Senior Seminar Med Surg Quiz #2

A client with AIDS has histoplasmosis. The nurse should assess the client for which expected finding? 1. Dyspnea 2. Headache 3. Weight gain 4. Hypothermia

1. Dyspnea

The nurse is teaching a client with MG about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 1. Taking medications as scheduled 2. Eating large, well-balanced meals 3. Doing muscle-strengthening exercises 4. Doing all chores early in the day while less fatigued

1. Taking medications as scheduled

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event 2. The client is experiencing early signs of ischemic bowel 3. The client should not have the nasogastric tube removed 4. This indicates inadequate preop bowel prep

1. This is a normal, expected event

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? 1. Muffled heart sounds 2. A rise in BP 3. JVD 4. Client expression of dyspnea

2. A rise in BP

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 1. 18% 2. 24% 3. 36% 4. 48%

3. 36%

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? 1. A urinary output of 50 mL/hr 2. A coagulation time of 5 minutes 3. A heart rate that is 90 bpm and irregular 4. A BUN level of 20 mg/dL

3. A heart rate that is 90 bpm and irregular

A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? 1. Sensation of palpitations 2. Causative factors, such as caffeine 3. BP and O2 sat 4. Precipitating factors, such as infection

3. BP and O2 sat

The nurse has conducted discharge teaching with a client diagnosed with TB who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? 1. "I need to continue medication therapy for 1 month." 2. "I can't shop at the mall for the next 6 months." 3. "I can return to work if a sputum culture comes back negative." 4. "I should not be contagious after 2-3 weeks of medication therapy."

4. "I should not be contagious after 2-3 weeks of medication therapy."

The nurse provides instructions to a client newly diagnosed with type 1 DM. The nurse recognizes accurate understanding of measures to prevent DKA when the client makes which statement? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my HCP if my blood glucose level is higher than 250 mg/dL."

4. "I will notify my HCP if my blood glucose level is higher than 250 mg/dL."

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? 1. "I will wash my face with cotton pads." 2. "I'll have to start chewing on my unaffected side." 3. "I should rinse my mouth if toothbrushing is painful." 4. "I'll try to eat my food either very warm or very cold."

4. "I'll try to eat my food either very warm or very cold."

The nurse has instructed the family of a client with stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."

4. "We need to remind him to turn his head to scan the lost visual field."

The community health nurse is instructing a group of young female clients about BSE. The nurse should instruct the clients to perform the examination at which time? 1. At the onset of menstruation 2. Every month during ovulation 3. Weekly at the same time of day 4. 1 week after menstruation begins

4. 1 week after menstruation begins

A client in v fib is about to be defibbed. To convery this rhythm effectively, the monophasic defib machine should be set at which energy level for the first delivery? 1. 50 J 2. 120 J 3. 200 J 4. 360 J

4. 360 J

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? 1. Bradycardia 2. Numbness in the legs 3. Nausea and vomiting 4. A rigid, boardlike abdomen

4. A rigid, boardlike abdomen

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas

4. Bananas

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? 1. Hematuria and pyuria 2. Dysuria and proteinuria 3. hematuria and urgency 4. Dysuria and penile discharge

4. Dysuria and penile discharge

The nurse is admitting a client with GB syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1. Nebulizer and pulse ox 2. BP cuff and flashlight 3. Flashlight and incentive spirometer 4. ECG monitoring electrodes and intubation tray

4. ECG monitoring electrodes and intubation tray

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in ICP if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

4. Exhaling during repositioning

The nurse is assessing a client with multiple trauma who is at risk for developing ARDS. The nurse should assess for which earliest sign of ARDS? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate

4. Increased respiratory rate

The nurse is caring for a client with a diagnosis of gout. Which lab value would the nurse expect to note in the client? 1. Ca level of 9.0 2. Uric acid level of 9.0 3. K level of 4.1 4. P level of 3.1

Uric acid level of 9.0

The nurse is monitoring a client who was diagnosed with type 1 DM and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply 1. tremors 2. anorexia 3. irritability 4. nervousness 5. hot, dry skin muscle cramps

1. tremors 3. irritability 4. nervousness

The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply 1. Hemodialysis 2. Peritoneal dialysis 3. Kidney transplant 4. Bilateral nephrectomy 5. Intense immunosuppression therapy

1. Hemodialysis 3. Kidney transplant 4. Bilateral nephrectomy

A client with a diagnosis of addisonian crisis is being admitted to the ICU. Which findings will the interprofessional HCP focus on? Select all that apply 1. Hypotension 2. leukocytosis 3. Hyperkalemia 4. Hypercalcemia 5. Hypernatremia

1. Hypotension 3. Hyperkalemia

The nurse is reviewing the lab results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? 1. Increased calcium level 2. Increased WBCs 3. Decreased BUN levels 4. Decreased number of plasma cells in the bone marrow

1. Increased calcium level

The nurse is admitting a client who is diagnosed with SIADH and has serum sodium of 118 mEq/L. Which HCP prescriptions should the nurse anticipate receiving? Select all that apply 1. Initiate an infusion of 3% NaCl 2. Administer IV furosemide 3. Restrict fluids to 800mL over 24 hours 4. Elevate the head of the bed to high Fowler's 5. Administer a vasopressin antagonist as prescribed

1. Initiate an infusion of 3% NaCl 3. Restrict fluids to 800mL over 24 hours 5. Administer a vasopressin antagonist as prescribed

A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the ED, frantic and screaming for help. The nurse should instruct the woman to take which immediate action? 1. Irrigate the eyes with water 2. Come to the ED 3. Call the HCP 4. Irrigate the eyes with diluted hydrogen peroxide

1. Irrigate the eyes with water

A client has frequent bursts of v tach on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1. It can develop into v fib at any time 2. It is almost impossible to convert to a normal rhythm 3. It is uncomfortable for the client, giving a sense of impending doom 4. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia

