Previous Tests
A client who has occasional gastric symptoms is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching?
"Eliminating bothersome foods will help."
A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse?
"Exercise, keep your blood sugar in check, and manage your stress."
The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, "I cannot catch my breath." How would the nurse document this finding?
"Experiences exertional dyspnea when walking 3 feet; states, I cannot catch my breath."
A client had cardiothoracic surgery and informed the nurse that he has a 6-month-old grandchild. The client states, "I can't wait to hold my grandchild!" What is the best response by the nurse?
"I am sure you are excited to see your grandchild but you must refrain from lifting, pushing, or pulling anything over 10 lb for at least 6 to 12 weeks."
When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the physician?
"I really don't like to be in small, enclosed spaces."
A client undergoes an arthroscopy at the outpatient clinic. After the procedure, the nurse provides discharge teaching. Which response by the client indicates the need for further teaching?
"I should use my heating pad this evening to reduce some of the pain in my knee."
A nurse is teaching a client with osteoporosis about dietary selections. What client statement indicates the teaching was effective?
"I will eat more dairy products to increase my calcium intake."
A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?
"I'll avoid eating or drinking anything 6 to 8 hours before the test."
A patient has been placed on telemetry following treatment for a non-ST wave elevation myocardial infarction (NSTEMI). Which of the patient's following statements indicates that the nurse should perform further patient teaching?
"If I get chest pain or shortness of breath, it will show up on my telemetry monitor."
The nurse is caring for a client who had a surgical amputation of the left leg related to complication from diabetes. The client asks the nurse, "If my leg is really gone, then why am I having such bad pain?" What is the best response by the nurse?
"It is called phantom pain and may come and go."
A client with rheumatoid arthritis informs the nurse that since he has been in remission and not having any symptoms, he doesn't need to take his medication any longer. What is the best response by the nurse?
"It is important that you continue to take your medication to avoid an acute exacerbation
A nurse is discussing Hodgkin's disease with a client recently diagnosed with the illness. The client says, "I know I am going to die." What response from the nurse would be most appropriate and accurate?
"Some clients survive 10 or more years."
A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best?
"Warfarin prevents clot formation in the atria of clients with atrial fibrillation."
A nurse is providing self-care education to a client who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the client?
"Wash your face with water and gentle soap each morning and evening."
The nurse is completing a preoperative assessment. The nurse notices the client is tearful and constantly wringing their hands. The client states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response?
"What are your concerns?"
While doing a health history, a client tells the nurse that her mother, grandmother, and sister died of cancer. The client wants to know what she can do to keep from getting cancer. What would be the nurse's best response?
"You can't prevent cancer, but you can have your blood analyzed for tumor markers to see what your risk level is."
Hypertension is diagnosed when the client demonstrates a systolic blood pressure greater than ______ mm Hg or a diastolic blood pressure greater than _____ mm Hg over a sustained period.
130, 80
A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as
18%.
The nurse is conducting a community education program on hip fracture risk. The nurse evaluates that the participants understand the program when the participants determine that client at highest risk for a hip fracture is a(n)
80-year-old man recently widowed.
Upon reporting to work and receiving report, a nurse has been assigned to provide care for three clients. Each of the clients has called out to the nurses' station requesting assistance. Which client should the nurse see first?
A 32-year-old male, who had a plaster cast applied to his leg 2 hours ago, who complains that the cast feels as if it's getting tighter
The nurse is caring for a patient with dementia in the long-term care facility when the patient has a change in cognitive function. What should the nurse suspect this patient may be experiencing?
A UTI
The nurse is reviewing urine tests to obtain client baseline information. Which of the following urine tests is preferred to identify characteristics of normal and abnormal urine?
A clean-catch midstream specimen from the first voiding of the morning
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?
A client with a nasogastric tube
The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?
Abdominal distention
Which term refers to moving away from midline?
Abduction
A nurse is assessing a client who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis?
Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin
The PACU nurse is caring for an older adult client who is recovering from surgery. The client states he is in pain. The nurse knows older adults react to medications differently than younger clients. What does this client's age put them at increased risk for? Select all that apply.
Acute confusion Respiratory depression Disorientation Longer recovery time
What special elements of care should be incorporated into the care of a client in traction? Select all that apply.
All of the answers are true.
A client has been involved in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. Other than the bone, what physical structures could be affected by this injury?
All options are correct.
Due to a lengthy history with Crohn's disease and the severity of symptoms, a client is being prepared for a colostomy. Which would be included in this client's individual care plan?
All options are correct.
Which elements of assessment of a traumatic musculoskeletal injury should be included when a client is evaluated. Select all that apply.
All should be included.
The nurse is assessing a patient upon admission to the hospital. What significant nursing assessment data is relevant to renal function? Select all that apply.
Any voiding disorders The patient's occupation The presence of hypertension or diabetes
The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client states he is allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?
Apply an allergy bracelet and flag the chart.
