RN Mentor Questions

A nurse is planning care for a client who is 2 days postop following a below the knee amputation. Which of the following nursing interventions should the nurse include in the plan to best promote the rehabilitation goal of ambulation with a prosthesis? A) Have the client sit upright in a bedside chair at least twice a day B) Position the client prone on a flat surface every 4 hours C) Ask physical therapy to show the client an example of prosthesis D) Arrange for a person who has prosthesis to visit the client

B) Position the client prone on a flat surface every 4 hours Rationale: Positioning the client on a firm mattress is essential for preventing hip flexion contractures. The nurse should assist the client into a prone position every 3-4 hours for 20-30 minute intervals if tolerated and not contraindicated. The nurse should instruct the client to pull the residual limb close to the other leg and contract the gluteal muscles of the buttocks. The rest are helpful but do not assist with ambulation directly

A nurse is caring for a client who is recovering from a radical mastectomy. The nurse understands that the specific goal for making a fist and releasing it on the affected side is to? A) Promote relaxation B) Reduce transient edema C) Prevent contractures D) Stimulate sensation

B) Reduce transient edema Rationale: During a radical mastectomy, the axillary lymphnodes are removed. Collateral circulation will eventually take over lymph node function but until that occurs, transient edema is likely. Making a fist and releasing it helps promote the mobilization of lymph and, therefore, reduce edema.

A nurse is preparing a client for an intravenous pyelogram (IVP). Which of the following findings should be reported to the provider? A) An allergy to poultry and egg products B) Vomiting and diarrhea for the last 6 hr C) Serum potassium of 3.6 D) Serum creatinine of 1.2

B) Vomiting and diarrhea for the last 6 hr Rationale: Vomiting and diarrhea will deplete fluids and cause dehydration, which may cause renal failure after a procedure that uses contract agent. It would be expected that this client may need to have IV hydration prior to and following

A nurse is planning to educate a client who has diabetes mellitus about adverse effects of insulin. Which of the following are associated with hypoglycemia? (Select all that apply) A) Bradycardia B) Diaphoresis C) Lowered blood pressure D) Palpitations E) Shakiness

B, D, E Rationale: Tachycardia as opposed to brady is a sign of hypoglycemia, hypertension as opposed to low BP is a sign of hypoglycemia, and the rest are manifestations of hypoglycemia

A nurse is teaching a client who has been admitted to the hospital with deep vein thrombosis of the left leg about measures to increase comfort and promote circulation. Which of the following responses by the client indicates a need for further teaching? A) "I will wear compression stockings on both legs" B) "I will apply moist heat to my left leg" C) "I will massage my left leg when it hurts" D) "I will keep my leg elevated while in bed"

C) "I will massage my left leg when it hurts" Rationale: elevating legs helps prevent venous pooling and promote venous return to the heart, massaging the leg should dislodge a DVT resulting in embolus making this statement indicative of a need for further teaching

Therapeutic digoxin level

0.5-2.0

Creatinine

0.6 - 1.2

INR

0.7-1.7 or 2-3 if on warfarin

A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next? 1) Monitor the client's vital signs 2) Administer epinephrine 3) Administer an antihistamine 4) Monitor the client's oxygen saturation level.

2) Administer epinephrine - The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema.

A nurse is reinforcing teaching with a client who has Multiple Sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? 1) Take this medication on an empty stomach 2) Avoid stopping this medication suddenly. 3) Use Chamomile tea to alleviate insomnia. 4) Consume a low- purine diet

2) Avoid stopping this medication suddenly. - The nurse should instruct the client to avoid stopping baclofen suddenly because it can result in adverse reactions, including seizures, paranoia, and hallucinations.

A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalcemia? 1) Anorexia 2) Bradycardia 3) Constipation 4) Polyuria

2) Bradycardia - The client who has hyperkalemia can have an irregular, slow heart rate, known as bradycardia.

A nurse is collecting data from a client who has kypokalemia. Which of the following findings should the nurse identify as the priority? 1) Abdominal pain 2) Dysrhythmia 3) Lethargy 4) Muscle weakness

2) Dysrhythmia - When using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding for a client who has hypokalemia is dysrhythmia

A nurse is monitoring an older adult client who has a history of enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? 1) Administer doxazosin 2) Palpate the abdomen 3) Insert an indwelling urinary catheter 4) Notify the primary care provider.

2) Palpate the abdomen -When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should palpate the abdomen to determine if the client has a distended bladder from urinary retention.

A nurse is contributing to the plan of care for a client who has a MRSA infection and is contact isolation precautions. Which of the following actions should the nurse take? 1) Remove gloves after leaving client's room. 2) Keep the door of the client's room closed at all times. 3) Have a designated stethoscope in the client's room. 4) Wear a mask when working within 1 meter ( 3 feet ) of the client.

3) Have a designated stethoscope in the client's room. - The nurse should designate equipment to leave in the client's room to avoid cross-contamination. The designated equipment should be disposed of or decontaminated before leaving the client's room. - The nurse should remove gloves before leaving the client's room. - The nurse should keep the door of a client's room closed at all times if the client requires airborne precautions. - The nurse should wear a mask when working within 1 m (3 feet) of a client who requires DROPLET precautions.

A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? 1) Collect a sputum specimen 2) Administer ceftriaxone 3) Initiate oxygen at 4L/minvia nasal cannula 4) Obtain blood cultures

3) Initiate oxygen at 4L/minvia nasal cannula - When using the airway, breathing, circulation approach to client care, the first action the nurse should take is to initiate oxygen. Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's oxygen saturation levels at 95% or greater, which will maximize the ability of the hemoglobin to support the oxygen needs of the body.

A nurse is caring a client who is in Buck's traction. Which of the following interventions should the nurse perform to prevent skin breakdown? 1) Use hot water and antibacterial soap to bathe the client. 2) Massage the skin over the bony prominence's to promote circulation. 3) Keep the skin dry and free of perspiration 4) Limit the use of moisturizers on the skin over bony prominence's.

