psych4
What glomerular filtration rate (GFR) would the nurse estimate for a 30-year-old patient with a creatinine clearance result of 60 mL/min?: 80 ml/min 60 mL/min 90 mL/min 120 mL/min
60 mL/min
A geriatric nurse is performing an assessment of body systems on an 85-year-old client. The nurse should be aware of what age-related change affecting the renal or urinary system?: Urinary incontinence Increased bladder capacity Decreased glomerular filtration rate Increased ability to concentrate urine
Decreased glomerular filtration rate
The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient about Visual problems caused by ptosis. Weakness on the affected side of the face. Poor appetite caused by loss of taste. Triggers leading to facial discomfort.
Triggers leading to facial discomfort.
A 48-yr-old male patient who weighs 242 lb (110 kg) undergoes a nephrectomy for massive kidney trauma from a motor vehicle crash. Which postoperative assessment finding is most important to communicate to the surgeon? Blood pressure is 102/58. Urine output is 20 mL/hr for 2 hours. Incisional pain level is reported as 9/10. Crackles are heard at bilateral lung bases.
Urine output is 20 mL/hr for 2 hours.
A client is scheduled to have a fundoplication. What statement by the client indicates a need to review preoperative teaching? "I will take stool softeners for several weeks." "I will still take my PPI after this surgery." "After the operation I can eat anything I want." "I will have to eat smaller, more frequent meals."
"After the operation I can eat anything I want."
A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this client's teaching? (Select all that apply.): "Increase carbohydrate intake for energy." "Avoid drinking fluids just before and during meals." "Eat high-fiber foods to promote gastric emptying." "Rest before meals if you have dyspnea." "Have about six small meals a day."
"Avoid drinking fluids just before and during meals." "Rest before meals if you have dyspnea." "Have about six small meals a day."
A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this client's teaching? "If you miss a dose of this drug, notifiy your health care provider immediately." "Change positions slowly when you get out of bed." "Discontinue the medication if you develop a urinary infection." "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)."
"Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)."
The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient? "You may be able to prevent Bell's palsy by doing facial exercises regularly." "Call the doctor if you experience pain or develop herpes lesions near the ear." "Medications to treat Bell's palsy work only if started before paralysis onset." "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy."
"Call the doctor if you experience pain or develop herpes lesions near the ear."
A client presents at the ambulatory clinic reporting recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the client may have an ulcer. How should the nurse explain the formation and role of acid in the stomach to the client?: "Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food." "The body requires an acidic environment in order to synthesize pancreatic digestive enzymes; the stomach provides this environment." "As digestion occurs in the stomach, the stomach combines free hydrogen ions from the food to form acid." "The acidic environment in the stomach exists to buffer the highly alkaline environment in the esophagus."
"Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food."
A nurse has taught a patient about dietary changes that can reduce the chances of developing cancer. What statement by the patient indicates the nurse needs to provide additional teaching? "Vegetables, fruit, and high-fiber grains are important." "I'm so glad I don't have to give up my juicy steaks." "I'll have to cut down on the amount of bacon I eat." "Foods high in vitamin A and vitamin C are important."
"I'm so glad I don't have to give up my juicy steaks."
The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use? "I use my long acting inhaler 2 times a day, like my health care provider ordered." "I've been taking Tylenol 650 mg every 6 hours for chest wall pain." "I know if I lose weight, I will not have to use my rescue inhaler as often." "I've been using my albuterol inhaler more frequently over the last 4 days."
"I've been using my albuterol inhaler more frequently over the last 4 days."
A patient in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate? "It is normal to be fatigued even for years afterward." "Are you getting adequate rest and sleep each day?" "This is not normal and I'll let the provider know." "Try adding more vitamins B and C to your diet."
"It is normal to be fatigued even for years afterward."
After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? "The lower abdomen is the best location because it is closest to the pancreas." "Changing injection sites from the thigh to the arm will change absorption rates." "I can reach my thigh the best, so I will use the different areas of my thighs." "By rotating the sites in one area, my chance of having a reaction is decreased."
"The lower abdomen is the best location because it is closest to the pancreas."
A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this client's teaching? (Select all that apply.) "Wash your feet every other day." "Treat any blisters or sores with Epsom salts." "Soak your feet in a tub each evening." "Do not walk around barefoot." "Trim toenails straight across with a nail clipper."
"Wash your feet every other day." "Do not walk around barefoot." "Trim toenails straight across with a nail clipper."
The nurse is caring for a client who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output?: A pulse oximetry reading of 94% A heart rate of 54 bpm An increase in preload related to ambulation A change in position from standing to sitting
A heart rate of 54 bpm
The ED nurse is assessing a client complaining of dyspnea. The nurse auscultates the client's chest and hears wheezing throughout the lung fields. What might this indicate about the client? Hemothorax The need for physiotherapy A narrowed airway Pneumonia
A narrowed airway
During the assessment of a young adult patient with infective endocarditis (IE), the nurse would expect to find A pruritic rash on the chest. A new regurgitant murmur. New onset bradycardia. Substernal chest pressure.
A new regurgitant murmur.
The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? A patient manifesting jugular venous distention and dependent peripheral edema while sitting up. A patient with a respiratory rate of 38 breaths/min A patient with loud expiratory wheezes Oxygen saturation of 88% on room air.
