RN Concept-Based Assessment Level 2 Online Practice B
The nurse is providing discharge teaching to a client about managing diverticulitis. Which of the following statements should the nurse include in the teaching? -"Use bisacodyl suppositories to stimulate a bowel movement" -"Avoid lifting objects greater than 50 pounds" -"Consume a clear liquid diet until symptoms resolve" -"Take a probiotic 15 minutes after taking a prescribed antibiotic to prevent antibiotic-related diarrhea"
"Consume a clear liquid diet until symptoms resolve" The nurse should recommend the client consume a clear liquid diet until manifestations such as abdominal pain, nausea, and vomiting have resolved. A clear liquid diet is low in fiber and does not stimulate intestinal motility.
A nurse is assessing a client who has acute cholecystitis. Which of the following findings should the nurse expect? Select all that apply A: Fever B: Dyspepsia C: Pain radiating to the left shoulder D: Blood-tinged stools E: Eructation -
Fever, Dyspepsia, Eructation
A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition for a malabsorption disorder. Which of the following findings should the nurse identify as an indication that the client's nutritional status is improving? -Intake of fluid is less than output of urine over the past 2 days -1kg (2.2 lb) weight gain over the past 2 days -Blood glucose 206 mg/dL -Prealbumin 13 mg/dL
1 kg (2.2 lb) weight gain over the past 2 days Total parenteral nutrition is administered to clients who have inflammatory bowel disorders and are unable to tolerate enteral nutrition. A weight gain of 0.5 kg (1.1 lb) daily is an indication that the client is responding to the parenteral nutrition.
A nurse is preparing to mix NPH insulin aspart in a single syringe for a client who has type 2 diabetes mellitus. Identify the sequence the nurse should follow.
1. Inject air into the vial equal to the amount of NPH insulin prescribed 2. Inject air into the vial equal to the amount of insulin aspart prescribed 3. Withdraw the prescribed volume of insulin aspart into the syringe 4. Withdraw the prescribed volume of NPH insulin into the syringe
A nurse is evaluating a client's understanding of dietary teaching to treat hyperlipidemia. Which of the following menu choices by the client indicates an understanding of the teaching? A: A black bean burger on a whole grain bun B: Oatmeal with whole milk C: A baked potato with butter D: A pork sausage patty on a biscuit
A black bean burger on a whole grain bun
A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for developing respiratory acidosis? -fever -abdominal ascites -anxious -nasogastric suctioning
A client who has abdominal ascites The nurse should identify that a client who has abdominal ascites can experience a restriction of chest expansion, which impairs gas exchange and places the client at an increased risk for developing respiratory acidosis.
A nurse is teaching a client who recently lost his partner to a terminal illness. The client asks how his 4-year-old son is expected to react to the death of his partner. Which of the following information should the nurse include in the teaching? -A preschooler has no concept of death -A preschooler is often interested in what happens to the body after death -A preschooler often believes that death is reversible -A preschooler understands that death happens to everyone
A preschooler often believes that death is reversible The nurse should identify that preschoolers tend to have difficulty understanding the reality of death and often believe that it is reversible. Because of magical thinking, the preschooler might think that his thoughts or behavior might have caused the person to die.
A nurse in an emergency department is assessing a client who displays manifestations of a small bowel obstruction. Which of the following findings should the nurse expect? Select all that apply A: Abdominal distention B: Flank pain C: Hypervolemia D: Vomiting E: Hyperactive bowel sounds
Abdominal distention, vomiting, hyperactive bowel sounds
A nurse is assessing a newly admitted client who has an intense fear of heights. Which of the following clinical names for this fear should the nurse document in the client's medical record? A: Agoraphobia B: Xenophobia C: Acrophobia D: Glossophobia
Acrophobia
A nurse is reviewing the laboratory records of a client who has AIDS. Which of the following laboratory results should the nurse review to determine if the client is at risk for malnutrition? A: WBC count B: Albumin level C: CD4 T cell count D: C-reactive protein level
Albumin level
A nurse is caring for a school-age child who was admitted to the emergency department for acute asthma exacerbation. Which of the following actions should the nurse take first? A: Encourage the child to take frequent sips of cool fluids. B: Apply humidified oxygen with a simple mask .C: Start a peripheral access IV. D: Administer an albuterol nebulizer treatment
Apply humidified oxygen with simple mask
A nurse a reviewing the laboratory report of a client who is taking atorvastatin. Which of the following findings should the nurse identify as an indication that the medication is having an adverse effect? A: LDL 100 mg/dL B: Total cholesterol 199 mg/dL C: Aspartate aminotransferase (AST) 45 units/L D: Creatine kinase (CK) 120 units/L
Aspartate aminotransferase (AST) 45 units/L
A nurse is assessing a preschool-age child who has chickenpox. The parent asks the nurse how to treat the child's fever. Which of the following responses should the nurse make? A: "Avoid giving aspirin to your child." B: "Place your child in a cool bath for 20 minutes twice per day." C: "Lower the room temperature to stimulate shivering." D: "Give eight doses of acetaminophen in 24 hours according to the child's weight."