3) Keep the skin dry and free of perspiration - The nurse should not leave moisture on the skin for prolonged periods of time because it can cause skin breakdown.

Phosphorus

3.0-4.5

Potassium

3.5-5.1

aPTT

30-40 (under 30 risk for clots, over 40 risk for bleeding) for HEPARIN

A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease ( COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan? 1) Direct the client to inhale with pursed lips 2) Instruct the client to lean back when coughing 3) Set the oxygen level at 5 L/min 4) Encourage abdominal breathing.

4) Encourage abdominal breathing. - The nurse should encourage abdominal breathing, which reduces the workload on the accessory muscles of respiration during dyspneic episodes.

A nurse is caring for a client who is 24 hours postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications? 1) Place one or two pillows beneath the clients knee's while he is in bed. 2) Offer sips of water to the client following oral care. 3) Massage the clients lower extremities with lotion every 2 hours. 4) Encourage the client to use an incentive spirometer every hour while awake.

4) Encourage the client to use an incentive spirometer every hour while awake. Rationale:- The nurse should assist the client to use the incentive spirometer in addition to coughing and deep breathing every hour while awake for the first 24 hr postoperatively and at least every 2 hr while awake thereafter. An incentive spirometer will inflate the client's alveoli and improve ventilation to prevent postoperative pneumonia.

A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? 1) I may develop excessive bruising 2) I should call my doctor if I get a headache 3) I may develop gastric reflux 4) I should call my doctor if my ankles swell.

4) I should call my doctor if my ankles swell. -Swelling of the ankles can indicate heart failure. The client should report this finding to the provider.

A nurse is caring for an older adult client who has a reddened area over the sacrum. Which of the following actions should the nurse take? 1) Massage the site with moisturizing lotion. 2) Place a doughnut-shaped cushion under the client's sacral area. 3) Apply a sterile gauze dressing to the site. 4) Minimize the time the head of the bed is elevated.

4) Minimize the time the head of the bed is elevated. - The nurse should minimize the time the head of the bed is elevated to reduce pressure on the sacral area. - The nurse should not massage nor apply moisturizing lotion to a reddened area because it can cause further skin injury. - The nurse should not place a donuts-type device under the client's sacral area because it can contribute to the development of a pressure injury. - The nurse should collect further data before determining what type of dressing is needed.

A nurse is assisting with discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? 1) Avoid lying on the operative side. 2) Expect decreased sensation for the first postoperative week. 3) Cross legs at the ankles 4) Obtain a raised toilet seat

4) Obtain a raised toilet seat - The nurse should instruct the client to use a raised toilet seat to avoid flexing the hip more than 90°, which increases the risk for dislocation.- The nurse should instruct the client that lying on the operative side is allowed but the client should place pillows between the legs to prevent dislocation of the hip.

A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration. 1) Instill 10ml of air through the NG tube 2) Place the client in a supine position. 3) Irrigate the NG tube 4) Pinch the NG tube

4) Pinch the NG tube - The nurse should pinch the NG tube to prevent secretions from draining into the client's throat, which can cause aspiration.

A nurse is caring for a client who has terminal pancreatic cancer. The client states" I don't think I can on on any longer." Which of the following responses should the nurse make? 1) Can I get you something for the pain. 2) You should talk about this with your family. 3) Tomorrow will be a better day. 4) Tell me more about the way you are feeling.

4) Tell me more about the way you are feeling. - The nurse is establishing a trusting relationship by seeking clarification and encouraging the client to verbalize feelings.

RBC

4.5-5.0 million

WBC

5-10 thousand

BUN

7-22

pH

7.35-7.45

Calcium

8.5-10.9

Chloride

98-107

HbA1c

<6% (>6.5% indicated DM)

A nurse is re-warming a client after coronary artery bypass graft surgery. Which of the following complications can result from rewarming the client too quickly? A) Acidosis B) Infection C) Hypertension D) Necrosis

A) Acidosis Rationale: Metabolic acidosis associated with hypoxia can occur if a client is rewarmed too quickly. Acidosis develops after the client starts to shiver so rewarming at a rate no faster than 1 degree C (1.8 degrees F) per hour is recommended

A nurse is caring for a client who is 1 day postop following a craniotomy and notes a weight increase of 4 lb from the preoperative weight and a urine output of 75mL/3hr. Which of the following actions should the nurse take first? A) Auscultate breath sounds B) Obtain an arterial blood gas C) Request a portable chest x-ray D) Prepare the client for a thoracentesis

A) Auscultate breath sounds Rationale: It appears this client may have fluid volume excess (weight gain and decreased output) which could be related to syndrome of inappropriate antidiuretic hormone as a surgical complication

A nurse is caring for a client who was admitted with a bleeding duodenal ulcer. Which of the following assessment findings of the client's emesis should the nurse expect? A) Coffee - ground appearance B) Bright red in color C) Containing fat D) Bright green in color

A) Coffee - ground appearance Rationale: Coffee ground vomit indicates GI bleeding as the blood has been partially digested. Bright red emesis would come from bleeding such as esophageal varices

A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated with this client? A) Combination oral contraceptives B) Intrauterine device C) Latex condom D) Contraceptive sponge

A) Combination oral contraceptives Rationale: these contraceptives increase estrogen levels which can stimulate the growth of any remaining cancerous breast cells

A nurse is caring for a client who is 3 days postoperative. The client states "something popped and gushed when I coughed", which of the following is the priority nursing intervention? A) Cover the area with a sterile, moist dressing B) Flex the clients knees C) Reassure the client D) Instruct the client to avoid coughing

A) Cover the area with a sterile, moist dressing Rationale: the priority action addresses the client's safety. Keeping the wound moist with a sterile isotonic solution prevents cell damage and infection that might interfere with wound healing

A nurse is caring for a client who has femoral thrombophlebitis and is prescribed heparin. Which of the following is an appropriate nursing intervention for the client? A) Elevate the affected leg B) Question the heparin prescription C) Provide cooling blankets for the client D) Administer aspirin for dicomfort

A) Elevate the affected leg Rationale: Thrombophlebitis is an inflammatory process that causes a blood clot to form and block one or more veins, usually in your legs. Treatment for femoral thrombophlebitis includes rest, elevation of the affected leg, analgesics, and anticoagulants. Heparin is appropriate and the client is more likely to feel cold in the extremities and request warm blankets.