1. It can develop into v fib at any time

A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? 1. Lying recumbent following meals 2. Consuming small, frequent, bland meals 3. Taking H2-receptor antagonist medication 4. Raising the head of the bed on 6-inch blocks

1. Lying recumbent following meals

A client with carcinoma of the lung develops SIADH as a complication of the cancer. The nurse anticipates that the HCP will request which prescriptions? Select all that apply 1. Radiation 2. Chemo 3. Increased fluid intake 4. Decreased oral sodium intake 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone

1. Radiation 2. Chemo 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1. Return of distal pulses 2. Brisk bleeding from the site 3. Decreasing edema formation 4. Formation of granulation tissue

1. Return of distal pulses

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced ET 4. Acute respiratory distress syndrome

1. Right pneumothorax

A client's ECG strip shows atrial and ventricular rates of 110 bpm. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? 1. Sinus tach 2. Sinus brady 3. Sinus dysrhythmia 4. Normal sinus rhythm

1. Sinus tach

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain

1. Sweating and pallor

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? 1. Temp of 101.6F orally 2. Complaints of discomfort during respositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep-breathing exercises

1. Temp of 101.6F orally

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? 1. The client's pain rating 2. Nonverbal cues from the client 3. The nurse's impression of the client's pain 4. Pain relief after appropriate nursing intervention

1. The client's pain rating

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1. The neurovascular status is normal because of increased blood flow through the leg 2. The neurovascular status is moderately impaired, and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour 4. The neurovascular status is adequate from an arterial approach, but venous complications are arising

1. The neurovascular status is normal because of increased blood flow through the leg

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function? 1. The passage of flatus 2. Absent bowel sounds 3. The client's ability to tolerate food 4. Bloody drainage from the colostomy

1. The passage of flatus

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat 2. Increase intake of fluids. including juices 3. Eat a good supper when anorexia is not as severe 4. Eat less often, preferably only 3 large meals daily

2. Increase intake of fluids. including juices

A client is being admitted to the hospital for treatment of acute cellulitis of lower left leg. During the admission assessment, the nurse expects to note which finding? 1. An inflammation of the epidermis only 2. A skin infection of the dermis and underlying hypodermis 3. An acute superficial infection of the dermis and lymphatics 4. An epidermal and lymphatic infection caused by Staphylococcus

2. A skin infection of the dermis and underlying hypodermis

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply 1. Tremors 2. Weight loss 3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face

3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face

The nurse is assessing a client with epididymitis. THe nurse anticipates which findings on physical examination? 1. Fever, diarrhea, groin pain, and ecchymosis 2. Nausea, painful scrotal edema, and ecchymosis 3. Fever, nausea, vomiting, and painful scrotal edema 4. Diarrhea, groin pain, testicular torsion, and scrotal edema

3. Fever, nausea, vomiting, and painful scrotal edema

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder

3. Flaccid paralysis

A client is admitted to a hospital with a diagnosis of DKA. The initial blood glucose level is 950 mg/dL. A continuous IV infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL. The nurse would next prepare to administer which medication? 1. An ampule of 50% dextrose 2. NPH insulin subQ 3. IV fluids containing dextrose 4. Phenytoin for the prevention of seizures

3. IV fluids containing dextrose

A client is brought to the ED in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated HCP's prescription? 1. Endotracheal intubation 2. 100 units of NPH insulin 3. IV infusion of normal saline 4. IV infusion of sodium bicarb

3. IV infusion of normal saline

The nurse is caring for a client following an autograft and grafting to a burn would on the right knee. What would the nurse anticipate to be prescribed for the client? 1. Out-of-bed activities 2. Bathroom privileges 3. Immobilization of the affected leg 4. Placing the affected leg in a dependent position

3. Immobilization of the affected leg

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers analgesics with little relief. Which problem may be causing the pain? 1. INfection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. THe recent occurrence of the fracture

3. Impaired tissue perfusion

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 bpm, and a urine output of 20 mL over the past hour. The nurse reports the findings to the HCP and anticipates which prescription? 1. Transfusing 1 unit of packed RBCs 2. Administering a diuretic to increase urine output 3. Increasing the amount of IV lactated ringers solution administered per hour 4. Changing the IV lactated ringers solution to one that contains 5% dextrose in water

3. Increasing the amount of IV lactated ringers solution administered per hour

A client arrives in the ED with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? 1. Apply an eye patch 2. Perform visual acuity tests 3. Irrigate the eye with sterile saline 4. Remove the piece of wood using a sterile eye clamp

3. Irrigate the eye with sterile saline

The nurse is caring for a client following a gastrojejunostomy (Billiroth II procedure). Which postop prescription should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the NG tube 4. Coughing and deep-breathing exercises

3. Irrigating the NG tube

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1. Ambulate following a meal 2. Eat high-carb foods 3. Limit the fluids taken with meals 4. Sit in a high Fowler's position during meals

3. Limit the fluids taken with meals

The nurse is caring for a client following enucleation and notes the presence of bright red drainage on the dressing. Which action should the nurse take at this time? 1. Document the finding 2. Continue to monitor the drainage 3. Notify the HCP 4. Mark the drainage on the dressing and monitor for any increase in bleeding

3. Notify the HCP

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which signs/symptoms of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain relieved by food intake 4. Pain radiating down the right arm

3. Pain relieved by food intake

The nurse is reviewing the lab results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL. Which dietary selection does the nurse suggest to the client? 1. Roast pork 2. Cheese omelet 3. Pasta with sauce 4. Tuna fish sandwich

3. Pasta with sauce

The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency? 1. Cyanosis 2. Arm edema 3. Periorbital edema 4. Mental status changes

3. Periorbital edema

The client with AIDS is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions noted on the skin