Avoid giving aspirin to your child
A nurse is developing a plan of care for a client who is scheduled to have an induction of labor due to a fetal demise. Which is the following actions should the nurse include? A: Limit the amount of time the client spends with the newborn after birth. B: Discourage the client from having other family members see the newborn. C: Inform the client that an autopsy of the newborn is required by federal law. D: Bathe, diaper, and dress the child before bringing the newborn to the client
Bathe, diaper, and dress the child before bringing the newborn to the client
A nurse in a provider's office is assessing a client who is taking warfarin to treat atrial fibrillation. Which of the following findings should the nurse identify as an adverse effect that should be reported to the provider? A: Black, tarry stools B: Ringing in the ears C: Urinary retention D: Recent hallucinations
Black, tarry stools
A nurse is assessing a client who has hypermagnesemia. Which of the following manifestations should the nurse expect?
Bradycardia
A nurse is providing dietary teaching for a client who has GERD. The nurse should instruct the client to avoid which of the following items? A: Caffeinated coffee B: Shell fish C: Apple juice D: Green beans
Caffeinated coffee
A nurse is assessing a 6-month-old infant who has gastroenteritis with mild dehydration. Which of the following findings should the nurse expect? A: Absence of tears when crying B: Loss of 6% of body weight C: Sunken anterior fontanel D: Capillary refill greater than 2 seconds
Capillary refill greater than 2 seconds
A nurse is assessing a client who has a new diagnosis of hypothyroidism. Which of the following manifestations should the nurse expect? A: Cold intolerance B: Diaphoresis C: Weight loss D: Tachycardia
Cold intolerance
A nurse is providing teaching about home care to the parent of a child who has pediculosis capitis. Which of the following information should the nurse include? A: Soak the child's combs and brushes in hot water for 5 min .B: Rinse the child's hair each day with 236.5 mL (1 cup) of vinegar .C: Seal the child's nonwashable toys in plastic bags for 7 days. D: Comb the child's hair daily with an extra fine-tooth comb.
Comb the child's hair daily with an extra fine-tooth comb
A nurse is assessing a client who is receiving intravenous medications. Which of the following findings should the nurse identify as a manifestation of respiratory acidosis? A: Confusion B: Flushed, moist skin C: Hyperreflexia D: Bounding peripheral pulses
Confusion
A nurse on a pediatric unit is preparing an in-service for coworkers about failure to thrive in infants. Which of the following risk factors should the nurse include? A: Congenital hypothyroidism B: Meconium staining at birth C: Macrosomic at birth D: Congenital heart disease
Congenital heart disease
A nurse is caring for a client who has severe hypothermia. Which of the following actions should the nurse take?
Contact a specialized team to place the client on cardiopulmonary bypass
A nurse is assessing a client for manifestations of left-sided heart failure. Which of the following findings should the nurse expect? -Weight gain -Enlarged liver -Distended abdomen -Cool extremities
Cool extremities The nurse should expect to find cool extremities in the client who has left-sided heart failure due to a decreased cardiac output leading to impaired tissue perfusion.
A nurse is reviewing the laboratory results of a client who is receiving gentamicin for the treatment of an infection related to renal calculi. Which of the following findings should the nurse report immediately to the provider? A: Potassium level 4.2 mEq/L B: WBC count 10,000/mm3 C: Magnesium 2 mEq/L D: Creatinine 2.5 mg/dL -
Creatinine 2.5 mg/dL
A nurse is admitting a client who has peptic ulcer disease and an upper gastrointestinal bleed. Which of the following manifestations should the nurse expect? Select all that apply A: Dark, tarry stools B: Bright red emesis C: Increased heart rat eD: Increased blood pressure E: Bounding peripheral pulses -
Dark tarry stools, bright red emesis, increased heart rate
A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? -Brown discoloration of the lower extremities -Superficial ulcer on the medial aspect of the ankle -Dependent rubor -Telangiectasias
Dependent rubor The nurse should expect redness to the lower extremities, or dependent rubor, when the client's legs are dangling or in a dependent position.
A nurse is reviewing the medical record of a client who has decreased urinary output. Which of the following findings should the nurse identify as a risk factor for the development of pyelonephritis?
Diabetes mellitus
A nurse is caring for a client who has renal calculi and is taking oxybutynin for pain. Which of the following findings should the nurse identify as an adverse effect of this medication? -Increased salivation -Bradycardia -Tinnitus -Distended bladder
Distended bladder The nurse should identify oxybutynin as having anticholinergic effects that can result in urinary retention. The nurse should monitor the client's intake and output and assess for bladder distention.
