proctored Exam1

A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority?

1) Altered level of consciousness

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia?

1) Blurry vision 2) Tachycardia 3) Sweating

A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine the fluid losses?

1) Body weight

A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe?

1) Buffalo hump 2) Purple striations 3) Moon face

A nurse is reinforcing discharge teaching with a client about how to care for a newly created meal conduit. Which of the following instructions should the nurse include in the teaching?

1) Change the ostomy pouch daily

A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?

1) Cover the client's wound with a moist, sterile dressing.

A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication?

1) Decreased tremors

A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching?

1) Decreasing anxiety 2) Controlling emesis 3) Reducing the amount of narcotic needed for pain relief

A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect?

1) Edema 2) Erythema 3) Tophi 4) Tight skin

A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take?

1) Encourage fluid intake 2) Monitor the puncture site for hematoma

A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first?

1) Feel for a carotid pulse

A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of the following manifestations should the nurse monitor?

1) Hypotension

A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication?

1) Iron

A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3 way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first?

1) Notify the provider 2) Determine the patency of the tubing

A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?

1) Stop the transfusion

A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?

1) Take this medication between meals

A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse of the provider?

1) Thick, red-colored urine

A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend?

1) Wash daily with an antibacterial soap

A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication the client needs further teaching?

1) Will keep my house at a cool temperature

A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates and understanding of the teaching?

1) Will need to take this medication for the rest of my life

A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?

A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?

A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following?

A sensory warning that a seizure is imminent

A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax?

Absence of breath sounds

A nurse is caring for an older adult client who has dysphagia and left sided weakness following a stroke. Which of the following actions should the nurse take?

Add thickener to fluids

A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching?

Administer an opioid analgesic to the client 30 min prior to initiating CPM exercise.

A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client?

Airway obstruction

A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk to the client?

Airway obstruction

A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease?

An expanding circular rash

A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take?

Attempt to determine what the client was looking for

A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the clients postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first?

Auscultate the client's abdomen

A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching?

Avoid bending at the waist

A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching?

Avoid medications in capsule or enteric form

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?

Breathe in through her nose and out through pursed lips

A nurse is collecting data from a client who has Cushing's syndrome. Which of the following manifestations should the nurse expect?

Bruising

A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make?

Bypass surgery must be very frightening for you

A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take?

Calmly ask the client if he would like to listen to some music

A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the nurse notes a white creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions?

Candidiasis

A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?

Change the nasal drip pad as needed

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? .

Check the client's vital signs.

A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take?

Check the pedal pulse every 15 min

A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities?

Checking pupillary responses to light

A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client?

Chest x-ray

A nurse is the contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastectomy with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm?

Combing her hair

A nurse is collecting data from a client who has a possible cataract. Which of the following manifestation should the nurse expect the client to report?

Decreased color perception

A nurse is caring for a new client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect?

Denial

Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause?

Do you sleep well at night?

A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take?

Don clean gloves to remove the dressing

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

Drop in systolic BP more than 10 mmHG on inspiration

A nurse is caring for a client who is postoperative open reduction and internal fixation with the placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take?

Empty the suction device every 4 hr

A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?

Encourage the client to drink 8 glasses of water a day.

A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take?

Encourage the client to drink a carbonated beverage 1 hr before meals.

A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take?

Ensure the client's weights are hanging freely from the bed

A nurse is caring for a client who is experiencing an acute of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?

Evaluate fluid and electrolyte levels

A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds?

Expiratory wheeze

A nurse is collecting data from client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease?

Feel so much better after eating

A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a prescription for lorazepam preoperatively. Which of the following statements by the client should indicate to the nurse that the medication has been effective?

Feel very sleepy

A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

Fever

A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching?

Forgetfulness gradually progressing to disorientation

A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report?

Frequent mood changes

A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching?

Fresh berries

A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200fimm3 . Which of the following food items brought by the family should the nurse prohibit from being given to the client?

Fresh fruit basket

A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take?

Fully recollapse the reservoir after emptying it

A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The burse should recognize this as a manifestation of which of the following?

Granulation tissue

A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?

Hardened skin

A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take?

Help the client write down questions to ask his provider

A nurse is assisting with teaching a client who has a history of smoking about recognizing early manifestation of laryngeal cancer. The nurse should instruct the client to monitor and report which of the following manifestations of laryngeal cancer?

Hoarseness

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. the nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Hypertension

A nurse is assisting in the care of a client who has diabetes insipidus.The nurse should monitor the client for which of the following manifestations?