3. Positive punch biopsy of the cutaneous lesions

The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity

3. Presence of a "hot spot" on the cast

A client with GB syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 1. Giving client full control over care decisions and restricting visitors 2. Providing positive feedback and encouraging active ROM 3. Providing information, giving positive feedback, and encouraging relaxation 4. Providing IV administered sedatives, reducing distractions, and limiting visitors

3. Providing information, giving positive feedback, and encouraging relaxation

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? 1. Hypoglycemia 2. Level of hoarseness 3. Respiratory distress 4. Edema at the surgical site

3. Respiratory distress

The nurse is caring for a client who had an AKA 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? 1. Apply ice to the site 2. Call the HCP 3. Rewrap the residual limb with an elastic compression bandage 4. Apply a dry, sterile dressing and elevate the residual limb on 1 pillow

3. Rewrap the residual limb with an elastic compression bandage

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? 1. Speak loudly 2. Speak frequently 3. Speak at a normal volume 4. Speak directly into the impaired ear

3. Speak at a normal volume

The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? 1. Speak loudly, but mumble or slur the words 2. Speak loudly and clearly while facing the client 3. Speak at normal tone and pitch, slowly and clearly 4. Speak loudly and directly into the client's affected ear

3. Speak at normal tone and pitch, slowly and clearly

The nurse performs an admission assessment on a client with a diagnosis of TB. The nurse should check the results of which diagnostic test that will confirm this diagnosis? 1. Chest x-ray 2. Bronchoscopy 3. Sputum culture 4. Tuberculin skin test

3. Sputum culture

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate? 1. COntinue to suction 2. Notify the HCP immediately 3. Stop the procedure and reoxygenate the client 4. Ensure that the suction is limited to 15 seconds

3. Stop the procedure and reoxygenate the client

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? 1. Restrict all visitors 2. Restrict fluid intake 3. Teach the client and family about the need for hand hygiene 4. Insert an indwelling urinary catheter to prevent skin breakdown

3. Teach the client and family about the need for hand hygiene

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply 1. The nurse who never had roseola 2. The nurse who never had mumps 3. The nurse who never had chickenpox 4. The nurse who never had german measles 5. The nurse who never received the varicella zoster vaccine

3. The nurse who never had chickenpox 5. The nurse who never received the varicella zoster vaccine

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? 1. Redness around the pin sites 2. Pain on palpation at the pin sites 3. Thick, yellow drainage from the pin sites 4. Clear, watery drainage from the pin sites

3. Thick, yellow drainage from the pin sites

A client arrives at the ED with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition? 1. Pyelonephritis 2. Glomerulonephritis 3. Trauma to the bladder or abdomen 4. Renal cancer in the client's family

3. Trauma to the bladder or abdomen

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm? 1. Asystole 2. A fib 3. V fib 4. V tach

3. V fib

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 bpm. The nurse determines that the client is experiencing which dysrhythmia? 1. Sinus tach 2. V fib 3. V tach 4. Premature ventricular contractions

3. V tach

The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? 1. Administer O2 2. Check the client's vitals 3. Ventilate the client manually 4. Start CPR

3. Ventilate the client manually

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? 1. Using sterile sheets and linens 2. Performing strict hand-washing technique 3. Wearing gloves and a gown only when giving direct care to the patient 4. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

3. Wearing gloves and a gown only when giving direct care to the patient

The client has developed a fib, with a ventricular rate of 150 bpm. The nurse should assess the client for which associated signs and/or symptoms? 1. Flat neck veins 2. Nausea and vomiting 3. hTN and dizziness 4. HTN and headache

3. hTN and dizziness

The nurse performs a physical assessment on a client with type 2 DM. Findings include a fasting blood glucose level of 120 mg/dL, temp of 101F, pulse of 102 bpm, respirations of 22 br/min, and BP of 142/72 mmHg. Which finding would be the priority concern to the nurse? 1. pulse 2. respiration 3. temperature 4. BP

3. temperature

The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? 1. Elevated for 3 hours, then flat for 1 hour 2. Flat for 3 hours, then elevated for 1 hour 3. Flat for 12 hours, then elevated for 12 hours 4. Elevated on pillows continuously for 24-48 hours

4. Elevated on pillows continuously for 24-48 hours

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? 1. Fatigue 2. Weakness 3. Weight gain 4. Enlarged lymph nodes

4. Enlarged lymph nodes

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postop period for which most frequent complication of this type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance

4. Fluid and electrolyte imbalance

The nurse is caring for the client with increased ICP. THe nurse would note which trend in vital signs if the ICP is rising? 1. Increasing temp, increasing pulse, increasing RR, decreasing BP 2. Increasing temp, decreasing pulse, decreasing RR, increasing BP 3. Decreasing temp, decreasing pulse, increasing RR, decreasing BP 4. Decreasing temp, increasing pulse, decreasing RR, increasing BP

2. Increasing temp, decreasing pulse, decreasing RR, increasing BP

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired ROM while the client ambulates

2. Injury to the brachial plexus nerves

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20.60. What action should the nurse implement based on this finding? 1. Provide the client with materials on legal blindness 2. Instruct the client that he or she may need glasses when driving 3. Inform the client of where he or she can purchase a white cane with a red tip 4. Inform the client that it is best to sit near the back of the room when attending lectures

2. Instruct the client that he or she may need glasses when driving

When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply 1. Limiting the time with the client to 1 hour per shift 2. Keeping pregnant women out of the client's room 3. Placing the client in a private room with a private bath 4. Wearing a lead shield when providing direct client care 5. Removing the dosimeter film badge when entering the client's room 6. Allowing individuals younger than 16 years in the room as long as they are 6 feet away from the client.

