day with opportunities for rest. safety

A student nurse finds a client setting on the side of the bed with both hands on his knees saying "I can't breathe". What should the nurse do? a. Leave the client there and go get help b. Have the client get on hands and knees in the floor c. Tell the client to relax and lay them back in bed with the bed totally flat d. Try to calm the client and instruct them to do purse lip breathing.

d. Try to calm the client and instruct them to do purse lip breathing. safety

Which of the following would NOT be included in the nurse's discharge instructions to a client with venous peripheral vascular disease? a. Keep extremities elevated when sitting b. Rest at first sign of pain c. Keep extremities warm ( but do not use a heating pad) d. Try to keep from changing position often.

d. Try to keep from changing position often. management of care

a client admits to the hospital 1 day ago w/lower right abdominal pain. the pt was sent to the OR to have his appendix removed. which of the following may warrant a phone call to the doctor? a. WBC count 17,000/mm b. fever 101.4 c. pt states "i don't feel right" d. all of the above

d. all of the above (WBC count 17,000/mm, fever 101.4, pt states "i don't feel right") infection control