Hypotension

A nurse is caring for a client who is receiving a unit of packed RBC's. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations?

Hypotension

A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to the provider?

Increase in serum creatinine

A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period?

Ineffective airway clearance related to thick copious secretions.

A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take?

Irrigate the catheter as prescribed

A nurse is caring for a client who has hemiplegia following a stroke. The clients adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make?

It must be hard to see your mother so ill and upset

A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?

Large incisions will be made in the burned tissue to improve circulation

A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Lethargy

A nurse is contributing to the plan of care for an older adult who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan?

Maintain abduction of the right hip

A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan?

Monitor client's cardinal fields of vision

A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?

Monitor intake and output hourly

A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?

Monitor platelet levels

A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider?

Need something for the horrible pain in my eye

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Obtain a pair of slipper socks for the client.

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Peripheral edema

A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and close-suction drains in place. Which of the following interventions should the nurse include in the plan?

Place the client in a high Fowler's position

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

Postictal phase

A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?

Potassium 2.5 mEq/L

A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action?

Prevent aspiration

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

Prevent bladder distention

A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility.

Propel a wheelchair equipped with knobs on the wheels

A nurse is caring for a client who is postoperative following a tracheostomy and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

Provide humidified oxygen.

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

Purulent

A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan?

Re-establish communication

A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects?

Reducing anxiety

A nurse in a provider's office is collecting data for a 45 year old client who is having manifestations associated with perimenopause. Which of the following findings should the nurse expect?

Report of dryness with vaginal intercourse

A nurse is reviewing the laboratory results if a client who is postoperative and has a respiratory rate of 7fimin. The arterial blood gas (ABG) values include: Ph 7.22 PaCO2 6 ffmmHG Base excess -2 paO2 7ff mmhg Oxygen saturation ff0% Bicarbonate 2ff mEqfiL Which of the following interpretations of the BAG values should the nurse make?

Respiratory acidosis

A nurse is caring for a patient who has myasthenia gravis (MG). Which of the following is a complication of MG for which the nurse should monitor?

Respiratory difficulty

A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the following interventions should the nurse identify as the priority?

Scheduled the pain medication on a routine basis

A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following laboratory values should the nurse review to determine the client's renal function?

Serum creatinine

(103.5 F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket?

Shivering

A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching?

Should call the clinic before taking any over -the -counter medications

A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?

Sitting, leaning forward over the bedside table

A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer?

Sun exposure

A nurse is reinforcing teaching to a client who is scheduled for an intravenous yelogram. Which of the following should the nurse include in the teaching?

Take a laxative the evening before the procedure

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home . Which of the following instructions should the nurse include in the teaching

Take temperature once a day

A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching?

Take the medication 45 min before eating

A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take?

Tell the client to remain in the bathroom after toileting and obtain a wheelchair

A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?

Test the drainage for glucose.

A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make?

The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible

A nurse reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make?

The pain will dissipate if you ambulate frequently

A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse?

The wound has a halo of erythema on the surrounding skin

A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching?

This test will measure the intraocular pressure of the eye

A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times?

Three to seven days after menses stops

A nurse is caring for a client who asks why she is being prescribed aspiring 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?

To prevent blood clotting

A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client?

Took my metformin before breakfast

A nurse is caring for a client who has second and third degree burns and a prescription for a high calorie, high protein diet. Which of the following menu choices should the nurse recommend?

Turkey and cheese sandwich with scalloped potatoes

A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus?

Urine output 650 mL/hr

A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

Verify that the suction regulator is on

A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia?

Vitamin B12

A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching?

Will abstain from sexual intercourse

A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective?

Will take a stool softener until my eye is healed

A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking ferrous sulfate twice a day. Which of the following statements by the client indicate and understanding of the teaching?

Will take the medication with orange juice

A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

Will wear stockings with elastic tops

A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?

You may feel some cramping during the procedure

A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching?

You should wear glasses instead of contacts while taking this medication

A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching?

You will remain NPO for 8 hours before the procedure

A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider?

abdomen is distended

A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report?

abnormal vaginal bleeding

A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect?

hyperventilation

A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

interventions should the nurse include in the plan of care? 1) Maintain the client in Fowler's position

A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?

loss of peripheral vision

A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

will not exercise if my urine is positive for ketones

A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching?

will take a tub bath instead of a shower

A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (select all that apply)

✔Dyspnea ✔Barrel chest ✔Clubbing of the fingers ✔Shallow respirations