A nurse is instructing a client recently diagnosed with Addison's disease. The nurse correctly states that the disease result from inadequate production of which of the following hormones from the adrenal cortex? A) Glucocorticoids B) Mineralcorticosteroids C) Adrenal Androgens D) ACTH

A) Glucocorticoids Rationale: Glucocorticoids provide anti-inflammatory protection and are produced by the adrenal cortex

A nurse is caring for a client who has deep partial thickness and full thickness thermal burns over 40% of his total body surface who is receiving IV fluids. The nurse is planning to perform which assessment to confirm effective fluid replacement? A) Hourly urine output B) Temperature measurement every 4 hours C) Hematuria check D) Bowel sounds assessment

A) Hourly urine output Rationale: Checking for a urine output each hour is indicated for a urine output of 30-50mL/hr. This is the most reliable indicator of adequate fluid replacement.

A nurse is caring for a client on a medical unit who was intubated endotracheally while in the ICU. Which of the following nursing assessments indicates tracheal stenosis? A) Increased coughing B) Diaphragmatic breathing C) Hemoptysis D) Kussmaul Respirations

A) Increased coughing Rationale: Tracheal stenosis causes increased coughing, an inability to cough up secretions, and difficulty talking and/or breathing

A nurse is caring for a client who has isotonic dehydration. Which of the following findings does the nurse expect to see when assessing the client? A) Increased hematocrit B) Bradycardia C) Distended neck veins D) Decreased urine specific gravity

A) Increased hematocrit Rationale: When dehydration involves plasma volumes, the percentage of red blood cells in the serum increases due to hematoconcentration and causes an increase in hematocrit.

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following is the first action the nurse should take? A) Inquire why the client refuses the pain medication B) Administer a PRN antianxiety medication C) Assist the client in changing positions D) Obtain the client's vital signs

A) Inquire why the client refuses the pain medication Rationale: Using the nursing process is the first action the nurse should take to assess the reason for the client's refusal.

A nurse is caring for a client on the medical unit. Which of the following findings indicate that the client likely has a pulmonary embolism? A) Stabbing chest pain B) Calf tenderness C) Elevated temperature D) Hypoventalation

A) Stabbing chest pain Rationale: Manifestations of a pulmonary embolism include sudden chest pain that is sharp and stabbing; others are dyspnes, cough, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom

A nurse is caring for a patient who is 4 days postoperative following the creation of a colostomy and refuses to look at the stoma. Which of the following nursing assessments is appropriate? A) The client is still experiencing shock and denial and is not ready for further teaching at this time B) The client has not retained information that was given before surgery and needs a repetition of all teaching C) The clients refusal to acknowledge the reality of the colostomy indicates that preoperative teaching was inadequate D) The client has had adequate teaching and should be expected to begin assuming responsibility for self care

A) The client is still experiencing shock and denial and is not ready for further teaching at this time Rationale: The repetition of teaching may not be affective because the client is not ready for learning anything further because they are still in shock and adjusting

A nurse finds that a client has a thyroid-stimulating hormone (TSH) level of 8.3 mIU/L. Which of the following assessment findings should the nurse expect? A) Weight gain and bradycardia B) Insomnia and diarrhea C) Diploplia and photophobia D) Irritability and diaphoresis

A) Weight gain and bradycardia Rationale: TSH levels of 0.4-4.2 mIU/L are within the expected reference range. An elevated level indicates hypothyroidism which is characterized by weight gain. bradycardia, cold intolerance, paresthesia, hearing loss, depression, and many more

A nurse is reinforcing teaching with a client who has Systemic Lupus Erthematosus (SLE) and is to begin taking mythylprednisolone orally. Which of the following statements should the nurse include in the teaching? A) limit contact with large groups of people B) Take medication on an empty stomach C) Follow a low protein diet D) Avoid taking over the counter calcium supplements

A) limit contact with large groups of people Rationale: Glucocorticoids cause immunosuppression and may mask infection. The client should limit contact with sources of possible infections, such as large groups of people.

A nurse is assessing several clients. The nurse should recognize that which of the following clients is most at risk for developing complications from immobility? A) 3 year old with a burned foot B) 80 year old with a fractured hip C) 30 year old with a fractured ankle D) 42 year old with a urinary catheter

B) Rationale: Due to the client's advanced age and degree of immobility, this client is MOST at risk for complications

A nurse is providing teaching about nonpharmacologic pain relief for an older adult client who has severe pain and inflammation in her left knee joint from osteoarthritis. Which of the following responses by the client requires further instruction from the nurse? A) "I will need an additional 1-2 hours of rest each day if possible" B) "When my arthritis acts up I will immobilize the affected joints until the pain and inflammation decrease" C) "I will use a warm, moist compress on my knee to decrease the discomfort" D) "A cold pack wrapped in a towel will help decrease inflammation in my knee"

B) "When my arthritis acts up I will immobilize the affected joints until the pain and inflammation decrease" Rationale: Immobility will increase the loss of joint movement and should be avoided. Gentle exercise of affected extremities should be performed even when joints are painful and inflamed. Warm and cold can be used on painful and inflamed joints