A patient with a respiratory rate of 38 breaths/min
A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy? Respiratory alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis
Respiratory alkalosis
Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? Respiratory effort Level of consciousness Decreased ROM Energy level
Respiratory effort
The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the client is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the client's blood? A complete blood count (CBC) An arterial blood gas (ABG) study capillary blood samples Pulse Oximetry
An arterial blood gas (ABG) study
A diabetes nurse is assessing a client's knowledge of self-care skills. What would be the most appropriate way for the educator to assess the client's knowledge of nutritional therapy in diabetes? Ask the client to keep a food diary and review it with the nurse. Reviewing the client's actual food intake is the most accurate method of gauging the client's diet. Ask the client to describe a typical day's food intake. Have the client describe an optimally healthy meal.
Ask the client to keep a food diary and review it with the nurse.
The nurse notices a circular lesion with a red border and clear center on the arm of a summer camp counselor who is in the clinic complaining of chills and muscle aches. Which action should the nurse take to follow up on that finding? Auscultate the heart sounds. Ask the patient about recent outdoor activities. Check the patient's TDap immunization for recency. Palpate the lesion for induration.
Ask the patient about recent outdoor activities.
A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? Teach the patient about injections for the nodules. Draw blood for rheumatoid factor analysis. Demonstrate massage techniques Assess the nodules for skin breakdown or infection.
Assess the nodules for skin breakdown or infection.
A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client's blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take? Assess the rate and quality of the client's pulse. Measure the specific gravity of the client's urine. Administer intravenous pain medications. Position the client to lay on the surgical incision.
Assess the rate and quality of the client's pulse.
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? Pain medication for chest discomfort Ciprofloxacin (Cipro) 400 mg IV Chest x-ray via stretcher Blood cultures from two sites
Blood cultures from two sites
Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? Cloudy and foul-smelling urine Temperature 100.1° F Complaint of flank pain Blood pressure 90/48 mm Hg
Blood pressure 90/48 mm Hg
A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority? Placing the client on bedrest Delegating taking a set of vital signs Calling the Rapid Response Team Instituting bleeding precautions
Calling the Rapid Response Team
A nurse is preparing to administer pantoprazole (Protonix) intravenously. What actions by the nurse are most appropriate? (Select all that apply.): Take vital signs frequently during infusion. Can be infused with Peripheral IV line Infuse pantoprazole using an IV pump. Administer drug via piggybag with dextrose. Administer the drug through a separate IV line.
Can be infused with Peripheral IV line Infuse pantoprazole using an IV pump. Administer the drug through a separate IV line.
Which action should the nurse in the emergency department take first for a new patient who is vomiting blood? Insert a large-gauge IV catheter. Inquire if the patient is taking anticoagulation medication at home. Check blood pressure and heart rate. Prepare to deliver emergent uncrossmatched PRBCs.
Check blood pressure and heart rate.
The health care provider suspects the Somogyi effect in a 50-yr-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take? Check the blood glucose during the night Limit simple carbohydrates in your diet. Increase the long-acting insulin dose. Start taking your blood glucose before each meal and use a sliding scale to maintain glucose control.
Check the blood glucose during the night
A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? Check the vital signs. Elevate the foot of the bed. Give the PRN pain medication. Irrigate the NG tube.
Check the vital signs.
Which patient choice for a snack 2 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? Peanut butter and jelly sandwich Decaffeinated Peppermint Tea Cherry gelatin with fruit Glass of low-fat milk
Cherry gelatin with fruit
The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? Erythrocyte Sedimentation Rate: 22 mm/hr Platelet count: 210,000/mm3 Creatinine level : 3.2 mg/dL White blood cell count: 4800/mm3
Creatinine level : 3.2 mg/dL
A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) Monitor calorie count when meal is complete Cutting foods up into small bites Screen patient for aspiration while feeding the patient Thickening liquids prior to drinking
Cutting foods up into small bites Thickening liquids prior to drinking
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? Add a small amount of normal saline to moisten the specimen. Refrigerate the sputum specimen and submit it once it is chilled. Discard the specimen and assist the client in obtaining another specimen. Immediately take the sputum specimen to the laboratory.
Discard the specimen and assist the client in obtaining another specimen.
A patient hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL (61 mmol/L). What medication does the nurse prepare to administer? Epoetin alfa (Epogen) Oprelvekin (Neumega) Mesna (Mesnex) Filgrastim (Neupogen)
Epoetin alfa (Epogen)
A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.) Assess hematocrit and hemoglobin levels Evaluate the client's renal function. Ensure that an informed consent is present. Auscultate bilateral breath sounds Ask the client about any allergies.
Evaluate the client's renal function. Ensure that an informed consent is present. Ask the client about any allergies.
A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? Assess tactile sensation in the client's hands. Examine the client's feet for signs of injury. Notify the health care provider. Clip the client's toe nails.
Examine the client's feet for signs of injury.
A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? Whirlpool baths Hot or cold packs Anti-inflammatory medications Analgesics
Hot or cold packs
A nurse has auscultated a client's abdomen and noted one or two bowel sounds in a 2-minute period of time. How should the nurse document the client's bowel sounds? Hypoactive Normal Paralytic ileus Hyperactive
Hypoactive
When obtaining a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS), the nurse should: Inspect the skin for rashes or discoloration. Assess for the presence of chest pain. Inquire about urinary tract problems. Ask the patient about any increase in energy before bed.