A patient has a cast removed after bone healing takes place. What should the nurse instruct the patient to do after removal? (Select all that apply.)
Apply an emollient lotion to soften the skin. Control swelling with elastic bandages, as directed. Gradually resume activities and exercise.
A nurse is preparing a client to undergo a colostomy procedure. What type of procedure will the client be undergoing based on the accompanying image?
Ascending colostomy
The nurse is caring for an 84-year-old client who is being admitted for diagnostic studies for a potential renal disorder. The nurse planning care has initiated a care plan of "Knowledge Deficit related to poor understanding of diagnostic studies as manifested by client statements of not understanding diagnostic procedures and elevated anxiety." Which nursing interventions does the nurse include in the plan of care? Select all that apply.
Assess client's level of understanding. Remain with client and answer questions. Administer an ordered sedative. Use simple language.
A nurse is assessing a client who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?
Assess for a patent airway.
The nurse is caring for a client on a monitored telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which action would the nurse do first?
Assess the client.
A client with an arm cast reports pain. What nursing interventions should the nurse provide in order to reduce the incidence of complications? Select all that apply
Assess the fingers for color and temperature. Assess for a pressure sore Determine the exact site of the pain.
The nurse is caring for a client postoperatively after undergoing a coronary artery bypass graft. What intervention can the nurse provide to reduce the risk of the development of wound dehiscence?
Assist the client to splint with a pillow when coughing and deep breathing.
The nurse is preparing to measure the client's abdominal girth as part of the physical examination. At which location would the nurse most likely measure?
At the umbilicus
Which of the following causes odor in perspiration?
Bacteria on the skin
A client with newly diagnosed emphysema is admitted to the medical-surgical unit for evaluation. Which does the nurse recognize as a deformity of the chest wall that occurs as a result of overinflation of the lungs in this client population?
Barrel chest
The nurse is caring for a client who is receiving a loop diuretic for the treatment of heart failure. What assessment should the nurse prioritize?
Blood pressure
The health care provider has prescribed continuous positive airway pressure (CPAP) with the delivery of a client's high-flow oxygen therapy. The client asks the nurse what the benefit of CPAP is. What would be the nurse's best response?
CPAP allows a lower percentage of oxygen to be used with a similar effect.
A client with acquired immune deficiency syndrome (AIDS) comes to the clinic reporting difficulty swallowing. The client says, "It hurts so much when I swallow." Inspection reveals creamy white patches in the client's mouth. What will the nurse suspect?
Candidiasis
The nurse is assessing a client who has dyspnea and considering the process of gas exchange. Which structural characteristic of capillaries best enables gas exchange at the cellular level?
Capillaries are one cell-layer thick.
A client comes into the emergency department with reports of abdominal pain. What should the nurse ask first?
Characteristics and duration of pain
Your client is a 72-year-old male who has just undergone a transurethral resection of the prostate (TURP) and is returned to the nursing unit with a 3-way catheter for administering bladder irrigation. Your client complains of bladder discomfort and a feeling or urgency to void, Which nursing action is best to take first?
Check that the urinary drainage catheter is patent and not kinked.
The nurse is caring for a client who has just returned from the cardiac catheterization laboratory following a coronary angioplasty. What is the nurse's priority assessment?
Check the temperature, color, and capillary refill of the affected extremity.
When examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract, which of the following would be most important?
Checking if the mucous membranes are dry
The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following?
Chordae tendineae
A client arriving at the emergency department is diagnosed with a dislocation. Assessment would most likely reveal which of the following? Select all that apply.
Complaint of a popping sound Swelling Pain
A client postoperatively reports to the nurse the need to urinate, but is unable to void. What should the nurse expect the healthcare provider to order? Select all that apply.
Complete a straight catheterization. Perform a bladder scan.
A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?
Contact the health care provider and report the findings.
The school nurse is instructing a group of high school students on the considerations with tattooing and body piercing. Which instruction would be included in the discussion? Select all that apply.
Cosmetic pigment is approved by the Federal Food, Drug, and Cosmetic Act. Infection is a potential complication of tattoos and piercings. Tattoo is injected into the dermal layer of the skin.
Which of the following would be considered a mechanical defense mechanism?
Coughing
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected?
Crackles
When a client is instructed not to take a drug with dairy products, what else can the client drink when swallowing the medication? Select all that apply
Cranberry juice
Which term refers to a grating or crackling sound or sensation?
Crepitus
The nurse has admitted a new client to the unit. This client has an open draining sore on his leg. What diagnostic test would the nurse anticipate being ordered?
Culture and sensitivity
Which of the following urine characteristics would the nurse anticipate when caring for a client whose lab work reveals a high urine specific gravity related to dehydration?
Dark amber urine
A female client comes to the clinic and tells the nurse, "I am getting all these little hairs on my chin. I never had them before I turned 50." What does the nurse understand is the cause of the terminal hairs on the face?