A nurse manager has just held a staff development inservice with the RNs on his unit regarding pathologies that can cause crepitus. When asked to identify a client at risk, which of the following responses by one of the attendees indicates that clarification is still needed? A) A client who is postoperative with a chest tube B) A client who has Chron's disease C) A client who has a tracheostomy tube D) A client who has tempromandibular joint problems

B) A client who has Chron's disease Rationale: all of the answers have a risk for crepitus besides Chron's disease which is an inflammatory process

A nurse is caring for an older adult client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following assessment findings should the nurse expect to observe in the client's affected extremity? A) Absent pulses B) Ankle swelling C) Hair loss D) Skin atrophy

B) Ankle swelling Rationale: Ankle swelling is common with venous, absent pulses is arterial, skin atrophy is arterial, and hair loss is arterial

A nurse is obtaining a guaiac test from a client. Which of the following assessment findings by the nurse provide the appropriate rationale for the prescription? A) Bile in Vomit B) Blood in stool C) Infestation of parasites D) Microorganisms in the urine

B) Blood in stool Rationale: The guaiac test detects the presence of blood in the stool. It is a commonly used point of care test for fecal occult blood

A nurse suspects that a client may have hearing loss. Which of the following assessment data may indicate to the nurse the need for additional assessment of potential hearing loss? A) Frequent use of steroids B) Chronic use of salicylates C) Intermittent use of antacids D) Habitual use of laxatives

B) Chronic use of salicylates Rationale: Steroids are not considered ototoxic however, can damage muscles, diminish bone density, and cause visual complications, such as cataracts and glaucoma. Salicylates (aspirin) can cause ototoxicity manifested as tinnitus and/or hearing loss

A nurse is caring for a client who has meniere's disease. Which of the following structures of the ear should the nurse identify as the origin of the dizziness experienced during a flare? A) Malleus B)Cochlea C) Oval window D) Tympanic membrane

B) Cochlea Rationale: Meniere is a disease of the inner ear and the cochlea is located in the inner ear

A nurse is instructing an older adult client about the changes in cardiac function related to age. The nurse correctly explains that an increase in diastolic and systolic blood pressure occurs as part of the aging process because of? A) Complications of coronary artery disease B) Decreased elasticity of blood vessels C) Increase in cardiac output D) Complications of renal failure

B) Decreased elasticity of blood vessels Rationale: An expected older adult change is decreased elasticity of blood vessels. When arterial walls stiffen, blood pressure increases. Cardiac output remains the same and not all older adults with hypertension have coronary artery disease.

A nurse is caring for an older adult client who has just been diagnosed with hepatitis A and will be recuperating at home. The family asks the nurse how they should care for the client. Which of the following statements by the nurse is appropriate? A) During this illness she may take over the counter medications for discomfort B) Encourage the client to eat foods she likes that are high in carbs C) The doctor will prescribe a medication to help her liver heal faster D) Have her perform moderate exercise to increase her metabolic rate

B) Encourage the client to eat foods she likes that are high in carbs Rationale: while there are no approved medications to treat Hep A. the patients diet should be high in carbohydrates and calories, with only moderate amounts of protein and fat, especially if nausea is present

A nurse is caring for a client who has severely elevated blood pressure. Which of the following symptoms supports this condition? A) Vertigo B) Epistaxis C) Opthalmia D) Torticollis

B) Epistaxis Rationale: Epistaxis (nosebleed) is a manifestation of elevated blood pressure. Hypertension is often asymptomatic but when severely elevated it can also cause headaches, dizziness, facial flushing, and fainting

A nurse is caring for a client who is scheduled for a vaginal hysterectomy with a bilateral oophrectomy. Which of the following hormone related changes should the nurse include in the preoperative teaching? A) Increased vaginal bleeding B) Excessive perspiration C) Increased vaginal discharge D) Increased libido

B) Excessive perspiration Rationale: Removal of the ovaries (oophrectomy) will precipitate menopause. Excessive perspiration and flushing are vasomotor reactions to menopause and may be more severe after an oophrectomy. The client will no longer have uterine bleeding because the uterus has been removed, vaginal dryness and decreased libido are more likely to occur

A nurse is caring for a client diagnosed with chronic glomerulonephritis with oliguria. The nurse instructs the client that which of the following potential electrolyte imbalances will be monitored closely? A) Hypercalemia B) Hyperkalemia C) Hypomagnesemia D) Hypophosphatemia

B) Hyperkalemia Rationale: Oliguria causes potassium retention, leading to hyperkalemia, and calcium is usually lower instead of higher.

A nurse is preparing discharge teaching for an adult client who has just returned from a barium swallow. Which of the following instructions should the nurse include in the discharge teaching? A) Wait 24 hr after the procedure to eat normally B) Increase oral fluids and take a mild laxative until all white colored stool has passed C) Expect a sore throat for 1-2 days after the procedure D) Take 1 oz of an antacid every 1-2 hours while awake for the first 24 hours

B) Increase oral fluids and take a mild laxative until all white colored stool has passed Rationale: The barium ingested for this procedure must be removed. Laxatives should be given until the client is having regular bowel movements and the nurse or client sees no further white colored stool. Failure to remove the barium ingested may cause fecal impaction and or bowel obstruction

A nurse is monitoring a client who recently had a cast placed on his lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal? A) Report a dull, throbbing pain B) Lack of sensation between the first and second toes C) Capillary refill of three seconds in the nails and toes D) Extremities that are cool bilaterally

B) Lack of sensation between the first and second toes Rationale: Indicates peripheral nerve impairment and is an abnormal finding that can indicate compartment syndrome. If the extremities are cool BILATERALLY it is an indication of the clients overall body temperature and general circulatory status which is an expected finding

A nurse is caring for a client who is recovering from a thyroidectomy and demonstrating a harsh, high pitched respiratory sound. Which of the following is the appropriate nursing intervention? A) Provide humidity B) Notify the provider C) Lower the head of the bed D) Reposition the client