A nurse is planning discharge teaching for the parent of a newborn. Which of the following information should the nurse include? A: "Cover your newborn with a light blanket while she is sleeping." B: "Do not bathe your newborn immediately after she eats." C: "Place your newborn in a crib with a bumper pad." D: "Wash your newborn's face with a mild soap."
Do not bathe your newborn immediately after she eats
A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make? A: "Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby." B: "Moving the crib near a window in the nursery will provide your baby with necessary fresh air and natural light." : "Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet." D: "Placing your baby on her tummy in the crib will hasten drowsiness and provide a more restful night's sleep."
Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet
A nurse is developing a plan of care for a client who is 1 hr postoperative following open carpal tunnel release to treat a musculoskeletal injury. Which of the following interventions should the nurse include in the plan? A: Elevate the client's arm above the heart. B: Apply heat to the client's surgical site. C: Instruct the client to avoid moving their fingers. D: Monitor the client's ability to complete wrist range-of-motion.
Elevate the client's arm above the heart
A nurse is caring for a client who has developed cellulitis in a lower extremity. Which of the following actions should the nurse take? -Apply warm dary packs initially then apply cool moist packs to the lower extremity -Elevate the extremity 7.6 to 15.2 cm above heart level -Gently massage the affected extremity for 10-15 min every shift -Apply a topical corticosteroid to any open areas on the affected extremity twice per day
Elevate the extremity 7.6 to 15.2 cm above heart level The nurse should elevate the client's affected extremity 7.6 to 15.2 cm (3 to 6 in) above the heart to promote venous return and decrease edema.
A nurse is assessing for adverse medication reactions with a client who reports taking more than the recommended doses of acetaminophen for the management of chronic pain. Which of the following findings should the nurse identify as an adverse effect of acetaminophen? A: Elevated aspartate aminotransferase levels B: Decreased skin turgor C: Elevated WBC count D: Decreased audio acuity
Elevated aspartate aminotransferase levels
A nurse is assessing an infant whose guardian reports, "My baby has been crying nonstop, has a fever, and has been pulling at her ear." Which of the following manifestations should the nurse expect for an infant who might have otitis media ? -Enlarged postauricular lymph nodes -Increased flatulence with constipation -Indicates a desire to such more frequently -Slow bounding heart rate
Enlarged postauricular lymph nodes The nurse should expect an infant who has otitis media to have enlarged postauricular and cervical lymph nodes, fever, pain, rhinorrhea, vomiting, and diarrhea. The fever might be as high as 40° C (104° F).
A nurse is caring for a client who has respiratory acidosis due to opioid oversedation. Which of the following actions should the nurse take first? A: Place the client on mechanical ventilation .B: Apply oxygen using a rebreather oxygen mask. C: Ensure a patent airway using a chin-lift maneuver. D: Administer a reversal agent to the client.
Ensure a patent airway using a chin-lift maneuver
A nurse is caring for a client who has generalized anxiety disorder. Which of the following medications should the nurse plan to administer?
Escitalopram
A nurse is counseling a client who recently lost her partner in a motor-vehicle crash. Which of the following reactions should the nurse identify as part of the second stage of the grieving process? A: Persistent feelings of hopelessness B: Loss of self-esteem C: Chronic physical manifestations D: Feeling anger toward family members
Feeling anger toward family members
A nurse is teaching a client who has a new diagnosis of peripheral neuropathy about foot care. Which of the following statements should the nurse include? A: "Wear open-toe shoes to allow air to circulate around your feet. "B: "Use a heating pad set on low to warm your feet when they feel cold." C: "File your toenails straight across to prevent ingrown toenails." D: "Apply a thin layer of lotion between your toes twice per day."
File your toenails straight across to prevent ingrown toenails
A nurse is monitoring a client who has metabolic acidosis due to salicylate overdose. For which of the following findings should the nurse monitor? -Flushed, dry skin -Seizures -Hyperreflexia -Positive Trousseau's sign
Flushed, dry skin The nurse should monitor a client who has metabolic acidosis for manifestations of warm, flushed, and dry skin due to vasodilation from an increased respiratory rate and the loss of CO2.
A nurse is assessing a client who has generalized anxiety disorder and is experiencing a moderate level of anxiety. Which of the following manifestations should the nurse expect? A: Focuses on the source of the anxiety B: Exhibits an inability to speak C: Experiences auditory hallucinations D: Feels surroundings are unreal
Focuses on the source of anxiety
A nurse is providing teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include? A: "Administer the medication into your child's abdomen." B: "Expect your child to sleep for several hours after receiving the medication." C: "Place your child's unused extra syringes in the refrigerator for storage." D: "Give a second injection if the first fails to reverse your child's symptoms."