2. Keeping pregnant women out of the client's room 3. Placing the client in a private room with a private bath 4. Wearing a lead shield when providing direct client care

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. 1. Lesion is painful to touch 2. Lesion is highly metastatic 3. Lesion is a nevus that has changes in color 4. Skin under the lesion is reddened and warm to touch 5. Lesion occurs in body area exposed to outdoor sunlight

2. Lesion is highly metastatic 3. Lesion is a nevus that has changes in color

The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the ICU. Which findings should alert the nurse to the presence of a possible postop complication? Select all that apply 1. Anxiety 2. Leukocytosis 3. Chvostek's sign 4. Urinary output of 800 mL/hr 5. Clear drainage on nasal dripper pad

2. Leukocytosis 4. Urinary output of 800 mL/hr 5. Clear drainage on nasal dripper pad

A client is admitted to an ED, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? 1. Warm the client 2. Maintain a patent airway 3. Administer thyroid hormone 5. Administer fluid replacement

2. Maintain a patent airway

A client admitted to the hospital with chest pain and a history of type 2 DM is scheduled for cardiac cath. Which medi would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1. Glipizide 2. Metformin 3. Repaglinide 4. Regular insulin

2. Metformin

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

2. Nail bed pressure

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure value of 23. What should be the nurse's initial action? 1. Apply normal saline drops 2. Note the time of day the test was done 3. Contact the HCP 4. Instruct the client to sleep with the head of the bed flat

2. Note the time of day the test was done

A client with CKD returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temp is 38.5C. Which nursing action is most appropriate? 1. Encourage fluid intake 2. Notify the HCP 3. Continue to monitor vital signs 4. Monitor the site of the shunt for infection

2. Notify the HCP

A client is diagnosed with the disorder involving the inner ear. Which is the most common client complete associated with a disorder involving this part of the ear? 1. Pruritis 2. Tinnitus 3. Hearing loss 4. Burning in the ear

2. Tinnitus

The nurse is administering fluids IV as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1. Vital signs 2. Urine output 3. Mental status 4. Peripheral pulses

2. Urine output

A client with MI is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1. Bradycardia 2. Ventricular dysrhythmias 3. Rising diastolic BP 4. Falling central venous pressure

2. Ventricular dysrhythmias

An oxygen delivery system is prescribed for a client with COPD to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? 1. Face tent 2. Venturi mask 3. Aerosol mask 4. Tracheostomy collar

2. Venturi mask

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wearing a gown and gloves to change the bed linens, and gloves only for the bath

2. Wearing a gown and gloves

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1. A negative Kernig's sign 2. Absence of nuchal rigidity 3. A positive Brudzinski's sign 4. A Glasgow Coma scale score of 15

3. A positive Brudzinski's sign

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsiflex the client's foot 2. Measure the abdominal girth 3. Ask the client to extend the arms 4. instruct the client to lean forward

3. Ask the client to extend the arms

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? 1. Bed rest 2. Ibuprofen 3. Bending or lifting 4. Application of heat

3. Bending or lifting

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? 1. Dry cough 2. Hematuria 3. Bronchospasm 4. Blood-streaked sputum

3. Bronchospasm

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1. Call a code 2. Call the HCP 3. Check the client's status and lead placement 4. Press the recorder button the ECG console

3. Check the client's status and lead placement

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken

3. Chest pain that occurs suddenly

A gastrectomy is performed on a client with gastric cancer. In the immediate postop period, the nurse notes bloody drainage from the NG tube. The nurse should take which most appropriate action? 1. Measure abdominal girth 2. Irrigate the NG tube 3. Continue to monitor the drainage 4. Notify the HCP

3. Continue to monitor the drainage

The nurse is assessing a client 24 hours following cholecystectomy. The nurse notes that the T-tube has drained 750mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? 1. Clamp the T-tube 2. Irrigate the T-tube 3. Document the findings 4. Notify the HCP

3. Document the findings

The nurse developing a teaching plan for a client with glaucoma. What instruction should the nurse include in the plan of care? 1. Avoid overuse of the eyes 2. Decrease the amount of salt in the diet 3. Eye meds will need to be administered for life 4. Decrease fluid intake to control the intraocular pressure

3. Eye meds will need to be administered for life

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose 2. Fluid is grossly bloody in appearance and has a pH of 6 3. Fluid clumps together on the dressing and has a pH of 7 4. Fluid separates into concentric rings and tests positive for glucose

4. Fluid separates into concentric rings and tests positive for glucose

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead there are fib waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm? 1. A fib 2. Sinus tach 3. V fib 4. V tach

1. A fib

The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer? 1. Dysuria 2. Hematuria 3. Urgency on urination 4. Frequency of urination

2. Hematuria

The nurse is planning to teach a client with GERD about substances to avoid. Which items should the nurse include on this list? Select all that apply 1. Coffee 2. Chocolate 3. Peppermint 4. Nonfat milk 5. Fried chicken 6. Scrambled eggs

1. Coffee 2. Chocolate 3. Peppermint 5. Fried chicken

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply 1. Fever 2. Positive Cullen's sign 3. Complaints of indigestion 4. Palpable mass in the LUQ 5. Pain in the URQ after a fatty meal 6. Vague LRQ abdominal discomfort

1. Fever 3. Complaints of indigestion 5. Pain in the URQ after a fatty meal

THe community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? 1. Hairdressers 2. The homeless 3. Children in daycare centers 4. Individuals living in a group home

1. Hairdressers

The community health nurse is conducting on educational session with community members regarding the signs and symptoms associated with TB. The nurse informs the participants that TB is considered as a diagnosis if which signs and symptoms are present? Select all that apply 1. Dyspnea 2. Headache 3. Night sweats 4. A bloody, productive cough 5. A cough with the expectoration of mucoid sputum

1. Dyspnea 3. Night sweats 4. A bloody, productive cough 5. A cough with the expectoration of mucoid sputum

The nurse is reviewing a client's record and notes that the HCP has documented that the client has chronic renal disease. On review of the lab results, the nurse most likely would expect to note which finding? 1. Elevated creatinine level 2. Decreased Hgb 3. Decreased RBC count 4. Increased number of WBCs in the urine