B) Notify the provider Rationale: Laryngeal stridor is a high pitched, harsh breathing sound. It signals respiratory distress, a serious complication of thyroid surgery that requires aggressive intervention. The nurse should notify the provider immediately

A nurse is providing discharge teaching for a client who has a diagnosis of diabetic neuropathy. Which statement by the client demonstrates an understanding of the teaching? A) "I can use a heating pad on my feet to keep them warm" B) "I can go barefoot as long as I stay inside the house" C) "I will wash my feet daily and apply lotion except between my toes" D) "I will trim my toenails every morning, rounding them to the corners"

C) "I will wash my feet daily and apply lotion except between my toes" Rationale: Diabetic neuropathy is a major risk factor that can lead to amputation of an extremity. Foot care is essential. The client should inspect the feet daily in order to recognize early injury. The client must also clean the feet daily with mild soap and warm water. Lotion is applied to the feet to prevent drying and cracking. However, no lotion between toes because it offers an environment for bacterial growth. Reduced sensation from neuropathy could put the patient at risk for thermal injury if using a heating pad, and toenails should only be trimmed on a PRN basis, not every morning

A nurse is caring for a client who is 2 days postoperative following gastric surgery. Which of the following assessments should concern the nurse the most? A) Irritability and mild confusion of the client B) Hypoactive bowel sounds in all quadrants C) 200mL of bright red drainage via the NG tube D) 300 mL of yellow greenish drainage from the NG tube

C) 200mL of bright red drainage via the NG tube Rationale: Two - 3 days postoperative gastric surgery, the client should no longer have bright red drainage from the NG tube. Drainage should be noted as either yellow-greenish or clear. Bright red drainage indicates blood loss, and can be a result of disrupted suture line, or other internal bleeding. Volume loss from blood is a medical emergency

A college student who was diagnosed with mononucleosis 2 weeks ago arrives at the clinic. Which of the following should be the greatest concern to the nurse? A) Headache and fatigue B) Swollen lymph nodes in the neck C) Abdominal pain in the left upper quadrent D) Fever and soar throat

C) Abdominal pain in the left upper quadrent Rationale: Left upper quadrent pain indicates an enlarged spleen, which can rupture, leading to internal hemorrhage, which should be of most concern to the nurse. The rest are common findings with mononucleosis and cal last up to 4 weeks along with malaise, chills, and anorexia.

A nurse is caring for a client who has biliary colic. The nurse should understand that which of the following treatment options is effective in managing the clients pain? A) Oxygen and fluid administration B) Warm compresses C) Antispasmodics and anticholinergics D) Antacids

C) Antispasmodics and anticholinergics Rationale: The spasm of the duct that occurs as it attempts to dislodge the obstruction causes severe pain that is managed with these drugs

A nurse is collecting data from a client who has heart failure and is on digoxin. Which of the following outcomes from the medication should the nurse expect? A) Increased heart rate B) Decreased urinary output C) Decreased shortness of breath D) Increased weight

C) Decreased shortness of breath Rationale: The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion. The nurse should expect the client's heart rate to decrease because digoxin decreases the client's sympathetic nerve tone, which slows the heart rate.

A nurse is caring for a client the first 72 hours after the onset of a cerebrovascular accident (CVA). Into which of the following positions should the nurse assist the client? A) Turn the clients head to the side with the head of the bed elevated at 60 degrees B) Place the clients head on a flat pillow with the foot of the bed higher than the head C) Elevate the head of the bed no more than 30 degrees with the clients head in a neutral midline position D) Place the client in a dorsal recumbent position with pillows under the head for comfort

C) Elevate the head of the bed no more than 30 degrees with the clients head in a neutral midline position Rational: Keeping the patient flat or in this position helps prevent further increases in intracranial pressure, a major risk for the first 72 hours after the onset of a CVA or stroke

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following is an expected finding? A) Urine negative for ketones B) Distended neck veins C) Kussmaul respirations D) Elevated blood pressure

C) Kussmaul respirations Rationale: Kussmaul respirations are an expected finding with DKA. They are deep and rapid and cause respiratory alkalosis as the body tries to exhale carbon dioxide rapidly to correct acidosis. Ketones would be present in the blood, signs of dehydration are common, and the client is more likely to have orthostatic hypotension with DKA`

A nurse is caring for an older adult in the PACU following an open hip fracture repair. In which of the following positions should the nurse place the client? A) Leg on the affected side adducted B) Hip extremely rotated on the affected side C) Leg on the affected side abducted D) Hip flexed on the affected side

C) Leg on the affected side abducted Rationale: the client's leg should be abducted. adduction or external rotation of the leg will cause the hip to dislocate

A nurse is caring for a client who has been admitted to the hospital with a possibal myocardial infarction. Which of the following findings indicate the presence of a MI? A) Headache B) Hemoptysis C) Nausea D) Diarrhea

C) Nausea Rationale: Nausea is an expected MI manifestation along with chest pain, vomiting, diaphoresis, dyspnea, fatigue, palpitations, and dizziness

A nurse is preparing to admit an older adult client who has recently been diagnosed with pernicious anemia. Which of the following should the nurse expect to find when assessing the client? A) Thick white coating on the clients tongue B) Decreased pulse rate C) Paresthesias in the hands and feet D) Muscle cramps in lower legs and thighs

C) Paresthesias in the hands and feet Rationale: Paresthesias, such as tingling sensations in the hands and feet are expected with pernicious anemia. Other manifestations include weight loss and fatigue

A client who has experienced an inhalation injury reports episodes of respiratory wheezing. The nurse assesses the client and does not hear wheezing. Which is an appropriate nursing intervention? A) Increase the IV infusion rate B) Elevate the head of bed at least 60 degrees C) Re-assess the client's airway immediately D) Document the findings as indicating resolution of airway obstruction

C) Re-assess the client's airway immediately Rationale: Wheezing after an inhalation injury indicates partial airway obstruction. If the wheezing disappears. it could mean the client can no longer force air through the injured airways. This is a life threatening emergency and requires immediate intubation. The nurse should assess the client immediately for airway obstruction and summon the rapid response team.