Give a second injection if the first fails to reverse your child's symptoms
A nurse is assessing a client for manifestations of GERD. Which of the following findings indicates to the nurse that the client might have GERD? -Decreased salivation -Diarrhea -Tonsillitis -Globus
Globus The client who has manifestations of GERD will have globus, which is a feeling of something being in the back of the throat.
A nurse in a community health clinic is reviewing data from the medical records of four clients. Which of the following communicable diseases requires reporting by the nurse? -Gonorrhea -Herpes genitalis -Human papillomavirus -Bacterial vaginosis
Gonorrhea Gonorrhea is an infectious condition listed on the Nationally Notifiable Infectious Conditions Listing. The nurse should report this communicable disease to the Centers for Disease Control and Prevention.
A nurse is reviewing the laboratory results of an adult male client who has hyperlipidemia and is making lifestyle changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has achieved a therapeutic response? -LDL 168 mg/dL -HDL 50 mg/dL -Total cholesterol 268 mg/dL -Triglycerides 250 mg/dL
HDL 50 mg/dL This finding indicates that the client has achieved a therapeutic response from a lifestyle change because the HDL is within the expected reference range of greater than 45 mg/dL for an adult male client.
A nurse is conducting a visual assessment for a client who is at risk for developing glaucoma. Which of the following findings should the nurse identify as a risk factor for this condition? A: Heredity B: Gender C: Anemia D: Hypoglycemia
Heredity
A nurse is participating in a health fair by providing screenings for osteoporosis. Which of the following should the nurse recognize as a risk factor for the disease? -BMI 26 or above -Excessive sun exposure -Frequent weight-bearing exercise -Hip fracture 6 months ago
Hip fracture 6 months ago The nurse should recognize that a client who has a history of hip fracture, especially after the age of 50, is at greater risk for developing regional osteoporosis.
A nurse is preparing to administer medication to a client who has a history of hypertension. The nurse should identify that which of the following is administered for antihypertensive therapy? A: Ginkgo biloba B: Digoxin C: Hydrochlorothiazide D: Acetaminophen
Hydrochlorothiazide
A nurse is reviewing the medical record of a client who has age-related macular degeneration (AMD). Which of the following findings should the nurse identify as a risk factor for this visual impairment? A: Male sex B: Hypertension C: Chronic obstructive pulmonary disease D: Osteoporosis
Hypertension
A nurse is caring for a client who is experiencing a hyperglycemic-hyperosmolar state related to complications of diabetes mellitus. Which of the following findings should the nurse expect? A: Fruity-scented breath B: Serum glucose 350 mg/dLC: pH 7.32 D: Hypotension
Hypotension
A nurse is assessing a client who has generalized anxiety disorder and has been practicing adaptive use of coping mechanisms. Which of the following responses indicates the client's adaptive use of suppression? A: "I teach my children about healthy eating because my anxiety makes me want to overeat." B: "I started taking kickboxing classes to release the stress I feel from work." C: "I avoid thinking about problems that worry me until I have time to focus on a solution." D: "I let my partner choose the movie for date night since I yelled at him when I was stressed."
I avoid thinking about problems that worry me until I have time to focus on a solution
A nurse is providing teaching for a client following cataract surgery. Which of the following statements indicates to the nurse that the client understands the teaching? A: "I will have my best vision 3 weeks after my surgery." B: "I should report a creamy white discharge from my eye to my doctor." C: "I will avoid getting water in my eyes until the second day after surgery." D: "I should avoid using the vacuum cleaner for several weeks."
I should avoid using the vacuum cleaner for several weeks
A nurse is providing teaching for a client who has peripheral neuropathy of the lower extremities. Which of the following client statements indicates an understanding of the teaching? A: "I should wash my feet with soap before I try to treat my calluses." B: "I should limit wearing the same shoes 2 days in a row." C: "I should use home remedies to treat any blisters or sores on my feet." D: "I should use adhesive tape to secure a dressing on my foot when I have skin breakdown."
I should limit wearing the same shoes 2 days in a row
A nurse is providing teaching about home care with a parent of a child who has scabies. Which of the following statements by the parent indicates an understanding of the teaching? A: "I should apply the cream only to the areas where there is a rash. "B: "I should wash my child's bed linens and clothing in hot water and detergent." C: "I should expect my child's rash to go away within 72 hours after starting treatment." D: "I should leave the cream on my child for 4 hours before washing it off."
I should wash my child's bed linens and clothing in hot water and detergent
A nurse is providing discharge teaching for a client who has a new diagnosis of COPD. Which of the following client statements indicates an understanding of the teaching? A: "I will quickly complete my household errands in the morning before taking a break." B: "I will breathe out slowly through pursed lips if I feel short of breath." C: "I will try to eat three large meals every day." D: "I will not get a flu shot because I might get an infection."