Inquire about urinary tract problems.
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding? Decreased venous O2 pressure Cheyne-Stokes respirations HbA1c at 8% Kussmaul respirations
Kussmaul respirations
Which patient at the cardiovascular clinic requires the most immediate action by the nurse?: Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL Patient with stable angina whose chest pain has recently increased in frequency Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg
Patient with stable angina whose chest pain has recently increased in frequency
A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best? Prepare to administer folic acid. Prepare to administer cobalamin (vitamin B12). Perform a Hemoccult test on the client's stools. Encourage high-protein foods.
Perform a Hemoccult test on the client's stools.
When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n): QRS interval of 0.14 second. QT interval of 0.38 second. PR interval of 0.18 second. isoelectric ST segment.
QRS interval of 0.14 second.
A 56-yr-old female patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect? Decreased blood pressure Elevated urine ketones Increased urine output Recent weight gain
Recent weight gain
A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to: Send a glass of milk or orange juice to the patient in the diagnostic testing area. Take the lunch tray to the patient in the diagnostic testing area. Ask that diagnostic testing area staff to start a 5% dextrose IV. Request that if testing is further delayed, the patient be returned to the unit to eat.
Request that if testing is further delayed, the patient be returned to the unit to eat.
A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril for the management of heart failure. Which finding by the home health nurse is a priority to communicate to the health care provider? Serum BNP of 150 pg/mL Serum potassium level 3.0 mEq/L after 1 week of therapy Presence of 1+ to 2+ edema in the feet and ankles Palpable liver edge 2 cm below the ribs on the right side
Serum potassium level 3.0 mEq/L after 1 week of therapy
A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find?: Abdominal pain that increases with knee flexion Severe, steady right lower quadrant pain Marked hyperactive bowel sounds Abdominal pain associated with nausea and vomiting
Severe, steady right lower quadrant pain
The nurse is caring for a client who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following? Sputum production Throat discomfort Epistaxis Shortness of breath
Shortness of breath
A nurse works with patients who have alopecia from chemotherapy. What action by the nurse takes priority? Referring patients to a reputable wig shop Reassuring patients that this change is temporary Teaching measures to prevent scalp injury Helping patients adjust to their appearance
Teaching measures to prevent scalp injury
The nurse analyzes the laboratory results of a patient. Which finding would require immediate action? The serum sodium of 135 mEq/L . The serum calcium level is 8 mg/dL. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg. The bicarbonate level (HCO3-) is 31 mEq/L.
The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? The patient cleans the catheter while taking a bath each day. The patient plans 30 to 60 minutes for a dialysate exchange. The patient changes the catheter dressing daily. The nurse overhears the patient scheduling a vacation out of town with family member.
The patient cleans the catheter while taking a bath each day.
The nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? The patient puffs up the cheeks while exhaling. The patient's ratio of inhalation to exhalation is 1:3 The patient states, "this method will help me control my shortness of breath." The patient inhales slowly through the nose.
The patient puffs up the cheeks while exhaling.
Which information helps the nurse confirm the previous diagnosis of chronic stable angina? The patient states, "the pain wakes me up at night." Increase in troponin level. Q-wave development on recent EKG. The patient reports, "The pain goes away after a nitroglycerin tablet."
The patient reports, "The pain goes away after a nitroglycerin tablet."
The nurse working on the heart failure unit knows that teaching an older patient with newly diagnosed heart failure is effective when the patient states that: The patient will call the clinic if her weight goes up 3 pounds in 1 week. The nitroglycerin patch is to be used when chest pain develops. An additional pillow can help her sleep if they are short of breath at night. The patient will intake 2-3 liters of fluids everyday to maintain proper hydration .
The patient will call the clinic if her weight goes up 3 pounds in 1 week.
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162,R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient's cardiac rhythm as: Sinus tachycardia with frequent PVCs. Ventricular fibrillation. Atrial flutter. Ventricular tachycardia.
Ventricular tachycardia.
The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjögren's syndrome? Abdominal assessment Renal function studies Oxygen saturation Visual acuity
Visual acuity
An admission nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? Atropine (Sal-Tropine) Sotalol (Betapace) Heparin infusions Warfarin (Coumadin)
Warfarin (Coumadin)
The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with: antibiotics. anticoagulants. diuretics. antihypertensives.
anticoagulants.
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse? pH 7.29, PaCO2 30 mm Hg, and PaO2 65 mm Hg pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? Sinus tachycardia Speech alterations Dyspnea with activity Bleeding gums
speech alterations
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance angiography. Which priority question should the nurse ask before the test? "Are you taking any cardiac medications?" "Have you had a recent blood transfusion?" "Do you have allergies to iodine or shellfish?" "When was your last caffeine intake?"
"Do you have allergies to iodine or shellfish?"
A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client's teaching? "Drink plenty of fluids to prevent dehydration." "Drink any flavor of Gatorade to supplement fluid loss." "Increase your protein intake by drinking more milk." "You should drink approximately 1 liter of fluids daily."
"Drink plenty of fluids to prevent dehydration."
A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states: "I could choose nasal spray rather than injections of vitamin B12." "I need to start eating more red meat and liver." "I will need to take folic acid supplement." "I will stop having a glass of wine with dinner."