A nurse is caring for a hospitalized client who has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? A) Perform tracheostomy care using medical asepsis B) Allow room to insert 3 fingers under the clean tracheostomy ties C) Soak the inner cannula of the tracheostomy tube in half strength hydrogen peroxide D) Cut a sterile gauze pad to place between the neck and tracheostomy tube

C) Soak the inner cannula of the tracheostomy tube in half strength hydrogen peroxide Rationale: surgical asepsis should be used, the nurse should only be able to insert two fingers not three, cut gauze fibers should not be anywhere near the wound, but soaking the inner cannula of the tracheostomy tube in half strength hydrogen peroxide helps to loosen secretions and is indicated

A client is recently discharged following a below the knee amputation. Which observation by the nurse indicated a need for additional teaching? A) The client lies in a prone position B) The client sleeps on a firm mattress C) The client elevated the residual limb on a pillow D) The client wraps the residual limb with an elastic bandage

C) The client elevated the residual limb on a pillow Rationale: Elevating the residual limb increases the risk of hip and knee flexion contractures. The client should not elevate the limb in the home setting.

A nurse is caring for an adult client who is grieving. Which of the following factors is the greatest risk for developing complicated grief? A) The client's parent died B) The client lived far from the deceased C) The death was sudden D) The client had a close relationship with the deceased

C) The death was sudden Rationale: complicated grief is likely when the death is sudden and unexpected, the rest are forms of dysfunctional grief

A nurse is assessing a client's abdominal wound 3 days after surgery. The incision is found to be draining serosanguineous fluid, and is slightly pink and swollen with some crusting on the edges. Which of the following conclusions can the nurse draw from these observations? A) The incision is showing early signs of infection B) The incision is showing early signs of dehiscence C) The incision is showing signs of healing appropriately and without complications D) The incision is showing signs of fistula development

C) The incision is showing signs of healing appropriately and without complications Rationale: these assessment findings are consistent with normal wound healing, early sings of infection include: warmth, erythema, increased pain, and purulent drainage

A nurse is caring for a client who has lupus and is on prednisone for several months, the nurse understands that the client is at risk for developing which of the following adverse effects of prednisone? A) hypotension B) hyperkalemia C) osteoparosis D) depression

C) osteoparosis Rationale: this is the only one listed that is an adverse effect of prednisone

A nurse is providing discharge teaching for a client who has had a left total hip athroplasty. Which of the following client statements should the nurse recognize as a need for further action? A) "I will continue to walk and perform leg exercises" B) "I should not cross my legs at the ankles or knees" C) "I must clean the hip incision with soap and water every day" D) "I can put my own socks and shoes on after the incision heals"

D) "I can put my own socks and shoes on after the incision heals" Rationale: The action of putting socks on involved leaning forward. The client should not bend, stoop, or flex the hips more than 90 degrees. This motion can result in dislocation of the femoral head. The surgeon may forbid this motion for several months, or even permanently. The client should use an assistive device (dressing sticks, shoehorns with extended handles) for dressing

A nurse is providing skin care teaching to a client diagnosed with cancer who is undergoing external radiation treatment. Which of the following statements by the client indicates the teaching has been efective? A) "I will use petroleum based lotions on the areas being radiated" B) "I will dry areas being radiated by rubbing in a circular pattern" C) "I will apply sunscreen to the areas being radiated while in the sun" D) "I will use my hand instead of a washcloth to wash the areas being radiated"

D) "I will use my hand instead of a washcloth to wash the areas being radiated" Rationale: NO powders, lotions, ointments, lotions or creams should be applied to radiated areas,. Radiated areas should be dried by gently patting NOT rubbing. Sunscreen should not be applied to radiated areas, protective clothing, staying in the shade when in intense sun, or avoiding sun all together should be used as protection instead. Using hands is more gentle than using a washcloth making that statement indicative of effective teaching.

A client is admitted to the ICU with 25% total body surface area burns following a house fire. There is no prior medical history note on this client. Which of the following IV fluids would be contraindicated for this patient? A) Whole blood B) Lactated Ringers C) Plasmalyte D) 0.45% sodium chloride

D) 0.45% sodium chloride Rationale: 0.45% sodium chloride is a hypotonic solution and is contraindicated for clients with burns

A nurse is discussing the acquisition of health care associated infections (HAIs) with a newly licensed nurse. The nurse notes that the teaching has been effective when the newly licensed nurse states that an iatrogenic infection is one that results from? A) Improper hand hygiene B) Drug resistance C) Inappropriate waste disposal D) A diagnostic or therapeutic procedure

D) A diagnostic or therapeutic procedure Rationale: HAIs of the iatrogenic type are associated with diagnostic and therapeutic procedures where as breaks in infection protocols such as improper hand hygiene, inappropriate waste disposal and drug resistance are sources of nosocomial HAIs

A nurse is assessing an older client in a long term care facility for associated symptoms of a myocardial infarction. Which of the following findings should indicate to the nurse that the client may be experiencing a myocardial infarction? A) Sudden hemoptysis (coughing up blood) B) Acute diarrhea C) Frontal headache D) Acute confusion

D) Acute confusion Rationale: this is a clinical manifestation of an MI along with nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, fatigue

A nurse is providing care to an older adult client postoperatively. How should the nurse expect the client's age to affect pain management? A) Perception of pain will be decreased B) Pain will be reported more frequently C) Opioids are too dangerous to administer D) Analgesics will have longer duration of action

D) Analgesics will have longer duration of action Rationale: Renal and liver function declines with age. Since many medications are metabolized in the kidneys and liver, it is common for medications to have a longer duration of affect in older clients. Older clients do not have a decreased perception of pain, this is a common misperception.