I will breathe out slowly through pursed lips if I feel short of breath
A nurse is teaching about ezetimibe with a client who has hyperlipidemia. Which of the following client statements indicates an understanding of the teaching? -I should avoid this medication with milk -I will return to have my cholesterol levels checked in 2 weeks -I can expect to lose weight while taking this medication -I understand that muscle tenderness is an expected result of this medication
I will return to have my cholesterol levels checked in 2 weeks
A nurse is providing teaching about home care with an adolescent client who has a skin infection caused by MRSA. Which of the following client statements indicates an understanding of the teaching? -I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach -I will wash my clothes in cold water and detergent -I will throw away my razor after using it three times -I will apply imiquimod cream to the lesions before going to bed each night
I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach The client should soak for at least 5 min in a bathtub filled one-fourth full of water with ½ cup of bleach once or twice per week. This will help prevent reoccurrence of the infection.
A nurse is providing teaching to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) skin infection. Which of the following client statements indicates an understanding of the management of antibiotic resistant infections? -I will keep the infected area open to air to help it heal -I can sleep in the same bed as my partner after I have been taking antibiotics for 24 hours -I should sit on upholstered chairs instead of hardback chairs -I will wash all uninfected skin areas with a fresh washcloth
I will wash all uninfected skin areas with a fresh washcloth The nurse should instruct the client to wash the uninfected skin areas with a fresh washcloth to prevent contamination of the unaffected areas of the skin with the MRSA infection.
A nurse is teaching a client who has COPD about preventing pneumonia. Which of the following client statements indicates an understanding of the teaching?" A. I will drink one and a half liters of fluids every day." B: "I will get the pneumonia vaccine yearly." C: "I will spray an aerosol disinfectant in my house every day." D: "I will wash my hands whenever I come home from the grocery store."
I will wash my hands whenever I come home from the grocery store
A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching? A: "I'll wash my feet every day with soap and lukewarm water." B: "I'll apply lotion to my feet daily, especially in between my toes." C: "It's okay for me to go barefoot in the house, but not outside." D: "I'll soak my feet every evening before bedtime."
I'll wash my feet everyday with soap and lukewarm water
A nurse is assessing a school-age child who has asthma and shortness of breath. Which of the following assessment findings should the nurse identify as the priority? A: Inaudible lung sounds B: Persistent cough C: Yellow zone peak flow meter reading D: Prolonged expiration phase
Inaudible lung sounds
A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of the following manifestations should the nurse expect? -Increased urination -Sweating -Dizziness -Loose stools
Increased urination The nurse should expect the client to exhibit manifestations of hyperglycemia, including increased thirst, nausea, vomiting, increased urination, flushed dry skin, acetone breath odor, and a weak, rapid pulse.
A nurse is admitting an infant who has pertussis. Which of the following actions should the nurse take?
Initiate droplet precautions for the infant
A nurse is planning discharge for a postpartum client. The client tells the nurse she is having subdermal implant placed for contraception at her 6 week follow-up examination and asks about the adverse effects of the implant. Which of the following manifestations should the nurse include? -Irregular bleeding -Fatigue -Shoulder pain -Recurrent urinary tract infections (UTIs)
Irregular bleeding The nurse should inform the client that irregular bleeding is possible when using a subdermal implant as a form of contraception. Other possible adverse effects include amenorrhea, heavy bleeding, headaches, nervousness, nausea, skin changes, and vertigo. With this method, a very small rod is placed on the underside of the upper arm, just underneath the skin. The implant is hardly noticeable and compared to oral contraceptives, the failure rate is less than 1%. One of the major advantages with this method is that fertility rapidly returns after its removal.
A nurse is assessing a client for manifestations of right-sided heart failure. Which of the following findings should the nurse expect? -Jugular vein distention -Fatigue -Angina -Hacking cough
Jugular vein distention The nurse should expect to find jugular vein distention (JVD) in the client who has right-sided heart failure due to right ventricular failure and pressure building in the venous system.
A nurse is providing teaching to a client about preventing hearing loss from trauma. Which of the following instructions should the nurse include in the teaching? -Keep your mouth open when sneezing -Block one nostril when blowing your nose -Use an ear wick candle to remove excess cerumen from the canal -Lubricate cotton-tipped applicators with mineral oil to clean the ear canal
Keep your mouth open when sneezing The nurse should instruct the client to keep the mouth open while sneezing to reduce the pressure in the middle ear. Sudden pressure changes can damage the ossicles and perforate the ear drum.
A nurse is reviewing a client's home medication list during admission to a long-term care facility. The nurse should identify that the client takes which of the following medications to manage osteoarthritis? Select all that apply A: Lidocaine 5% patches B: Celecoxib C: Vancomycin D: Cyclobenzaprine E: Glucosamine -
Lidocaine 5% patches, Celecoxib, Cyclobenzaprine, Glucosamine
A nurse is providing teaching to a client who has calcium oxalate renal calculi. Which of the following statements should the nurse include in the teaching? A: "Decrease your calcium intake." B: "You should consume at least 2,400 milligrams of salt per day." C: "Limit the amount of spinach in your diet." D: "Increase your fluid intake to one and a half liters daily."