Decreased ratio of estrogen to androgen hormones
The nurse is caring for a client who has had diarrhea for 3 days. What major problems associated with severe or prolonged diarrhea should the nurse monitor for when caring for this client? Select all that apply.
Dehydration Electrolyte imbalances Vitamin deficiencies
The client is scheduled for a biopsy for suspected cancer of the prostate. The nurse recognizes the purpose of this surgical procedure is:
Diagnostic
A client who has recently started working in a coal mine is concerned the effects on long-term health. How does the nurse advise the client to prevent occupational lung disease? Select all that apply.
Do not smoke, or quit smoking if currently smoking. Wear appropriate protective equipment when around airborne irritants and dusts.
A client is being treated for diverticulosis. Which points should the nurse include in this client's teaching plan? Select all that apply.
Do not suppress the urge to defecate. Drink at least 8 to 10 large glasses of fluid every day. Use bulk-forming laxatives Encourage an individualized exercise program
Which of the following measures would the nurse recommend to an ostomate to help facilitate a regular bowel pattern without relying on irrigation? Select all that apply.
Drinking prune juice Performing mild exercise Using a stool softener
When do coronary arteries primarily receive blood flow?
During diastole
A nurse is providing information on food allergies to a group of teachers. What food items would the nurse inform the teachers are common allergens?
Eggs and nuts
A client is receiving treatment for a head injury. Which of the following would the nurse do related to positioning to reduce the risk of further injury?
Elevate the client's head slightly while keeping the neck neutral.
The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance?
Elevate the legs higher than the heart.
A 65-year-old client with severe chest pain is evaluated in the emergency department. A tentative diagnosis of myocardial infarction (MI) is made. Which of the following electrocardiogram (ECG) changes supports the diagnosis that the client is experiencing a myocardial infarction?
Elevated ST segment
In which instance may a surgeon operate without informed consent?
Emergency situations
The nurse assesses a client who is bleeding profusely from the nose. The nurse documents this finding as which condition?
Epistaxis
An 11-year-old boy has been brought to the ED by his teacher, who reports that the boy may be having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. What interventions should the nurse prioritize?
Establishing a patent airway and beginning cardiopulmonary resuscitation
When caring for an adolescent client recovering from rheumatic fever, which diversional activity would the nurse advise against?
Exercise
Which is the primary preventable cause of skin cancer?
Exposure to UV radiation
A nurse is reviewing the various manifestations of anemia across the lifespan and notes a significant difference in how the older adult client responds to anemia versus a younger individual. Which concepts related to aging and the response to anemia does the nurse recognize? Select all that apply.
Fatigue is often greater than in younger clients. Heart rate does not increase as much as in younger clients. Confusion is often greater than in younger clients.
The nurse has been caring for a client who has been prescribed an antibiotic for pharyngitis and has been instructed to take the antibiotic for 10 days. On day 4, the client is feeling better and plans to stop taking the medication. What information should the nurse provide to this client?
Finish all the antibiotics to eliminate the organism completely.
A sputum study has been ordered for a client who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample?
First thing in the morning
Which of the following is a function of the stomach? Select all that apply.
Food storage Secretion of digestive fluids Propels partially digested food into small intestine
The nurse is developing a plan of care for a patient with peptic ulcer disease. What nursing interventions should be included in the care plan? Select all that apply.
Frequently monitoring hemoglobin and hematocrit levels Observing stools and vomitus for color, consistency, and volume Checking the blood pressure and pulse rate every 15 to 20 minutes
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
Fried chicken
An ECG has been ordered for a newly admitted client. What should the nurse do prior to electrode placement?
Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth.
A patient is admitted with severe dehydration related to diarrhea. The patient was hiking in the mountains during a camping trip and drank water from a mountain stream without purifying. What does the nurse know is the most likely cause of this diarrhea?
Giardia lamblia
The nurse is reporting on the results of client blood work to the oncoming nurse. Upon reviewing the data, it is noted that the client has an elevated uric acid level. Which inflammatory process would the nurse screen for on shift rounds?
Gout
A young mother brings her 4-year-old in to the pediatric clinic with a mild fever and a red, spotty rash that is beginning to fade. The child's heart rate is rapid, and the rhythm is abnormal. The mother states the child has been healthy until about 3 weeks ago when the child had a sore throat. The nurse suspects rheumatic carditis. What organism causes rheumatic carditis?
Group A beta-hemolytic strep
The nurse is assessing a client who is stating gastrointestinal upset and a feeling of bloating. Which type of meal would the nurse anticipate causing these types of symptoms?
Hamburger and French fries
Following the morning assessment of an older adult patient, the nurse has documented, "Edema 3+ present to ankles and feet; dorsalis pedis and posterior tibial pulses palpable bilaterally." The nurse should recognize that this patient may be exhibiting symptoms of:
Heart failure
A patient is scheduled for hip replacement surgery in a month. Which statement made by the client demonstrates understanding for the preoperative instructions?
I will stop taking my aspirin prior to my surgery."