A nurse is planning care for a client who has been diagnosed with hyperemesis gravidarum. Which of the following nursing actions will provide the best information about the nutritional status of the client? A) Calculate the total fluid intake each shift B) Record frequency and volume of emesis C) Obtain a urine and serum osmolarity D) Assess the urine for ketones daily

D) Assess the urine for ketones daily Rationale: Excessive ketones in the urine indicate the body is not using carbohydrates from food as fuel and is inadequately trying to break down fat. Monitoring the urine for ketones is one of the most common tests used to help diagnosis and monitor hyperemesis gravidarum.

A nurse is preparing a plan of care for a client following a CVA. Which of the following considerations takes priority when developing the plan of care? A) Preventing anxiety and depression B) Determining the cause of the CVA C) Supporting the family D) Basing the plan on the affected hemisphere

D) Basing the plan on the affected hemisphere Rationale: Identifying the affected hemisphere will provide the most guidance for developing an appropriate plan of care for the client. For example, when the left hemisphere is affected, the client will have deficits in the right visual field and difficulty with language

A client weighing 183 lbs is receiving an IV fluid bolus for the treatment of hypovolemia. Which of the following findings should the nurse recognize as most indicative of adequate fluid volume at this time? A) Heart rate of 110/min B) Urine output of 30 mL/hr C) BP of 104/84 D) Central Venous Pressure (CVP) of 5 mmHg

D) Central Venous Pressure (CVP) of 5 mmHg Rationale: CVP is a measurement of right ventricular preload. It is obtained by placing a pressure monitoring catheter close to the right atrium by way of central venous access, usually through the internal jugular or subclavian vein. An elevated CVP can indicate right ventricular failure or volume overload. A low CVP is often an indication of hypovolemia. Normal is between 1 and 8 so 5 is within expected range and would indicate adequate fluid volume.

A nurse is caring for a client diagnosed with myasthenia gravis who reports fatigue in the middle of the afternoon each day. Which of the following interventions could prevent this from occurring? A) Schedule more activities in the evening B) Eat a mid-afternoon snack C) Restrict the use of caffeinated beverages D) Change the clients medication schedule

D) Change the clients medication schedule Rationale: The client may be experiencing fatigue when blood levels of antimyasthenic medications are low. Changing the time meds are taken may allow a more consistent and therapeutic level of medication in the blood

During a follow up clinic visit with a client receiving home peritoneal dialysis, the nurse assesses the client. Which of the following findings should be reported to the provider immediately? A) Difficulty draining the effluent B) Redness at the access site C) Swelling in the legs D) Cloudy Effluent

D) Cloudy Effluent Rationale: Cloudy dialysate drainage indicates a possible bacterial infection in the peritoneum and should be reported to the provider immediately

A nurse is performing an admission assessment on a client who has a diagnosis of CVA and a.Fib, which of the following actions should the nurse implement first? A) Administer the scheduled warfarin B) Apply the prescribed pneumatic compression boots C) Consult the speech - language pathologist to assess swallowing D) Communicate NPO status to the unlicensed assistive personnel

D) Communicate NPO status to the unlicensed assistive personnel Rationale: The client just had a stroke and should be kept NPO until risk of aspiration is evaluated and a screening for ability to swallow is conducted

A nurse is assessing the cardiac functioning of an older adult client. Which of the following findings should the nurse expect to see as a result of normal aging? A) Increased elasticity of the heart valves B) Decreased thickness of the walls of blood vessels C) Decreased systolic blood pressure D) Decreased blood flow to the heart

D) Decreased blood flow to the heart Rationale: By age 60, maximal blood flow through the coronary arteries supplies the cardiovascular system with 35% less blood than during the earlier stages of life. Older adults heart valves usually decrease in elasticity, walls of blood vessels usually thicken, systolic blood pressure usually goes up

What is a positive cullens sign?

Ecchymosis of the periumbilical area is noted as a positive cullen's sign in patients with acute pancreatitis

Hgb

M: 14-18 F: 12-16

Hct

Males: 42-52% Females: 37-47%

A nurse is collecting data from client who reports a 55 year old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? 1) History of treatment of blood clots. 2) Topiramate use for migraine headaches 3) Increased serum cholesterol levels 4) Five year history of menopause manifestations

1) History of treatment of blood clots. - Estrogen increases the risk of blood clots. Therefore, a woman who has a history of blood clots should not receive HRT

A nurse is reviewing the laboratory results of a client who has type II diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? 1) Prealbumin 12mg/dl 2) HBA1c 6% 3) WBC 8,000/mm3 4) Creatinine 0.8 mg/dl

1) Prealbumin 12mg/dl - This laboratory value is below the expected reference range, indicating that the client's protein status is inadequate and that he is at risk for delayed wound healing due to malnutrition.

Magnesium

1.6-2.6

Sodium

135-145

Platelets

150,000-400,000

A nurse is reinforcing teaching with a client who has asthma. Which of the following statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply 1) I should use my budesonide inhaler before I use my albuterol inhaler. 2) I use my albuterol inhaler before I go swimming 3) Between office visits, I keep a record of how many times I use my albuterol inhaler. 4) I should expect to feel sleepy after using my albuterol inhaler. 5) I never forget to rinse my mouth after using my budesonide inhaler.

2, 3, 5 2) I use my albuterol inhaler before I go swimming - The client should use the albuterol inhaler before exercise to prevent exercise-induced bronchospasms. 3) Between office visits, I keep a record of how many times I use my albuterol inhaler. - The client should record the number of times that he uses his albuterol inhaler. This information can assist the provider to determine the effectiveness of the medication. 5) I never forget to rinse my mouth after using my budesonide inhaler. - The client should rinse his mouth after using a budesonide inhaler to reduce the risk for oral fungal infection. - The client should recognize that albuterol stimulates the sympathetic nervous system, which can cause nervousness and insomnia, along with increased heart rate and blood pressure. - The client should first use the albuterol inhaler, a bronchodilator, to open the airway and enhance the absorption of the budesonide, which is an inhaled corticosteroid.