1. Elevated creatinine level

The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? 1. Encouraging fluids 2. Providing frequent oral care 3. Coughing and deep breathing 4. Monitoring RBC count

1. Encouraging fluids

The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply 1. Facial edema in the morning 2. Weight loss of 20 lb in 1 month 3. Serum calcium level of 12 mg/dL 4. Serum sodium level of 136 mg/dL 5. Serum potassium level of 3.4 mg/dL 6. Numbness and tingling of the lower extremities

1. Facial edema in the morning 3. Serum calcium level of 12 mg/dL 6. Numbness and tingling of the lower extremities

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply 1. Fever 2. Nausea 3. Lethargy 4. Tremors 5. Confusion 6. Bradycardia

1. Fever 2. Nausea 4. Tremors 5. Confusion

The nurse provides home care instructions to a client with SLE and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."

1. "I should take hot baths because they are relaxing."

A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? 1. "I need to avoid getting the cast wet." 2. "I need to cover the casted leg with warm blankets." 3. "I need to use my fingertips to lift and move my leg." 4. "I need to use something like a padded coat hanger end to scratch under the cast if it itches."

1. "I need to avoid getting the cast wet."

THe nurse provides instructions to a client about measures to treat IBS. Which statement by the client indicates a need for further teaching? 1. "I need to limit my intake of dietary fiber." 2. I need to drink plenty, at least 8-10 cups daily." 3. "I need to eat regular meals and chew my food well." 4. "I will take the prescribed medications because they will regulate my bowel patterns."

1. "I need to limit my intake of dietary fiber."

The home health nurse visits a client with a diagnosis of type 1 DM. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? 1. "I need to stop my insulin." 2. "I need to increase my fluid intake." 3. "I need to monitor my blood glucose every 3-4 hours." 4. "I need to call the HCP because of these symptoms."

1. "I need to stop my insulin."

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? 1. "I should increase the fiber in my diet." 2. "I will need to avoid caffeinated beverages." 3. "I'm going to learn some stress reduction techniques." 4. "I can have exacerbations and remissions with Crohn's disease."

1. "I should increase the fiber in my diet."

The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? 1. "I should limit my fluids to 1 liter per day." 2. "I should use my treadmill or go for walks daily." 3. "I should follow a moderate- calcium, high-fiber diet." 4. "My alendronate helps to keep calcium from coming out of my bones."

1. "I should limit my fluids to 1 liter per day."

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for TB. Which instructions should the nurse include on the list? Select all that apply 1. Activities should be resumed gradually 2. Avoid contact with other individuals, except family members, for at least 6 months 3. A sputum culture is needed every 2-4 weeks once medication therapy is initiated 4. Respiratory isolation is not necessary because family members already have been exposed 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags 6. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment

1. Activities should be resumed gradually 3. A sputum culture is needed every 2-4 weeks once medication therapy is initiated 4. Respiratory isolation is not necessary because family members already have been exposed 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags

A client being hemodialyzed suddenly becomes SOB and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply 1. Administer oxygen to the client 2. Continue dialysis at a slower rate after checking the lines for air 3. Notify the HCP and RRT 4. Stop dialysis, and turn the client on the left side with head lower than feet 5. Bolus the client with 500 mL of normal saline to break up the air embolus

1. Administer oxygen to the client 3. Notify the HCP and RRT 4. Stop dialysis, and turn the client on the left side with head lower than feet

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply 1. Administer stool softeners as prescribed 2. Instruct the client to limit fluid intake to avoid urinary retention 3. Encourage a high-fiber diet to promote bowel movements without straining 4. Apply cold packs to the anal-rectal area over the dressing until the packing is removed 5. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding

1. Administer stool softeners as prescribed 3. Encourage a high-fiber diet to promote bowel movements without straining 4. Apply cold packs to the anal-rectal area over the dressing until the packing is removed

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the HCP and prepares to implement which priority interventions? Select all that apply 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate IV 5. Transporting the client to the coronary care unit 6. Placing the client in a low Fowler's side lying position

1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate IV

The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? 1. Age younger than 50 years 2. History of colorectal polyps 3. Family history of colorectal cancer 4. Chronic inflammatory bowel disease

1. Age younger than 50 years

The client sustains a contusion of the eyeball following a Trumatic injury with a blunt object. which intervention should be initiated immediately? 1. Apply ice to the affected eye 2. Irrigate the eye with cool water 3. Notify the HCP 4. Accompany the client to the ED

1. Apply ice to the affected eye

The nurse should evaluate that defib of a client was most successful if which observation was made? 1. Arousable, sinus rhythm, BL 116/72 2. Nonarousable, sinus rhythm, BP 88/60 3. Arousable, marked bradycardia, BP 86/54 4. Nonarousable, SVT, BP 122/60

1. Arousable, sinus rhythm, BL 116/72

The nurse is caring for a client who is post op following a pelvic exenteration and the HCP changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet? 1. Bowel sounds 2. Ability to ambulate 3. Incision appearance 4. Urine specific gravity

1. Bowel sounds

During the early postoperative period, a client who has undergone cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? 1. Call the HCP 2. Reassure the client that this is normal 3. Turn the client onto his or her operative side 4. Administer the prescribed pain medication and antiemetic

1. Call the HCP

A client is admitted to the Ed with chest pain that is consistent with MI based on elevated troponin levels. heart sounds are normal and vital signs are noted on the client's chart. The nurse should alert the HCP because these changes are most consistent with which complication? 1. Cardiogenic shock 2. Cardiac tamponade 3. Pulmonary embolism 4. Dissecting thoracic aortic aneurysm