Limit the amount of spinach in your diet
A nurse is teaching a group of newly licensed nurses about risk factors for peptic ulcers. Which of the following risk factors should the nurse include in the teaching? A: Bacterial infection with Escherichia coli B: Long-term use of NSAIDs C: Frequent use of proton pump inhibitors D: A diet that includes spicy foods
Long-term use of NSAIDs
A nurse is reviewing the medical record of a client who has AIDS and is experiencing anorexia. Which of the following medications should the nurse expect the provider to prescribe to reduce the client's risk of failure to thrive? A: Megestrol B: Ondansetron C: Famotidine D: Pancrelipase
Megestrol
A nurse is planning discharge teaching for the guardian of a child who had a cardiac catheterization. Which of the following instructions should the nurse include? -Monitor the site daily for drainage -Leave the pressure dressing on the 48 hr -Administer aspirin if the child reports pain -Resume tub baths in 24hr
Monitor the site daily for drainage The nurse should instruct the guardian to monitor the site daily for manifestations of infection, such as drainage, redness, and swelling. The guardian should report these findings to the provider.
A nurse is assessing a client who has an external fixator to the right lower arm following musculoskeletal trauma. Which of the following findings should indicate to the nurse that the client has developed compartment syndrome? -Serous drainage is present on the pin site dressings -Flushing of the skin on the right arm -Bounding pulse palpated in the radial artery -Numbness to the fingers on the right arm
Numbness to the fingers on the right arm The nurse should identify a decrease in sensation, such as numbness and tingling of the fingers, as one of the first indications that the client might be developing compartment syndrome of the right lower arm. Compartment syndrome is the result of edema and ischemia, a complication following musculoskeletal injury. Other manifestations include increased pain, paralysis, pallor, and decreased or absent pulses.
A nurse is caring for a client who has pneumonia. Which of the following actions is the priority for the nurse to take? -Monitor intake and output -Provide teaching about antibiotic therapy -Administer the influenza vaccine -Observe the client perform incentive spirometry
Observe the client perform incentive spirometry When using the airway, breathing, and circulation framework, the priority action the nurse should take is to observe the client perform incentive spirometry. Incentive spirometry improves gas exchange and oxygenation and stimulates coughing, which assists in clearing secretions.
A nurse is assessing a client for manifestations of heat stroke. Which of the following findings should the nurse expect? A: Hypertension B: Somnolence C: Oliguria D: Bradycardia -
Oliguria
A nurse is assessing a client who has renal calculi. For which of the following findings should the nurse notify the provider immediately? -Flank pain with radiation toward the scrotum -150 mL emesis -Oliguria with bladder distention -Blood pressure 160/90 mmHg
Oliguria with bladder distention The greatest risk to this client is injury due to bladder obstruction as indicated by decreased urinary output in the presence of bladder distention. The calculi can create an obstruction of the bladder neck or urethra. The nurse should identify this as a medical emergency and notify the provider immediately.
A nurse is assessing an 18-month-old toddler who has gastroenteritis with dehydration. The toddler is able to consume 3 mL of oral rehydration solution every 5 min but still has emesis and diarrhea. Which of the following medications should the nurse anticipate administering to the toddler? A: Polyethylene glycol B: Bumetanide C: Loperamide D: Ondansetron -
Ondansetron
A nurse is caring for a client who has right-sided hemiparesis following a stroke. Which of the following images is an indication that the nurse is correctly assisting the client to ambulate?
One hand on gait belt walking behind the patient on affected side (right side)
A nurse is teaching a client who has hypokalemia about nutrition management. Which of the following fruits should the nurse recommend as the best source of potassium? A: One small apple B: One-half cup of sweet cherries C: One-half cup of fresh pineapple D: One small orange
One small orange
A nurse is assessing a client who is experiencing diarrhea and vomiting and has a sodium level of 124 mEq/L. Which of the following manifestations should the nurse expect? -Orthostatic hypotension -Hoarse voice -Neck vein distention -Muscle twitching
Orthostatic hypotension The nurse should monitor the client who has a sodium level of 124 mEq/L for orthostatic hypotension. The expected reference range for sodium is 136 to 145 mEq/L. Other manifestations of hyponatremia include decreased deep tendon reflexes, headache, confusion, and lethargy.