Prealbumin normal range =

23-43

A nurse is caring for a client who is 4 days postoperatively following gastric bypass surgery. Thirty minutes after eating breakfast, the client reports vertigo. Upon assessment, the nurse finds the client sweating, tachycardic, and pale. Which of the following is the nurse priority at this time? A) Determine if the client is febrile and review the WBC count B) Assess the clients pulse oximetry reading C) Assist the client to take deep breaths and relax D) Encourage the client to maintain supine position

D) Encourage the client to maintain supine position Rationale: This is the priority action because following bariatric surgery, dumping syndrome occurs as a result of rapid emptying of food into the small intestine. Food contents and simple sugars exit the stomach too rapidly, attracting fluid into the upper intestine, and blood volume decreases. As a consequence, fluid shift occurs in the upper GI tract, causing the client to experience nausea and vomiting, sweating, syncope, palpitation, increased heart rate, and hypotension. Decreasing the amount of food eaten at one time, frequent feedings, and eliminating fluids at mealtime will decrease the incidence of dumping syndrome. A client experiencing dumping syndrome should be instructed to lie down in supine position after a meal to slow the movement of food.

A nurse is caring for a client hospitalized with a complete intestinal obstruction. Which of the following findings should the nurse expect? A) Absence of bowel sounds in all four quadrants B) Normal bowel sounds with passage of blood tinged stool C) Passing of flatus and high pitched gurgling present in all four abdominal quadrants D) Hyperactive bowel sounds above the obstruction and absent below

D) Hyperactive bowel sounds above the obstruction and absent below Rationale: the sounds are hyperactive above the obstruction as peristalsis tries to push material through the obstruction. With a complete obstruction, there are no bowel sounds below the obstruction

A nurse is caring for a client who has a cerebral lesion who develops hyperthermia. Based on the knowledge of pathophysiology, the nurse understands that which of the following areas of the brain may be affected? A) Wernicke's area B) Cerebral cortex C) Basal ganglia D) Hypothalamus

D) Hypothalamus Rationale: Wernicke's area is responsible for speech. Cerebral cortex is responsible for complex though processes and not for temp regulation. Basal ganglia is involved in a variety of functions including motor control and learning. The HYPOTHALAMUS is responsible for temperature regulation.

A nurse is admitting an adult client to the emergency department who experienced a head injury from a fall. The client was carried in by coworkers. Which of the following actions is the highest priority? A) Questions the client's coworkers about the mechanism of injury B) Check the clients pupils C) Measure the clients blood pressure and pulse rate D) Immobilize the client's cervical spine

D) Immobilize the client's cervical spine Rationale: This is the priority before any further assessment THEN check the pupils

A nurse is transfusing a client who has two units of whole blood. Which of the following findings is indicative of a hemolytic transfusion reaction? A) Bradycardia B) Paresthesia C) Hypertension D) Low Back pain

D) Low back pain Rationale: a common manifestation is lower back pain. Other manifestations include headache, chest pain, tachypnea, tachycardia, and hypotension

A nurse is assessing an older adult female client. Which of the following findings would be unexpected in relation to physiologic changes seen with aging? A) Increased chest wall rigidity and decreased cough reflex B) Decreased urinary sphincter tone and bladder capacity C) Decreased size and muscle tone of the breasts D) Lower back tenderness and decreased spinal column movement

D) Lower back tenderness and decreased spinal column movement Rationale: Onset of lower back tenderness and restriction of spinal column movement may indicate that a compression fracture has occurred due to osteoporosis. These are not common physiologic changes of aging.

A nurse is assessing a client's tissue perfusion status. Which of the following actions by the nurse is appropriate? A) Performing a Romberg test B) Checking nails for Beau's lines C) Palpating for respiratory excursion D) Performing blanch test

D) Performing blanch test Rationale: Blanch test is used to check capillary refill which is correct whereas the Romberg test is used to assess balance and gross motor function, Beau's lines in the nail result from illness or injury not perfusion, and respiratory excursion is to determine thoracic expansion

A nurse is caring for a client receiving a continuous morphine infusion who had a respiratory rate of 20/min 4 hrs ago. Currently the respiratory rate is 12/min. Which of the following is the appropriate nursing intervention? A) Flush the line with saline B) Administer nalaxone (Narcan) C) Elevate the head of the bed D) Slow the rate of the infusion

D) Slow the rate of the infusion Rationale: Decreasing the infusion rate is indicated here, you do not give nalaxone until respirations are less than 12

A client has a radial arterial line in place for blood pressure monitoring. Which of the following observations would require corrective action by the nurse? A) The line is maintained with IV fluids in a pressure bag B) The arterial monitoring system is recalibrated each shift C) The arterial line is used to obtain a sample for blood gas D) The transducer is positioned at the level of the right wrist

D) The transducer is positioned at the level of the right wrist Rationale: This is NOT correct and will result in an inaccurate reading. The transducer should be positioned at the level of the right atrium located at the fourth intercostal space

The nursing assessment of a client who is postoperative following a gastrectomy reveals pernicious anemia. Which of the following findings would the nurse expect? A) Iron deficiency B) Hemolytic blood loss C) Inadequate nutrition D) Vitamin B12 deficiency

D) Vitamin B12 deficiency Rationale: Gastric surgery interferes with the absorption of vitamin B12, causing pernicious anemia. This type of anemia results from a deficiency of intrinsic factor normally supplied by the gastric mucosa. This factor is essential for absorption of vitamin B12