"I could choose nasal spray rather than injections of vitamin B12."
After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition? "A decrease of intake of potassium is necessary." "I must decrease my intake of fat." "A decreased intake of carbohydrates will be required." "I will increase my intake of protein."
"I will increase my intake of protein."
After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition? "A decreased intake of carbohydrates will be required." "I will increase my intake of protein." "An increased intake of vitamin C is necessary." "I must decrease my intake of fat."
"I will increase my intake of protein."
A nurse cares for a client with colon cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How should the nurse respond?: "I have a good friend with a colostomy who would be willing to talk with you." "The enterostomal therapist will be able to answer all of your questions." "We will ask for a referral to talk to a specialist next time we see your doctor." "I will make a referral to the United Ostomy Associations of America."
"I will make a referral to the United Ostomy Associations of America."
After teaching a client who is prescribed a long-acting beta2 agonist medication for Asthma , a nurse assesses the client's understanding. Which statement indicates the client comprehends the teaching? "I will take this medication when I start to experience an asthma attack." "I will take this medication every morning to help prevent an acute attack." "I will be weaned off this medication when I no longer need it." "If I use my inhaler as ordered, it will will cure my asthma."
"I will take this medication every morning to help prevent an acute attack."
A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? "MS symptoms may worsen in the last trimester of pregnancy." "MS symptoms may be worse after the pregnancy." "Symptoms of MS are likely to become worse during pregnancy." "Women with MS are more likely to twins or triplets."
"MS symptoms may be worse after the pregnancy."
A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? "Benign tumors require their own blood supply to grow" "Malignant tumors may spread to other tissues or organs." "Benign tumors do not cause damage to other tissues." "Malignant cells reproduce more rapidly than normal cells."
"Malignant tumors may spread to other tissues or organs."
A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP). Which statements should the nurse include when delegating this client's care? (Select all that apply.) "Schedule additional time for teaching about prescribed therapies." "Plan to bathe the client in the evening when the client is most alert." "Remind the client to look at foot placement when walking." "Encourage the client to use a cane when ambulating." "Assess the client for symptoms related to pain and discomfort."
"Plan to bathe the client in the evening when the client is most alert." "Remind the client to look at foot placement when walking." "Encourage the client to use a cane when ambulating."
A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction. Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? "Do you have any allergies?" "What time did your chest pain begin?" "Do you take phosphodiesterase inhibitors?" "Do you take aspirin on a daily basis?"
"What time did your chest pain begin?"
A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test? "You need to fast for 8 hours prior to the test." "There will be a lot of noise during the test.""No metal objects can enter the procedure room." "You will need to lie still throughout the procedure."
"You will need to lie still throughout the procedure."
A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL?" How should the nurse respond? "Glucose in the blood prevents the formation of lactic acid and prevents acidosis." "If your blood sugar isn't high enough you will get sick." "Glucose is the only fuel used by the body to produce the energy that it needs." "Your brain needs a constant supply of glucose because it cannot store it."
"Your brain needs a constant supply of glucose because it cannot store it."
A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse anticipate the highest risk for hypoglycemia? 4:00 PM 10:00 AM 2:00 PM 12:00 PM
10:00 AM
A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How should the nurse document this client's assessment using the Glasgow Coma Scale shown below? 8 12 14 10
12
A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? Administer 25 mL dextrose 50% (D50) IV push. Insert a new intravenous access line. Encourage the client to drink orange juice. Administer 1 mg of intramuscular glucago
Administer 1 mg of intramuscular glucagon.
The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform? Administer the platelets as rapidly as the client can tolerate Establish IV access as soon as the platelets arrive from the blood bank Ensure that the client has a patent central venous catheter Aspirate 10 to 15 mL of blood from the client's IV immediately following the transfusion
Administer the platelets as rapidly as the client can tolerate
A client is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis. The nurse knows that which procedure will be involved? Angiography Arthrocentesis Paracentesis Myelography
Arthrocentesis
A nurse is admitting a client with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply. Aspirin-based drugs Penicillins NSAIDs Antihypertensives Sulfa-containing medications
Aspirin-based drugs NSAIDs Sulfa-containing medications
A nurse cares for a client who manifests Ventricular Tachycardia on a cardiac monitor. Which action should the nurse take first? Cardiovert the client with a biphasic defibrillator. Assess airway, breathing, and level of consciousness. Administer an amiodarone bolus followed by a drip. Begin cardiopulmonary resuscitation (CPR).
Assess airway, breathing, and level of consciousness.
A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take? Document the finding in the client's record. Report the tube as working in the hand-off report. Clamp the tube in preparation for removing it. Assess the client's abdomen and vital signs.
Assess the client's abdomen and vital signs.
A patient is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? Monitoring the patient for nausea Assessing the IV site every hour Educating the patient on side effects Providing warm packs for comfort
Assessing the IV site every hour
A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom? Auscultate for a pericardial friction rub. Assess for new onset cardiac murmur. Palpate the radial pulses bilaterally. Assess all lung fields for adventitious breath sounds.
Auscultate for a pericardial friction rub.