A mother calls the clinic asking for a prescription for amoxicillin for her 2-year-old son who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother?
I'll certainly inform the doctor, but if it is a cold, antibiotics won't be used because they do not affect the virus."
Which stage of a pressure sore is exhibited by deeply ulcerated tissue, exposing muscle and bone?
IV
What can the nurse do to meet the challenges in caring for a patient with cancer?
Identify own perception of cancer and set realistic goals.
The nurse is providing instruction to a group of new nurses orienting on the unit, highlighting the benefits of the automatic implanted cardioverter defibrillator (AICD). While pointing at a diagram of the heart, at which location would the nurse identify the placement of the electrical lead?
In the right ventricle near the septum
A client is complaining of problems with constipation. What dietary suggestion can the nurse inform the client may help facilitate the passage of stool?
Increase dietary fiber.
A client had a tracheostomy two hours ago. The nurse assesses the client and finds the client's breathing is shallow, with a respiratory rate of 30. The nurse notes increased mucus production around the tracheostomy and on the dressing. What are the priority nursing concerns? Select all that apply.
Ineffective airway clearance Impaired gas exchange
Which of the following interventions would be most appropriate for a client with a hiatal hernia and nursing diagnosis of Acute Pain related to reflux of gastric secretions?
Inform the client to remain upright for at least 2 hours after meals.
You are caring for a patient who just returned from the postanesthesia care unit (PACU) and rates current pain as "9 out of 10." Which of the following prescribed medications will provide the fastest relief from pain?
Intravenous morphine sulfate
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?
Intrinsic factor
The nurse is preparing to administer the solution in the attached image to a client. Which of the following types of solution is the nurse going to administer?
Isotonic
A client informs the nurse that she has been using a douche to cleanse the vagina on a daily basis and is now experiencing itching and burning in the vaginal area. What should the nurse explain to the client that occurs when the vaginal pH is changed?
It causes destruction of the normal flora of the vagina and allows the development of vaginal infections.
A young client has just been diagnosed with lymphoma. The client asks the nurse what a lymphoma is. What would be the nurse's best answer?
It is a group of cancers that affect the lymphatic system.
The nurse notes that the client has had a change in mental status. Why would it be important for the nurse to report extremes in the thought process of a client with cardiovascular disorder to the physician?
It may indicate a problem with oxygenation.
Which is the principal hardening ingredient of the hair and nails?
Keratin
Which term describes the time interval after primary infection when a microorganism lives within the host without producing clinical evidence?
Latency
The nurse is observing a client who is receiving a sulfonamide for Stevens-Johnson syndrome. The signs and symptoms that might indicate this syndrome include:
Lesions on the skin or mucous membranes
The nurse is developing a teaching plan for a client diagnosed with hypertension. What would be important for the nurse to emphasize as part of the plan of care?
Limiting sodium intake in the diet
A client arrives in the emergency department with a shoulder injury after falling from a stepladder. The physician informs the client that he will correct the shoulder dislocation by manipulation. When the client asks the nurse what is meant by the term dislocation, which explanation is the most accurate?
Manipulation repositions the bone ends manually
The nurse is caring for a client who has a deficiency in the formation of cartilage in joints. Which essential substance is absent?
Matrix
A nurse is preparing a care plan for a client with Alzheimer's disease. The client is unable to communicate or feel the pain and discomfort associated with acute urinary retention. Which nursing measures should be taken while caring for such a client? Select all that apply.
Measure fluid intake and output. Palpate the abdomen to check for distended bladder.
Cancer has many characteristics. What is one of the most discouraging characteristics of cancer?
Metastasis
The nurse is providing discharge teaching to a patient diagnosed with heart failure. What should the nurse teach this patient to do to monitor fluid balance?
Monitor weight daily.
What part of the GI tract begins the digestion of food?
Mouth
The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?
Multiple organ failure
Which of the following describes awakening at night to urinate?
Nocturia
A 45-year-old obese man arrives in a clinic reporting daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem?
Obstructive sleep apnea
A client with heart failure has been admitted to the cardiac clinic. What steps should the nurse take to ensure a proper assessment? Select all that apply.
Obtain an admission weight and thereafter weigh the client daily on the same scale, at about the same time of day, with the client wearing similar clothing. Note respiratory difficulties during activity and rest.
The nurse is explaining the three layers of tissue which make up the heart wall. As the nurse draws the layers in different colors to highlight the layers, which color would the nurse use for the heart valves?
Orange, the same color as the endocardium
A 16-year-old has come to the clinic and asks to talk to a nurse. The teen states that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do to keep from getting HIV. What would be the nurse's best response?
Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV.
A female client is worried she might have lice. Which finding should the nurse look for?
Oval, white dots stuck to the hair shafts
The nurse is preparing to assess a client's new stoma. Which finding would the nurse include in the documentation of a healthy stoma?
Pink color
The nurse observes that a client who had an arterial blood gas performed 30 minutes ago is still oozing blood from the puncture site. Pressure was held to the site for 5 minutes after the puncture and another 5 minutes when the site was still oozing. What factor does the nurse know will participate in the ability for the blood to clot?