1. Cardiogenic shock

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply 1. Check the level of the drainage bag 2. Reposition the client to his or her side 3. Contact the HCP 4. Place the client in good body alignment 5. Check the peritoneal dialysis system for kinks 6. Increase the flow rate of the peritoneal dialysis solution

1. Check the level of the drainage bag 2. Reposition the client to his or her side 4. Place the client in good body alignment 5. Check the peritoneal dialysis system for kinks

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Clear mentation 2. Minimal dyspnea 3. O2 sat of 85% 4. Arterial O2 level of 78 mm Hg

1. Clear mentation

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply 1. Maintain NPO status 2. Encourage coughing and deep breathing 3. Give small, frequent high-calorie feedings 4. Maintain the client in a supine and flat position 5. Give hydromorphone IV as prescribed for pain 6. Maintain IV fluids at 10 mL/hr to keep the vein open

1. Maintain NPO status 2. Encourage coughing and deep breathing 5. Give hydromorphone IV as prescribed for pain

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1. Malaise 2. Dark stools 3. Weight gain 4. LUQ discomfort

1. Malaise

The nurse is taking the history of a client with occupational lung disease. The nurse should assess whether the client wears which item during periods of exposure to silica particles? 1. Mask 2. Gown 3. Gloves 4. Eye protection

1. Mask

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1. Notify the HCP 2. Administer the prescribed pain medication 3. Call and ask the operating room team to perform surgery as soon as possible 4. Reposition the client and apply a heating pad on the warm setting to the client's abdomen

1. Notify the HCP

A client is admitted to the ED following a fall fro ma horse and the HCP prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action? 1. Notify the HCP before performing the catheterization 2. Use a small-sized catheter and an anesthetic gel as a lubricant 3. Administer parenteral pain med before inserting the catheter 4. Clean the meatus with soap and water before opening the cath kit

1. Notify the HCP before performing the catheterization

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. 1. Nuts 2. Corn 3. Liver 4. Apples 5. Lentils 6. Bananas

1. Nuts 3. Liver 5. Lentils

The nurse is assessing the patency of a client's left arm AV fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? 1. Palpation of a thrill over the fistula 2. Presence of a radial pulse in the left wrist 3. Visualization of enlarged blood vessels at the fistula site 4. Cap refill less than 3 seconds in the nail beds of the fingers on the left hand

1. Palpation of a thrill over the fistula

The nurse is conducting a history and monitoring lab values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply 1. Pathological fracture 2. Urinalysis positive for nitrates 3. Hgb level of 15.5 g/dL 4. Calcium level of 8.6 mg/dL 5. Serum creatinine level of 2.0 mg/dL

1. Pathological fracture 2. Urinalysis positive for nitrates 5. Serum creatinine level of 2.0 mg/dL

A client with AKI has a serum potassium level of 7 mEq/L. The nurse should plan which actions as a priority? Select all that apply 1. Place the client on a cardiac monitor 2. Notify the HCP 3. Put the client on NPO status except for ice chips 4. Review the client's meds to determine if any contain or retain potassium 5. Allow an extra 500 mL if IV fluid intake to dilute the electrolyte concentration

1. Place the client on a cardiac monitor 2. Notify the HCP 4. Review the client's meds to determine if any contain or retain potassium

The nurse is monitoring a client newly diagnosed with DM for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of DM if the blood glucose is not adequately managed? 1. Polyuria 2. Diaphoresis 3. Pedal edema 4. Decreased respiratory rate

1. Polyuria

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply 1. Polyuria 2. Headache 3. Bone pain 4. Nervousness 5. Weight gain

1. Polyuria 3. Bone pain

A client who is HIV-positive has had a tuberculin skin test. The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? 1. Positive 2. Negative 3. Inconclusive 4. Need for repeat testing

1. Positive

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function

1. Protecting the client from infection

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1. The right eye is tested, followed by the left eye, and then both eyes are tested 2. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye 3. The client is asked to stand at a distance of 40 feet from the chart and to read the largest line on the chart 4. THe client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision

1. The right eye is tested, followed by the left eye, and then both eyes are tested

The nurse is instructing a client with DM about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of what complication? 1. Peritonitis 2. Hyperglycemia 3. Hyperphosphatemia 4. Disequilibrium syndrome

2. Hyperglycemia

The nurse is preparing a plan of care for a client with DM who has hyperglycemia. The nurse places priority on which client problem? 1. Lack of knowledge 2. Inadequate fluid volume 3. Compromised family coping 4. Inadequate consumption of nutrients

2. Inadequate fluid volume

The nurse is caring for a client hospitalized with acute exacerbation of COPD. Which findings would the nurse expect to note on assessment of this client? Select all that apply 1. A low arterial PCO2 level 2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen sat with mild exercise 4. A widened diaphragm noted on the chest x-ray 5. Pulmonary function tests that demonstrate increased vital capacity

2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen sat with mild exercise

A client arrives in the emergency department following an automobile crash. The clients forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position? 1. Flat in bed 2. A semi-fowler's position 3. Lateral on the affected side 4. Lateral on the unaffected side

2. A semi-fowler's position

A client with type 1 DM calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? 1. "I should not exercise since I am taking insulin." 2. "The best time for me to exercise is after breakfast." 3. "The best time for me to exercise is mid- to late afternoon." 4. "NPH is a basal insulin, so I should exercise in the evening."

2. "The best time for me to exercise is after breakfast."

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? 1. 5 seconds 2. 10 seconds 3. 30 seconds 4. 60 seconds

2. 10 seconds

A client presents at the HCP's office with complaints of a ring-like rash on his upper leg. WHich question should the nurse ask first? 1. "Do you have any cats in your home?" 2. "Have you been camping in the last month?" 3. Have you or close contacts had any flu-like symptoms within the last few weeks?" 4. "Have you been in physical contact with anyone who has the same type of rash?"