The nurse caring for oncology patients knows that which form of metastasis is the most common? Via bone marrow Direct invasion Bloodborne Lymphatic spread
Bloodborne
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? Ask the patient to lie down to complete a full physical assessment. Complete the admission database to check for allergies before treatment. Briefly ask specific questions about this episode of respiratory distress. Delay the physical assessment to first complete pulmonary function tests.
Briefly ask specific questions about this episode of respiratory distress.
A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members should the nurse include in this interdisciplinary team meeting? (Select all that apply.) Clinical pharmacist Health care provider Respiratory Therapist Occupational therapist Registered dietitian
Clinical pharmacist Health care provider Registered dietitian
The nurse working with oncology patients understands that which age-related change increases the older patient's susceptibility to infection during chemotherapy? Diminished nutritional stores Decreased immune function Poor physical reserves Existing cognitive deficits
Decreased immune function
A nurse assesses a client with peritonitis related to a GI perforation. Which clinical manifestations should the nurse expect to find? (Select all that apply.) Decreased urine output Inability to pass flatus Bradycardia Hyperactive bowel sounds Distended abdomen
Decreased urine output Inability to pass flatus Distended abdomen
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? Orange-colored sputum Yellow-tinged sclera Blood tinged sputum. Difficulty hearing high-pitched voices
Difficulty hearing high-pitched voices
A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action? Auscultate the client's lungs Position the client in high Fowler's Obtain a blood specimen from the client Discontinue the transfusion
Discontinue the transfusion
A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed? Oxygen saturation of 92% Dyspnea on exertion Generalized weakness Muted systolic murmur
Dyspnea on exertion
A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this client's care? Electrolyte and fluid imbalance Edema and pain Hyperglycemia Cardiac and respiratory status
Electrolyte and fluid imbalance
A nurse cares for a client who has a new colostomy. Which action should the nurse take? Start the patient on bowel training. Reinforce stoma with pressure dressing. Empty the pouch frequently to remove excess gas collection. Teach the patient about the gas difusing bag.
Empty the pouch frequently to remove excess gas collection.
A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take? Encourage chlorhexidine rinse TID. Obtain an oral specimen for culture and sensitivity. Start the client on a broad-spectrum antibiotic. Encourage oral rinsing after fluticasone administration.
Encourage oral rinsing after fluticasone administration.
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient's ventilation? Encourage the patient to sit up at the bedside in a chair and lean forward. Increase the oxygen to 6L and place patient on Non-Rebreather (NRB) Mask. Ask the patient to rest in bed in a high-Fowler's position with pillows behind the head. Call the respiratory rapid response team, for assessment and support.
Encourage the patient to sit up at the bedside in a chair and lean forward.
A 58-yr-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which patient problem is present based on these findings? Disturbed body image Altered nutrition: less than required Excess fluid volume Activity intolerance
Excess fluid volume
A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which nursing intervention is the highest priority? Keep the patient NPO until the gag reflex returns. Ask patient about iodine or shellfish allergy. Place patient on airborne precautions. Give fluid bolus to encourage hydration.
Keep the patient NPO until the gag reflex returns.
A marathon runner comes into the clinic and states "I have not urinated very much in the last few days." The nurse notes a heart rate of 110 beats/min and a blood pressure of 100/58 mm Hg. Which action by the nurse is the priority? Perform an electrocardiogram. Teach the client to drink 2 to 3 liters of water daily. Give the client a bottle of water immediately. Start an intravenous line for fluids.
Give the client a bottle of water immediately.
A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult client who has been experiencing vital fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis? Cardiomyopathy Heart failure Valve dysfunction Pleurisy
Heart failure
After an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse evaluates the patient's response to the activity, which data would indicate that the exercise level should be decreased? Patient complains of fatigue. Respiratory rate goes from 14 to 20 breaths/min. Heart rate increases from 66 to 98 beats/min. O2 saturation drops from 99% to 95%.
Heart rate increases from 66 to 98 beats/min.
A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3- 18 mEq/L. Which manifestation should the nurse identify as an example of the client's compensation mechanism? Increased thirst and hunger Increased urinary output Increased rate and depth of respirations Increased release of acids from the kidneys
Increased rate and depth of respirations
The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly clients with MS are known to be particularly concerned about what variables? Select all that apply. Increasing disability Becoming a burden on the family Possible nursing home placement Loss of appetite Pain associated with physical therapy
Increasing disability Becoming a burden on the family Possible nursing home placement
The nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow? Inspection, percussion, palpation, and auscultation Inspection, palpation, percussion, and auscultation Inspection, palpation, auscultation, and percussion Inspection, auscultation, percussion, and palpation
Inspection, auscultation, percussion, and palpation
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? Abnormal lung sounds in the apices of both lungs Expiratory wheezes in both lungs Pleural friction rub in the right and left lower lobes Inspiratory crackles at the bases
Inspiratory crackles at the bases
The nurse is preparing a patient for thoracentesis. Which information is a priority to communicate to the health care provider? Pain level is 5 (on 0 to 10 scale) with a deep inspiration. Blood pressure is 100/70 mm Hg. The patient reached 450 mm on the incentive spirometer. International Normalized Ratio (INR) result of 3.
International Normalized Ratio (INR) result of 3.