A nurse is assessing a client who has musculoskeletal trauma following a motor-vehicle crash 2 days ago. Which of the following findings should the nurse report to the provider? A: Laboratory results B: Blood pressure C: Pain report D: ECG results
Pain report
A nurse is caring for a client who is experiencing an asthma attack. Which of the following procedures should the nurse use to assess the client's respiratory status? -Peak expiratory flow meter testing -Spirometry monitoring -Pulmonary function testing -Chest x-ray
Peak expiratory flow meter testing The peak expiratory flow meter provides a means of evaluating the maximum flow of air the client expels during forceful exhalation. It provides information on how well asthma is being controlled as a part of daily monitoring and can be used when a client is having an asthma attack. The flow meter testing helps to gauge the peak-expiratory zone the client is experiencing and determines if the client should use immediate-acting bronchial dilator inhalers or seek emergency help.
A nurse is providing teaching about exercise to a client who has osteoarthritis. Which of the following information should the nurse include? A: Increase daily intake of foods containing vitamin A. B: Limit alcohol consumption to 10 oz daily .C: Perform exercises to strengthen the abdominal core. D: Start a daily jogging regimen
Perform exercise even on days when joints are painful
A nurse is assessing a client in the triage room of an emergency department. Based on the client findings, which of the following actions should the nurse take?
Place a surgical mask on the client
A nurse is teaching a group of newly licensed nurses about hypothermia and the care of a client who has frostbite to the fingers and toes from cold exposure. Which of the following information should the nurse include in the teaching about frostbite? A: Slowly institute rewarming of the affected areas. B: Place the affected areas of frostbite in a warm water bath. C: Massage the affected areas of frostbite. D: Position the affected areas of frostbite flat after warming
Place the affected areas of frostbite in a warm water bath
A nurse in an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take? -restrict oral intake to clear fluids -place a heating pad on the client's abdomen -place the client in semi-Fowler's position -Administer an enema
Place the client in semi-Fowler's position The nurse should place the client in semi-Fowler's position to contain abdominal drainage in the lower abdomen and prevent it from seeping into the peritoneum.
A nurse is reviewing the laboratory results of an adult client who has metabolic alkalosis. Which of the following findings should the nurse expect? A: Calcium 9.5 mg/dL B: Bicarbonate 23 mEq/L C: Potassium 3 mEq/L D: pH 7.4 -
Potassium 3 mEq/L
A nurse is caring for a client who has deep vein thrombosis and is receiving heparin via continuous IV infusion. The client has a positive fecal occult blood test and abdominal tenderness upon palpation. Which of the following prescription should the nurse expect the provider to prescribe? A: Vitamin K B: Protamine sulfate C: Flumazenil D: Acetylcysteine
Protamine sulfate
A nurse is reviewing a client's medical record prior to a laparoscopic appendectomy. Which of the following findings should the nurse report to the provider? A: Prothrombin time 12 seconds B: History of sinusitis several times each year C: BMI of 24 D: Report of urinating small amounts twice daily
Report of urinating small amounts twice daily
A nurse in an emergency department is reviewing the laboratory report of a client who has hyperventilation. The client's ABG results are pH 7.50, PaCO2 29 mmHg, and HCO3 25 mEq/L. The nurse should interpret that these values are an indication of which of the following acid-base imbalances?
Respiratory alkalosis
A nurse is assessing a client who has a partial obstruction of the large bowel. Which of the following manifestations should the nurse expect?
Ribbon-like stools
A nurse is performing a focused assessment on a client who has cholelithiasis and reports pain. Which of the following areas should the nurse assess?
Right upper quadrant The nurse should assess the gallbladder for the presence of pain or discomfort as a result of biliary colic, which is caused by a gallbladder stone obstructing the bile duct. The pain can radiate from the right upper quadrant of the client's abdomen to the client's right shoulder.
A nurse in a provider's office is reviewing the medical record of a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? A: Chest x-ray results show increased lung space. B: Sputum culture shows gram positive bacteria. C: SpO2 level is 88%. D: Weight loss of 1.4 kg (3 lb) since prior visit.
Sputum culture shows gram positive bacteria
A nurse is caring for a client who has possible appendicitis. Which of the following actions should the nurse take? A: Palpate the left lower quadrant of the abdomen to check for rebound pain. B: Start IV fluid replacement. C: Treat the client's pain with oral opioid analgesics given with food. D: Administer a suppository to the client in preparation for surgery.
Start IV fluid replacement
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
Stay with the client until manifestations subside
A nurse is assessing a client who has deep-vein thrombosis (DVT) in the right lower extremity. Which of the following findings on the affected extremity should the nurse expect? A: Coolness B: Hyperpigmentation C: Swelling D: Distended, tortuous veins
Swelling
A nurse is reviewing the laboratory results of a client who is scheduled for surgery and notes a potassium level of 6 mEq/L. Which of the following ECG findings should the nurse expect? A: Heart rate 64/min B: Tall T waves C: Shortened PR interval D: QRS 0.08 seconds
Tall T-waves
A nurse is assessing a client whose parents recently died. The nurse should identify that which of the following findings places the client at risk for maladaptive grieving? A: The client lost his house in a house fire 1 month ago. B: The client has retired after 30 years of employment. C: The client's parent was an older adult. D: The client's parent had a chronic terminal illness
The client lost his house in a house fire 1 month ago
A nurse is planning care for a client following collection of admission data. Which of the following findings should the nurse identify as the priority client need? A: The client requests to see a priest for spiritual guidance. B: The client reports coughing and a change of voice whenever he eats. C: The client reports pain immediately following physical therapy .D: The client is worried about financially supporting his family because of his illness.