Platelets
The instructor is talking with a nursing student who is caring for a client with pericarditis. The instructor asks the student to name the main characteristic of pericarditis. What should be the student's answer?
Precordial pain
The physician orders a patient-controlled analgesia (PCA) infusion pump for the client after coronary artery bypass graft (CABG) surgery. When the nurse informs the client about the use of the PCA pump, which instruction is most important to include?
Press the control button whenever you feel you need pain medication. The PCA pump will not allow you to receive too much medication.
What is the major purpose of withholding food and fluid before surgery?
Prevent aspiration
Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)?
Pulse oximetry
The nurse is caring for a client who experienced a crushing injury of the lower extremities. Which of the following symptoms is essential to be reported to the physician?
Pulselessness
The nurse is performing hourly assessments on a client in the compensation stage of shock. In documenting the hourly urine output of 40 mL from the Foley catheter, which nursing action is most appropriate?
Record 40mL as the hourly output.
The hospice nurse is assigned to care for a patient with metastatic bone cancer who wants to remain at home. What is the therapeutic goal in the care of this patient?
Relieve pain and discomfort while promoting quality of life.
A nurse is describing the renal system to a client with a kidney disorder. Which structure would the nurse identify as emptying into the ureters?
Renal pelvis
The nurse is caring for a healthy adult client who developed a gastrointestinal virus in the last 24 hours that has caused vomiting and diarrhea and now has a diagnosis of dehydration. The nurse should know that a health care provider's order to initiate intravenous therapy is given primarily for which reason(s)? Select all that apply
Replace electrolytes. Replace fluids.
The nurse is discharging a client after a cardiac catheterization. What would the nurse include in the discharge teaching?
Report any numbness, tingling, or sharp pain in the extremity.
The physician orders an opioid analgesic for a client with a traumatic injury. The nurse would monitor the client closely for which of the following as the priority?
Respiratory depression
The RICE acronym is helpful for remembering treatment interventions for musculoskeletal injuries. Which of the following are components of the RICE acronym? Select all that apply.
Rest Ice Compression Elevation
A client with HIV will be started on a medication regimen of three medications. What class of drugs will the nurse instruct the client about?
Reverse transcriptase inhibitors
Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?
Review the scheduled procedure, site, and client.
One of the students asks what the consequences of uncorrected, left-sided heart failure would be. What would be the nursing instructor's best response?
Right-sided heart failure
A nurse stops to give first-aid to a burn victim who is seen running from a home. The victim's clothing is on fire. Which action is the nurse's immediate priority?
Roll the victim on the ground to smother the flames.
The nurse is preparing to assist a client about to undergo CABG. The physician is using a graft in the location shown in the accompanying image. What type of graft is the physician using?
Saphenous vein
What is the term for a lateral curving of the spine?
Scoliosis
Which type of shock is caused by an infection?
Septic
The nurse is answering questions regarding fecal matter for a client who is scheduled for a colon resection. The client is asking questions regarding the composition of the fecal matter and when it becomes a formed mass. The nurse is most correct to state at which location?
Sigmoid colon
The home care nurse is visiting a client newly discharged home after a lobectomy. What would be most important for the home care nurse to assess?
Signs and symptoms of respiratory complications
The nurse uses which term for the normal pacemaker of the heart?
Sinoatrial (SA) node
A client with peptic ulcer disease wants to know nonpharmacologic ways to prevent recurrence. Which of the following measures would the nurse recommend? Select all that apply.
Smoking cessation Substituting decaffeinated products for all forms of coffee Avoidance of alcohol Following a regular schedule for rest, relaxation, and meals
The nurse is caring for a client who has developed obvious signs of pulmonary edema. What is the priority nursing action?
Stay with the client.
The nurse is collecting a stool specimen from a patient. What characteristic of the stool indicates to the nurse that the patient may have an upper GI bleed?
Tarry and black
A client experiences a musculoskeletal injury that involves the structure that connects a muscle to the bone. The nurse understands that this injury involves which structure?
Tendon
The nurse is teaching the client with HIV about therapy. Which elements are essential for the nurse to include in the teaching plan? Select all that apply.
The CD4 count is the major indicator of immune function and guides therapy. Antiretroviral therapy targets different stages of the HIV life cycle.
A client with a Staphylococcus aureus infection present in a sacral pressure ulcer has received treatment with three courses of antibiotics without eliminating the infection. What does the nurse understand has occurred with the client?
The client has a multidrug-resistant strain of bacteria.
When a client with an indwelling urinary catheter wants to walk to the hospital lobby to visit with family members, the nurse teaches him how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information?
The client keeps the drainage bag below the bladder at all times.
The perioperative nurse is preparing to discharge a female client home from day surgery performed under general anesthetic. What instruction should the nurse give the client prior to the client leaving the hospital?
The client should not drive herself home.