2. "Have you been camping in the last month?"

The HCP has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis? 1. "I have had unprotected sex with multiple partners." 2. "I ate shellfish about 2 weeks ago at a local restaurant." 3. "I was an IV drug abuser in the past and shared needles." 4. "I had a blood transfusion 30 years ago after major abdominal surgery."

2. "I ate shellfish about 2 weeks ago at a local restaurant."

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? 1. "I will use a straw for drinking." 2. "I will drive only during the day time." 3. "I will be careful because the device alters balance." 4. "I will wash the skin daily under the lamb's wool liner of the vest."

2. "I will drive only during the day time."

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hr for 2 hours. The client received a single bolus of 500 mL of IV fluid. URine output for the subsequent hour was 25 mL. Daily lab results indicate that the BUN level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1. Hypovolemia 2. AKI 3. Glomerulonephritis 4. UTI

2. AKI

A client is diagnosed with scleroderma. Which interventions should the nurse anticipate to be prescribed? 1. Maintain bed rest as much as possible 2. Administer corticosteroids as prescribed for inflammation 3. Advise the client to remain supine for 1-2 hours after meals 4. Keep the room temp warm during the day and cool at night

2. Administer corticosteroids as prescribed for inflammation

A client has a neuro deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? 1. Is disoriented to person, place and time 2. Affect is flat, with periods of emotional lability 3. Cannot recall what was eaten for breakfast today 4. Demonstrates inability to add and subtract; does not know who is the president of the US

2. Affect is flat, with periods of emotional lability

A client calls the nurse in the ED and states that he was just stung by a bee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? 1. Advise the client to soak the site in hydrogen peroxide 2. Ask the client if he ever sustained a bee sting in the past 3. Tell the client to call an ambulance for transport to the ED 4. Tell the client not to worry about the sting unless difficulty with breathing occurs

2. Ask the client if he ever sustained a bee sting in the past

A client is brought to the ED with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply 1. Restrict fluids 2. Assess for airway patency 3. Administer O2 as prescribed 4. Place a cooling blanket on the client 5. Elevate extremities if no fractures are present 6. Prepare to give oral pain medication as prescribed

2. Assess for airway patency 3. Administer O2 as prescribed 5. Elevate extremities if no fractures are present

A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1. Increase sodium in the diet 2. Avoid sudden head movements 3. Lie still and watch the television 4. Increase fluid intake to 3000 mL/day

2. Avoid sudden head movements

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an IV infusion at a rate of 150 mL/hr, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL. The client's BUN level is 35 mg/dL and the serum creatinine level is 1.8 mg/dL, measured this morning. Which nursing action is the priority? 1. Check the urine specific gravity 2. Call the HCP 3. Put the IV line on a pump so that the infusion rate is sure to stay stable 4. Check to see if the client had a blood sample for a serum albumin level drawn

2. Call the HCP

The nurse is assessing the perineal wound in a client who has returned from the OR following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? 1. Clamp the surgical drain 2. Change the dressing as prescribed 3. Notify the HCP 4. Remove and replace the perineal packing

2. Change the dressing as prescribed

A client with a diagnosis of DKA is being treated in the ED. Which findings support this diagnosis? Select all that apply 1. Increase in pH 2. Comatose state 3. Deep, rapid breathing 4. Decreased urine output 5. Elevated blood glucose level

2. Comatose state 3. Deep, rapid breathing 5. Elevated blood glucose level

A client with DM demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? 1. Administer a sedative 2. Convey empathy, trust, and respect toward the client 3. Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear 4. Make sure that the client is familiar with the correct medical terms to promote understanding of what is happening

2. Convey empathy, trust, and respect toward the client

A client with MI suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1. Stridor 2. Crackles 3. Scattered rhonchi 4. Diminished breath sounds

2. Crackles

The ED nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury

2. Diminished breath sounds

The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? 1. Placing cool compresses on the affected arm 2. Elevating the affected arm on a pillow above heart level 3. Avoiding arm exercises in the immediate post op period 4. Maintaining an IV site below the AC area on the affected side

2. Elevating the affected arm on a pillow above heart level

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? 1. Coma 2. Flushing 3. Dizziness 4. Tachycardia

2. Flushing

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? 1. Cold, bluish-colored fingers 2. Numbness and tingling in the fingers 3. Pain that increases when the arm is dependent 4. Pain that is out of proportion to the severity of the fracture

2. Numbness and tingling in the fingers

The nurse is preparing to give a bed bath to an immobilized client with TB. The nurse should wear which items when performing this care? 1. Surgical mask and gloves 2. Particulate respirator, gown, and gloves 3. Particulate respirator and protective eyewear 4. Surgical mask, gown, and protective eyewear

2. Particulate respirator, gown, and gloves

The nurse is discussing the techniques of chest physiotherapy and postural drainage to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? 1. Palpation and clubbing 2. Percussion and vibration 3. Hyperoxygenation and suctioning 4. Administer a bronchodilator and monitor peak flow

2. Percussion and vibration

A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply 1. Flatulence 2. Peritonitis 3. Hemorrhage 4. Fistula formation 5. Bowel perforation 6. Lactose intolerance

2. Peritonitis 3. Hemorrhage 4. Fistula formation 5. Bowel perforation

The clinic nurse notes that the HCP has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 1. Positive patch test 2. Positive culture results 3. Abnormal biopsy results 4. Wood's light examination indicative of infection

2. Positive culture results

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? 1. Stoma is beefy red and shiny 2. Purple discoloration of the stoma 3. Skin excoriation around the stoma 4. Semi-formed stool noted in the ostomy pouch

2. Purple discoloration of the stoma

The nurse teaches a client with DM about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor

2. Shakiness 3. Palpitations 5. Lightheadedness

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1. BP 2. Status of airway 3. O2 flow rate 4. LOC