The client reports coughing and a change of voice whenever he eats
A nurse is assessing a client who has hyperthyroidism and has been taking methimazole for 6 months. Which of the following findings indicates a therapeutic response to the medication -The client's skin is warm and moist -The client reports sleeping longer during the night -The client is experiencing increased bowel movements -The client's weight is 1.4 kg (3.1 lb) less than baseline
The client reports sleeping longer during the night The nurse should recognize that insomnia is a manifestation of hyperthyroidism. The client's ability to sleep longer during the night indicates a therapeutic response to the medication.
A nurse is teaching about clonazepam with a young adult female client who has generalized anxiety disorder. Which of the following statements should the nurse include in the teaching? A: "You can safely continue taking this medication if you become pregnant." B: "This medication could cause you to have thoughts of self-harm." C: "You should take this medication 1 hour before eating." D: "Take this medication with an antacid if stomach upset occurs."
This medication could cause you to have thoughts of self-harm
A nurse is assessing a client who has acute pyelonephritis. Which of the following findings should the nurse expect? A: Pain with palpation to the substernal notch B: Urinary burning C Ecchymosis over the flank D: Radiating pain to the right shoulder
Urinary burning
A nurse is planning teaching for an adolescent who has exercise-induced asthma and has new prescriptions for cromolyn and albuterol inhalers. Which of the following instructions should the nurse plan to include in the teaching? A: Inhale the second puff of cromolyn 2 min after the first. B: Use the cromolyn following exercise if shortness of breath occurs. C: Use the albuterol prior to planned exercise. D: Cleanse the albuterol mouthpiece once every 2 weeks.
Use albuterol prior to planned exercise
A nurse is assessing a client who has developed Clostridium difficile as an adverse effect to ciprofloxacin. Which of the following medications should the nurse expect the provider to prescribe to treat the C. difficile?
Vancomycin
A nurse is reviewing the laboratory results of a client who is taking sulfasalazine to treat ulcerative colitis. Which of the following laboratory findings should the nurse identify as an adverse effect of sulfasalazine? -Total bilirubin 0.8 mg/dL -WBC count 4,000/mm^3 -Platelets 190,000/mm^3 -Creatinine 1 mg/dL
WBC count 4,000/mm^3 Agranulocytosis, or a very low WBC count, is an adverse effect of sulfasalazine. This condition results in a decreased WBC count. The nurse should identify that a WBC count of 4,000/mm3 is less than the expected reference range of 5,000 to 10,000/mm3, indicating an adverse effect of the medication.
A hospice nurse is visiting with a client following the death of her partner 1 month ago. The client is tearful and states she does not see how she can ever be happy again. Which of the following responses should the nurse make?
What are some of the best times with your partner that you remember?
A nurse is providing dietary teaching to a client who is at 13 weeks gestation and has hyperemesis gravidarum. Which of the following statements should the nurse make? A: "Drink fluids between, rather than with, meals." B: "Eat foods that are served warm." C: "Do not go more than 6 hr between meals." D: "Have a low-protein snack at bedtime." -
drink fluids between, rather than with, meals
A nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the following manifestations should the nurse expect? A: Protruding tongue B: Facial flushing C: Nasal flaring D: Tympany with chest percussion
nasal flaring
A nurse is providing teaching about home care to the parent of an adolescent who has infectious mononucleosis. Which of the following manifestations should the nurse intruct the parent to report to the provider? A: Swollen cervical lymph nodes B: Exudate on tonsils C: Lack of energy D: Onset of abdominal pain
onset of abdominal pain
A nurse is providing teaching to a client who has osteoporosis. Which of the following information should the nurse include in the teaching? A: Increase daily intake of foods containing vitamin A. B: Limit alcohol consumption to 10 oz daily .C: Perform exercises to strengthen the abdominal core. D: Start a daily jogging regimen
perform exercises to strengthen the abdominal core
A home health nurse is assessing a client who has COPD. The client has a respiratory rate of 22/min and reports shortness of breath. Which of the following actions should the nurse take first? A: Place the client in high-Fowler's position. B: Encourage the client to perform diaphragmatic breathing. C: Instruct the client to perform a huff-coughing technique. D: Administer a nebulized bronchodilator.
place the client in high-Fowler's position