A client is admitted to the acute care facility for vomiting and diarrhea. An intravenous (IV) catheter is inserted for the delivery of IV fluids. A family member is with the client and observes the nurse enter the room and begin touching the IV site without washing his hands or wearing gloves. Why should the client and family member be concerned with the nurse's actions?
The client will develop a healthcare-associated infection.
The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately?
The client's heart rate is greater than 90 beats/minute.
The PACU nurse is caring for a client who has been deemed ready to go to the postsurgical floor after her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select all that apply.
The client's preoperative level of consciousness The presence of family and/or significant others The client's full name
The nurse is caring for a client with Buerger's disease. The nurse knows that most of the care for this disease is carried out at home. What would be important to teach a client with Buerger's disease?
The importance of smoking cessation
A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate?
The pancreas secretes digestive enzymes.
The nurse is presenting about upper respiratory infections at an educational event for a local community group. What should the nurse be sure to include regarding cold tablets containing first-generation antihistamines?
They can cause urinary hesitancy.
Which of the following superficial fungal infections begins in the skin between the toes and spreads to the soles of the feet?
Tinea pedis
The nurse is caring for the client with massive blood loss from a gunshot wound. With little time to spare, which blood type is infused?
Type O-
The nurse reports to the cardiac nurse practitioner that the client is consistently exhibiting a normal sinus rhythm. What characteristics are understood? Select all that apply.
Upright P wave before each QRS complex Each impulse occurs regularly. Wave ends with a T wave Ventricles depolarize in the QRS complex.
A group of students is reviewing for a test on the urinary and renal system. The students demonstrate understanding of the information when they identify which of the following as part of the upper urinary tract?
Ureters
A client is recovering from a fractured hip. The nurse would suggest that the client increase intake of which of the following to facilitate calcium absorption from food and supplements?
Vitamin D
The nurse who teaches a client about preventing recurrent urinary tract infections would include which statement?
Void immediately after sexual intercourse.
A nurse is caring for a client with an ostomy pouch. When should the nurse ask the client to empty the pouch?
When the pouch is one-third to one-half full
A client is a passenger in a vehicle that was hit in the rear by another vehicle. The client is complaining of pain in the neck from the head rapidly moving forward and then back against the headrest. What type of injury does the nurse suspect the client sustained in the accident?
Whiplash injury
A client is admitted to an acute care facility with a diagnosis of appendicitis. Which laboratory results demonstrate the client's leukocytosis?
White blood cell (WBC) count of 22,000 cells/mm3
The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?
Withhold the medication and notify the physician of the heart rate.
For a patient with a disorder of the gastrointestinal (GI) system, which of the following histories would the nurse assess?
Work history for exposure to environmental toxic wastes or radioactive materials
What is the pH of gastric aspirate?
acidic
A client reports "bloody" urine to the nurse. What causes would the nurse relate the hematuria? Select all that apply.
acute glomerulonephritis renal stones extreme exercise
A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:
acute respiratory distress syndrome (ARDS).
A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what actions should the nurse perform? Select all that apply.
administer oxygen place the client in an upright position
To combat the most common adverse effects of chemotherapy, a nurse should administer an:
antiemetic.
A nursing instructor is instructing on the infectious process. The instructor explains that older adults are more susceptible to serious infections because they:
can have less efficient defense mechanisms than younger adults.
A client has received a diagnosis of right-sided heart failure. Although a major cause of right-sided failure is left-sided heart failure, there are other causes that contribute to the development of right-sided failure. What is another common cause?
chronic obstructive pulmonary disease
What is a modifiable risk factor for the development of atherosclerosis?
consumption of a high-fat diet
The nurse is admitting an older adult to a skilled nursing facility. What assessment parameters will the nurse expect to find with the musculoskeletal assessment? Select all that apply.
decreased endurance joint stiffness decreased range of motion
A client requires increased respiratory effort to breathe. Which factors may affect lung compliance? Select all that apply.
decreased surfactant edema fibrosis
A nurse is caring for a client with left-sided heart failure. What should the nurse anticipate using to reduce fluid volume excess?
diuretics.
Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system?
duodenum
The nurse is conducting an assessment on a client that has acute irritant contact dermatitis. What signs and symptoms would the nurse expect to see upon assessment? Select all that apply.
edema redness
A health care provider diagnoses primary osteoporosis in a client who has lost bone mass. For which client is primary osteoporosis most common?
elderly postmenopausal woman
Specific potential complications are common to specific types of burns. Which burns can impair ventilation?
face, neck, chest
A client with a musculoskeletal injury is instructed to make dietary alterations. The objective of this diet alteration is to facilitate the absorption of calcium from food and supplements. Considering the food intake objective, which food items should the nurse encourage the client to include in the diet? Select all that apply.
fatty fish vitamin D-fortified milk
When assessing an elderly client's gastrointestinal system, it is important for the nurse to remember that older clients tend to have:
less control of the rectal sphincter.