The nurse is caring for a client after kidney surgery. When assessing for bleeding, what assessment parameter should the nurse evaluate? Pain intensity Oral intake Radiation of pain Level of consciousness
LOC
A 21-yr-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient?: Lifelong anticoagulant therapy is needed after mechanical valve replacement. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty. Biologic valves will require immunosuppressive drugs after surgery. Biological valves have more longevity than mechanical valves.
Lifelong anticoagulant therapy is needed after mechanical valve replacement.
A client is undergoing testing to see if he has a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent with this diagnosis? Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
A client with chronic GERD has difficulty swallowing and has been working with a speech-language pathologist. What assessment finding by the nurse indicates that the priority goal for this problem is being met? Lungs clear after meals and snacks Properly performing swallowing exercises Choosing foods that are easy to swallow Patient report a decrease in over the counter proton pump inhibitor use.
Lungs clear after meals and snacks
The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How should the nurse determine the appropriate O2 flow rate? Minimize O2 use to avoid O2 dependency. Avoid administration of O2 at a rate of more than 2 L/min. Administer O2 according to the patient's level of dyspnea. Maintain the pulse oximetry level at 90% or greater.
Maintain the pulse oximetry level at 90% or greater.
The nurse caring for clients with gastrointestinal disorders should understand that which category best describes the mechanism of action of sucralfate (Carafate)? Mucosal barrier fortifier Proton pump inhibitor Histamine receptor blocker Gastric acid inhibitor
Mucosal barrier fortifier
A patient who has been experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first? Document changes in respiratory status. Administer IV methylprednisolone (Solu-Medrol). Encourage the patient to cough and deep breathe. Notify the health care provider.
Notify the health care provider.
A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? Hyperresponsive reflexes Excessive somnolence Heat intolerance Nystagmus
Nystagmus
Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia? Omelet and whole wheat toast Croissant with strawberry cream cheese Cornmeal muffin and orange juice Fruit plate with Greek yogurt
Omelet and whole wheat toast
Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement? Administer ceftriaxone 1 g IV. Give acetaminophen (Tylenol) PRN for fever. Arrange for a transesophageal echocardiogram. Order blood cultures drawn from two sites.
Order blood cultures drawn from two sites
The nurse advises a patient with myasthenia gravis (MG) to: Protect the extremities from injury due to poor sensory perception. Anticipate the need for daily plasmapheresis treatments. Perform physically demanding activities early in the day. Do frequent weight-bearing exercise to prevent muscle atrophy.
Perform physically demanding activities early in the day.
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? Codeine Piperacillin/tazobactam (Zosyn) 2 puffs of their Short acting Beta agonsist (SABA) Acetaminophen (Tylenol)
Piperacillin/tazobactam (Zosyn)
A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse? Ask to have the laboratory redraw the blood specimen. Place the client on a cardiac monitor immediately. Continue to monitor the client's intake and output. Teach the client to limit high-potassium foods.
Place the client on a cardiac monitor immediately.
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? Position the patient sitting up on the side of the bed. Give the patient the scheduled dose of morning medications: Lasix (furosimide), Correg (carvedilol), Warfarin (coumadin), Albuterol (albuterol sulfate) inhaler 2 puffs Obtain a collection device to hold 3 liters of pleural fluid. Remind the patient not to eat or drink anything for 6 hours.
Position the patient sitting up on the side of the bed.
The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence? SA node to AV node to bundle of His to Purkinje fibers SA node to bundle of His to AV node to Purkinje fibers SA node to bundle of His to Purkinje fibers to AV node The normal electrophysiological conduction route is SA node to AV node to bundle of His to Purkinje fibers.
SA node to AV node to bundle of His to Purkinje fibers
A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse's priority action? Slow down the normal saline infusion. Take the client's pulse. Call the respiratory rapid response team for support. Calculate the mean arterial pressure (MAP).
Slow down the normal saline infusion
A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? Start a large-bore IV with normal saline. Administer PRN Morphine Sulfate. Call the Rapid Response Team. Tell the client to remain lying down.
Start a large-bore IV with normal saline.
The nurse is caring for an acutely ill client. What assessment finding should prompt the nurse to inform the physician that the client may be exhibiting signs of acute kidney injury (AKI)? The client's urine is cloudy with a foul odor. The client reports an inability to initiate voiding. The client complains of acute flank pain. The client's average urine output has been 10 mL/hr for several hours.
The client's average urine output has been 10 mL/hr for several hours.
A client has returned to the nursing unit after an open Nissen fundoplication. The client has an indwelling urinary catheter, a nasogastric (NG) tube to low continuous suction, and two IVs. The nurse notes bright red blood in the NG tube. What action should the nurse take first? Notify the surgeon immediately. Assess the drainage for clots. Document the findings in the chart. Take a full set of vital signs.
Take a full set of vital signs.
Which information will the nurse plan to include when teaching a young adult who has a family history of testicular cancer about testicular self-examination? Testicular self-examination should be done at least weekly. Testicular self-examination should be done in a warm room. Schedule annual screening PET scan. The only structure normally felt in the scrotal sac is the testis.
Testicular self-examination should be done in a warm room.
The nurse is assessing a client's bladder by percussion. The nurse elicits dullness after the client has voided. How should the nurse interpret this assessment finding? The client's bladder is not completely empty. The client has a fluid volume deficit. The client has a ureteral obstruction. The client has kidney enlargement.
The client's bladder is not completely empty.