The human body has 206 bones, which are classified into four categories. Which types of bones are located in the forearm?
long bones
A client reports frequent episodes of reflux, and describes regurgitating small amounts of stomach contents into the esophagus. What sphincter is most likely not performing its normal physiologic function?
lower esophageal sphincter
Which cells are white blood cells with immune functions?
lymphocytes
A client undergoes an open reduction of a femur fracture, and returns to the orthopedic unit with a cast in place. What is the rationale for frequently assessing the client's pedal pulses?
maintaining adequate circulation
A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:
maintaining the client's fluid, electrolyte, and acid-base balance.
The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question?
metoclopramide
There are thousands of components of the musculoskeletal system that facilitate mobility and independent function. The function of skeletal muscle is promoting:
movement of skeletal bones.
Each bone is composed of cells, protein matrix, and mineral deposits. Which type of bone cell works to repair a bone fracture?
osteocytes
When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows
redness and induration.
The nurse cares for a client who receives feedings through a nasogastric (NG) tube and assesses the client for signs and symptoms of pulmonary complications. The nurse determines the client may be experiencing pulmonary complications when which sign is noted?
respiratory rate of 30
Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for receiving deoxygenated blood from the venous system?
right atrium
A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. What is the nurse's best response?
small intestine
There are thousands of components of the musculoskeletal system which facilitate mobility and independent function. Which component(s) are involuntary muscles? Select all that apply.
smooth muscle cardiac muscle
Which term describes the amount of blood ejected per heartbeat?
stroke volume
The nurse cares for a client with superficial partial-thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because
tissue edema may interfere with drug absorption via other routes.
The nurse working in the emergency department places a client in anaphylactic shock on a cardiac monitor and sees the cardiac rhythm shown. Which dysrythmia should the nurse document?
ventricular tachycardia
A client has been experiencing lower GI difficulties that have increased in severity, and the gastroenterologist is concerned that the client's bowel is not functioning properly. What function of the lower GI tract is most likely to be affected by the client's disorder?
water and electrolyte absorption
During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure?
wheezes with wet lung sounds
Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes no active gag reflex. What nursing action is a priority?
withhold food and fluids.
A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, "I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse?
"I understand your concern. The blood is screened very carefully for different viruses as well as HIV."
A 17-year-old girl with spina bifida is helping her mother prepare for her younger brother's birthday party. After blowing up a balloon, the girl develops erythema and itching around her mouth. This is likely due to which of the following?
A latex allergy
The nurse is caring for a client diagnosed with hypovolemic shock. Which outcome would be the best evidence of an improvement in client condition?
Alertness in level of consciousness
A client taking oral penicillin reports he has a sore mouth. On inspection, the nurse notes a black, furry tongue and bright red oral mucous membranes. The primary care physician is notified immediately because these symptoms may be caused by:
An allergic reaction
A nurse on the unit sustains a needlestick injury while caring for a client whose infectious status is unknown. What would be the best course of action for the nurse to follow?
Be tested for disease antibodies at appropriate intervals.
An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. The ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? Select all that apply.
Before meals At bedtime
Following a hip repair, the client develops hemoptysis, wheezing, and cyanosis. The nurse suspects a pulmonary embolus that originated from which site?
Bone marrow
During visiting hours, the nurse observes the sister of a critically ill client coughing violently in the hallway. After blowing her nose, she says "I have a touch of the flu." Which nursing intervention is the best choice for the nurse to follow?
Explain why the sister should not visit the client until she is over the flu.
The nurse is caring for a client who has just had total parenteral nutrition (TPN) ordered. The LPN is correct when informing the client that TPN is used for what?
To meet the client's caloric and nutritional needs
A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action?
maintaining an open airway
The six elements necessary for infection include a causative organism, a reservoir of available organisms, a portal or mode of exit from the reservoir, a mode of transmission from reservoir to host, a susceptible host, and
mode of entry into the host.
An client in the ambulatory surgery clinic is having difficulty undressing and putting clothing away. The client arrived via taxi, lives alone, and has few friends. The client will be unaccompanied before surgery and the client's children all live in different parts of the country. This client may not be a suitable candidate for ambulatory surgery because:
the client's postoperative care is questionable.
A client is having a TB skin test wants to know when the test results will be available. The nurse would tell the client that:
the results will be read in 48 to 72 hours.
A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women, most of whom are older than 60 years. What preventive measures should the nurse recommend to these women, who are at the risk of pneumococcal and influenza infections? Select all that apply.
vaccinations hand antisepsis
A 57-year-old client goes to his physician for difficulty. The physician prescribes an oral antibiotic for the client who has prostatitis. Which instruction by the nurse about the client's antibiotic use is a priority?
Take the medication until it is completely gone.
A 24-year-old man has suffered extensive head and neck injuries in a motorcycle accident and has been admitted to the intensive care unit (ICU) in apparent neurogenic shock. Which of the following are characteristics of this patient's diagnosis?