The home health nurse is assessing a client who is immunosuppressed. What is the most essential teaching for this client and the family? How to promote immune function through nutrition How to choose antibiotics based on the client's symptoms The importance of maintaining the client's vaccination status The need to report any slight changes in the client's health status
The need to report any slight changes in the client's health status
Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective? The periorbital and peripheral edema are resolved. The patient denies frequency with voiding The patient denies burning with voiding. The antistreptolysin-O (ASO) titer has decreased.
The periorbital and peripheral edema are resolved.
The nurse observes a student who is listening to a patient's lungs. Which action by the student indicates a good demonstration of respiratory assessment skills? The student instructs the patient to breathe slowly and deeply through the nose. The student listens complete respiratory cycle for each lung field auscultated, then moves the stethoscope. The student asks the patient to hold their breath and bear down for each lung field auscultated. The student asks the patient to pursed lip breath for each lung field auscultated.
The student listens complete respiratory cycle for each lung field auscultated, then moves the stethoscope.
A client with a recent history of intermittent bleeding is undergoing capsule endoscopy to determine the source of the bleeding. When explaining this diagnostic test to the client, what advantage should the nurse describe?: The test allows for painless biopsy collection. The test allows visualization of the entire peritoneal cavity. The test does not require fasting. The test is noninvasive
The test is noninvasive
The nurse is caring for a client admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this client. The nurse should recognize what implication of this assessment finding?: This result indicates muscle injury, but does not specify the source. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. Because the client has a history of unstable angina, this is a poor indicator of myocardial injury. This is an accurate indicator of myocardial injury.
This is an accurate indicator of myocardial injury.
A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.) Tomato sauce Decaffeinated coffee Peppermint Citrus fruits Chocolate
Tomato sauce Peppermint Citrus fruits Chocolate
Which information will the nurse include in the asthma teaching plan for a patient being discharged? Hold your breath for 5 seconds after using the bronchodilator inhaler. Monitor their Peek Expiratory Flow Rate (PEFR) monthly. Tremors are an expected side effect of rapidly acting bronchodilators. Inhale slowly and deeply when using the dry powder inhaler (DPI).
Tremors are an expected side effect of rapidly acting bronchodilators.
The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action? Respiratory rate of 26 breaths/min Pulse oximetry reading of 91% Use of accessory muscles in breathing Peak expiratory flow rate of 240 L/min
Use of accessory muscles in breathing
A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include an RBC count of 4,500,000/mL. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L). Serum potassium level 3.4 mEq/L. a hematocrit (Hct) value of 38%.
a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? Weight gain of 1 kg (2.2 lb) Urine output of 50 mL over 2 hours Heart rate of 106 beats/min O2 saturation of 88%
O2 saturation of 88%
Which prescribed action will the nurse implement first for a patient who has vomited 1100 mL of blood? Draw blood for type and crossmatch. Activate the rapid response team. Insert a nasogastric (NG) tube and connect to suction. Administer 1 L of lactated Ringer's solution.
Administer 1 L of lactated Ringer's solution.
When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is most appropriate for the nurse to include? Monitor labs for PTT levels. Conduct a family meeting in order to discuss a plan of extended hospital stay to complete IV antibiotic course of therapy. Arrange for placement of a long-term IV catheter. Teach the importance of completing all oral antibiotics.
Arrange for placement of a long-term IV catheter.
A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next?: Administer intravenous opioid medications. Insert a nasogastric tube for decompression. Position the client with knees to chest. Assess the client's bowel sounds.
Assess the client's bowel sounds.
The nurse is performing a neurologic assessment of a client whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)? Assess the client's eye opening and response to stimuli Document that the client currently lacks a level of consciousness Facilitate diagnostic testing in an effort to obtain objective data Assess the client's vital signs and correlate these with the client's baselines
Assess the client's eye opening and response to stimuli
A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? Use simple words and phrases to explain procedures. Assist with active range of motion (ROM). Observe for agitation and paranoia. Assess for altered level of consciousness.
Assist with active range of motion (ROM).
When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? Obtain the blood pressure. Auscultate the breath sounds. Assess the peripheral pulses. Attach the heart monitor.
Attach the heart monitor.
The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority? Administer the prescribed pain medication. Notify the health care provider immediately. Place NG tube for decompression. Document a set of vital signs.
Notify the health care provider immediately.
A patient tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? "Avoid getting salt water on the radiation site." "Do not expose the radiation area to direct sunlight." "Remember you should not drink alcohol for a year." "Have a wonderful time and enjoy your vacation!"
"Do not expose the radiation area to direct sunlight."
The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). What statements by the client indicate good understanding of the teaching? (Select all that apply.) "I sure hate to give up my coffee, but I guess I have to." "I just joined a gym, so I hope that helps me lose weight." "Sitting upright and lying down after meals will help." "Surgery can cure my GERD." "I will eat three small meals and three small snacks a day."
"I sure hate to give up my coffee, but I guess I have to." "I just joined a gym, so I hope that helps me lose weight." "Sitting upright and lying down after meals will help." "I will eat three small meals and three small snacks a day."
Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? "I will use a straw when I take my liquid iron." "I should increase my fluid and fiber intake while I am taking iron tablets." "I will call my health care provider if my stools turn black." "I should take the iron with orange juice about an hour before eating."
"I will call my health care provider if my stools turn black."
After teaching a client who is recovering from a colon resection, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) "I will use warm water and a soft washcloth to clean around the stoma." "Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown." "I might start bicycling and swimming again once my incision has healed." "I must change the ostomy appliance daily and as needed." "I must avoid dairy products to reduce gas and odor in the pouch."
"I will use warm water and a soft washcloth to clean around the stoma." "Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown." "I might start bicycling and swimming again once my incision has healed."
A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? "Be sure you get enough sleep at night." "Notify your provider at once if you get a fever." "Weigh yourself every day on the same scale." "Get plenty of sunlight for maximum vitamin D synthesis."
"Notify your provider at once if you get a fever."
A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How should the nurse respond? "You should discuss this with your family and health care provider." "We should wait until your family arrives to discuss such matters." "Why are you afraid of being placed on a breathing machine?" "What would you like to be done if you begin to have difficulty breathing?"
"What would you like to be done if you begin to have difficulty breathing?"
A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond? "Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this." "The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate." "Your small intestine will adapt over time to the absence of your appendix." "Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery."
"Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery."
A 57-year-old man with Escherichia coli food poisoning is admitted to the hospital with bloody diarrhea and dehydration. Which order will the nurse question? Infuse lactated Ringer's solution at 250 mL/hr. Monitor electolytes. Prepare patient for blood transfusion. Administer loperamide (Imodium) after each stool.
Administer loperamide (Imodium) after each stool.
Which medications will the nurse teach the patient about whose peptic ulcer disease is associated with Helicobacter pylori?: Omeprazole (Priolosec), nystatin (Mycostatin), and bismuth (Pepto-Bismol) Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix) Metoclopramide (Reglan), levofloxacin (Levoquin) , and promethazine (Phenergan)
Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec)
The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take: Antacids 30 minutes before each dose of sucralfate is taken. Antacids after meals and sucralfate 30 minutes before meals. A full glass of milk with the medication. Sucralfate at bedtime and antacids with each meal.
Antacids after meals and sucralfate 30 minutes before meals.
A patient with heart failure has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this patient would include information about: Anticoagulant therapy. IV amiodarone (Cordarone). Emergency cardioversion. Permanent pacemakers.
Anticoagulant therapy.
A nurse cares for a client with end stage congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.): The patient is manifesting JVD when sitting upright. Skin is warm to touchbounding pedal pulses Decrease in urine output Decrease in blood pressure Decrease in cardiac output
Decrease in urine output Decrease in blood pressure Decrease in cardiac output
When preparing a female patient with bladder cancer for intravesical chemotherapy, the nurse will teach about: Maintaining oral care during the treatments. Emptying the bladder before the medication. Obtaining wigs and scarves to wear. Premedicating to prevent nausea.
Emptying the bladder before the medication.
After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective? Increase in strength of peripheral pulses Decrease in premature ventricular contractions Decrease in premature atrial contractions Increase in the patient's heart rate
Increase in the patient's heart rate
Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider? An increase in troponin levels from baseline New development of first degree heart block on ECG. No change in the patient's reported level of chest pain A large bruise at the patient's IV insertion site
No change in the patient's reported level of chest pain
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Appropriate instructions for the patient include: Take the digoxin if the pulse is below 60 beats/min. Notify the health care provider if nausea develops. Take the hydrochlorothiazide before bedtime. Limit dietary sources of potassium.
Notify the health care provider if nausea develops.
A client with Guillain--Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? Prepare to assist with intubation Remind the client of the importance of deep breathing and coughing exercises Administer bronchodilators as prescribed Administer supplementary oxygen by nasal cannula
Prepare to assist with intubation
The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the client's plan of care?: Risk for imbalanced fluid balance related to hemodynamic variability Risk for ineffective breathing pattern related to hypotension Risk for falls related to orthostatic hypotension Risk for ineffective role performance related to hypotension
Risk for falls related to orthostatic hypotension
The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication: Reduces gastroesophageal reflux by increasing the rate of gastric emptying. Treats gastroesophageal reflux disease by decreasing stomach acid production. Neutralizes stomach acid and provides relief of symptoms in a few minutes. Protects the lining of the stomach.
Treats gastroesophageal reflux disease by decreasing stomach acid production.
Which statement about carcinogenesis is accurate? Normal hormones and proteins do not promote cancer growth. Tumor cells need to develop their own blood supply. An initiated cell will always become clinical cancer. Cancer becomes a health problem once it is 1 cm in size.
Tumor cells need to develop their own blood supply.
A patient with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the patient's oral chemotherapy medications. What action by the nurse is most appropriate? Crush the medications if the patient cannot swallow them. Wear personal protective equipment when handling the medications. No special precautions are needed for these medications. Give one medication at a time with a full glass of water.
Wear personal protective equipment when handling the medications.
A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important?: Family history of H. pylori infection Willingness to adhere to drug therapy Use of nicotine patches Alcohol intake of 1 to 2 drinks per week
Willingness to adhere to drug therapy
During the administration of the thrombolytic agent to a patient with an acute myocardial infarction, the nurse should stop the drug infusion if the patient experiences: Increase in the troponin level. A increase in PVCs. Bleeding from the gums. A decrease in level of consciousness.
a decrease in level of consciousness.