The patient has adequate blood volume but is profoundly vasodilated
The nurse is caring for a teenage girl who has had an anaphylactic reaction after being stung by a wasp. The nurse is providing patient teaching prior to the patient's discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
Thigh
The nurse is teaching a health class in the local public health center. What instructions should the nurse provide as the single most important measure to prevent the spread of infection?
Thorough handwashing
Nursing students are reviewing information about infectious diseases and events associated with infection. Students demonstrate understanding of the information when they identify the incubation period as which of the following?
Time between exposure and onset of symptoms
The parents of an 8-year-old express frustration because their child has frequent outbreaks of impetigo. The nurse is assessing their need for additional teaching. Which of the following statements by a parent would indicate that they need further teaching?
"Antibiotic treatment isn't necessary because the infection is self-limited,'
The nurse is completing a client's health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases?
"Do you currently smoke, or have you ever smoked?"
When assessing for substances that are known to harm workers' lungs, the occupational health nurse should assess their potential exposure to which of the following?
Asbestos
A client is hospitalized for an infected decubitus ulcer of the sacral area. The physician is planning to remove the dead and damaged tissue. What type of procedure will the nurse prepare the client for?
Debridement
The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.)
Decreases hypoxemia Decreases patient anxiety Sustains positive end expiratory pressure (PEEP)
The process of phagocytosis involves
Digestion of microbes by WBCs
An 18-year-old college student has been feeling extremely tired and makes an appointment at the university's health office. Which laboratory test would the nurse expect to have a lower than normal result if the cause of the client's fatigue is related to iron-deficiency anemia?
Hemoglobin (Hb) level
A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation?
Measles
The intensive care unit nurse is caring for a client with a transmissible spongiform encephalopathy. The nurse knows that this type of encephalopathy is caused by what type of infectious agent?
Prion
A nurse is completing a nutritional status of a client who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.
Serum albumin level Weight history Body mass index Blood urea nitrogen (BUN) level
A new nursing graduate is working at the hospital in the medical-surgical unit. The preceptor observes the nurse emptying a patient's wound drain without gloves on. What important information should the preceptor share with the new graduate about standard precautions?
Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens.
A patient with a recent diagnosis of HIV infection has expressed to the nurse that he is motivated to learn as much about his disease as possible. The patient has heard and read about the role of the different T cells, but is unclear of their roles in the immune response. Which of the following roles of T cells should the nurse identify? Select all that apply.
Stimulating the immune system Secreting cytokines Directly attacking antigens Activating other T cells
A client is admitted to the acute care unit with an infected leg wound. Which of the following is the part of the natural immune system that failed to protect the client against infection?
intact skin
It is important for a nurse to refer an HIV-positive client to support groups and resources because:
support groups and resources provide information about new HIV drug development and clinical drug trials to clients.
A patient, age 67 years, is admitted for diagnostic studies to rule out cancer. The patient is Caucasian, married, has been employed as a landscaper for 40 years, and has a 36-year history of smoking a pack of cigarettes daily. What significant risk factors does the nurse recognize this patient has? (Select all that apply.)
Age Cigarette smoking Occupation
The nurse is educating a patient with allergic rhinitis about how the condition is induced. What should the nurse include in the education on this topic?
Airborne pollens or molds
The family of a client, stung by a bee, rushed the client to the emergency room. The client is experiencing hives and redness at the site. Upon arrival, the client states, "I feel a lump in my throat and I am sweating. I can't breathe. I think I am going to die!" The nurse anticipates which emergency treatment next?
Administer an injection of epinephrine IV stat
The nurse is working on a gerontology unit. A family member calls and tells the nurse they want to bring the family in to see one of the clients on the unit. The family member is concerned because several of the family members have colds. What instructions should the nurse provide to someone with a respiratory infection?
Avoid visiting older adults
A high school student is brought to the doctor's office by her mother because the teen-ager is listless and tired all the time. A diagnosis is made of infectious mononucleosis. When the student asks the nurse to explain how the disease was acquired, the nurse correctly responds that the virus causing this disease is transmitted by which route?
Direct contact with an infected person or drinking glasses used by that person
The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a client's room. The nurse asks the client when he produced the sputum specimen and he states that the specimen is about 4 hours old. What action should the nurse take?
Discard the specimen and assist the client in obtaining another specimen.
A 22-year-old college student recently returned from a backpacking trip to Southeast Asia and has been experiencing increasing malaise over the past 2 weeks. Today, he is seeking care because he reports that he coughed up blood during a particularly heavy coughing fit this morning. The nurse would document the presence of:
Hemoptysis
An adult client has tested positive for tuberculosis (TB). While providing client teaching, what information should the nurse prioritize?
The importance of adhering closely to the prescribed medication regimen
A family member of a client in a long-term care facility asks the nurse why he cannot insert a catheter so the client will not develop skin breakdown from being wet. What should the explanation include when the nurse responds to the family member?
The invasive nature of the catheter provides a portal for infection.