2. Status of airway

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? 1. Lower the head of the bed 2. Test the drainage for glucose 3. Obtain a culture of the drainage 4. Continue to observe the drainage

2. Test the drainage for glucose

The nurse is instructing a client to perform a TSE. The nurse should provide the client with which information about the procedure? 1. To examine the testicles while lying down 2. That the best time for the examination is after a shower 3. To gently feel the testicle with 1 finger to feel for a growth 4. That TSEs should be done at least every 6 months

2. That the best time for the examination is after a shower

A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition? 1. Rupture of the bladder 2. The development of a vesicovaginal fistula 3.Extreme stress caused by the diagnosis of cancer 4. Altered perineal sensation as a side effect of radiation therapy

2. The development of a vesicovaginal fistula

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1. Decreased HR 2. Increased urine output 3. Increased BP 4. Elevated hematocrit

4. Elevated hematocrit

As part of chemo education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression. The nurse understands that further teaching is needed if the client makes which statement? 1. "I should avoid blowing my nose." 2. "I may need a platelet transfusion if my platelet count is too low." 3. "I'm going to take aspirin for my headache as soon as I get home." 4. "I will count the number of pads and tampons I use when menstruating."

3. "I'm going to take aspirin for my headache as soon as I get home."

A client calls the ED and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? 1. "Come to the ED." 2. "Apply calamine lotion immediately to exposed skin areas." 3. "Take a shower immediately, lathering and rinsing several times." 4. "It is not necessary to do anything if you cannot see anything on your skin."

3. "Take a shower immediately, lathering and rinsing several times."

The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? 1. "I change my pouch every week." 2. "I change the appliance in the morning." 3. "I empty the urinary collection bag when it is 2/3 full." 4. "When I'm in the shower I direct the flow of water away from my stoma."

3. "I empty the urinary collection bag when it is 2/3 full."

The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? 1. "My skin will have tiny red vesicles." 2. "The presence of the skin vesicles is caused by a virus." 3. "I have an autoimmune disease that causes blistering in the epidermis." 4. "The presence of red, raised papules and large plaques covered by silvery scales will be present on my skin."

3. "I have an autoimmune disease that causes blistering in the epidermis."

The nurse is preparing a group of Cub scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction? 1. "I need to bring a hat to wear during the trip." 2. "I should wear long-sleeved tops and long pants." 3. "I should not use insect repellents because it will attract the ticks." 4. "I need to wear closed shoes and socks that can be pulled over my pants."

3. "I should not use insect repellents because it will attract the ticks."

The nurse has taught the client about an upcoming ERCP procedure. The nurse determines that the client needs further information if the client makes which statement? 1. "I know I must sign the consent form." 2. "I hope the throat spray keeps me from gagging." 3. "I'm glad I don't have to lie still for this procedure." 4. "I'm glad some IV medication will be given to relax me."

3. "I'm glad I don't have to lie still for this procedure."

The nurse is collecting data from a client. Which symptom described by the client is claracteristic of an early symptom of BPH? 1. Nocturia 2. Scrotal edema 3. Occasional constipation 4. Decreased force in the stream of urine

4. Decreased force in the stream of urine

A client arrives at the ED following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1. 100% oxygen via an aerosol mask 2. Oxygen via nasal cannula at 6 L/min 3. Oxygen via nasal cannula at 15 L/min 4. 100% oxygen via a tight-fitting, nonrebreather face mask

4. 100% oxygen via a tight-fitting, nonrebreather face mask

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? 1. "I can sit down to put on my pants and shoes." 2. "I try to exercise every day and rest when I'm tired." 3. "My son removed all loose rugs from my bedroom." 4. "I don't need to use my walker to get to the bathroom."

4. "I don't need to use my walker to get to the bathroom."

THe nurse has given instructions to a client returning home after knee arthroplasty. Which statement by the client indicates that the instructions are understood? 1. "I can resume regular exercise tomorrow." 2. "I can't eat food for the remainder of the day." 3. "I need to stay off the leg entirely for the rest of the day." 4. "I need to report a fever or swelling to my HCP."

4. "I need to report a fever or swelling to my HCP."

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? 1. "I should notify my HCP if my feet or legs start to swell" 2. "My doctor told be to call his office if my pulse rate decreases below 60." 3. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." 4. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

4. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply 1. An irregularly shaped lesion 2. A small papule with a dry, rough scale 3. A firm, nodular lesion topped with crust 4. A pearly papule with a central crater and a waxy border 5. Location in the bald spot atop the head that is exposed to outdoor sunlight

4. A pearly papule with a central crater and a waxy border 5. Location in the bald spot atop the head that is exposed to outdoor sunlight

Nurse is performing in otoscopic examination a client with mastoiditis. On examination of the Tim panic membrane, which findings should the nurse expect observe? 1. A pink-colored tympanic membrane 2. A pearly colored tympanic membrane 3. A transparent and clear tympanic membrane 4. A red, dull, thick, and immobile tympanic membrane

4. A red, dull, thick, and immobile tympanic membrane

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? 1. A 25-year-old woman who runs 2. A 36-year-old man who has asthma 3. A 70-year-old man who consumes excess alcohol 4. A sedentary 65-year-old woman who smokes cigarettes

4. A sedentary 65-year-old woman who smokes cigarettes

The nurse is performing admission assessment on a client with a diagnosis of detached retina. Which sign or symptom associated with this Eye disorder? 1. Total loss of vision 2. Pain in the affected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision

4. A sense of a curtain falling across the field of vision

A client arriving at the ED has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? 1. A pink, edematous hand 2. Fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color to the skin, which is insensitive to touch

4. A white color to the skin, which is insensitive to touch

During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease? 1. Diarrhea 2. Hypermenorrhea 3. Abnormal bleeding 4. Abdominal distention

4. Abdominal distention

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defib. The nurse should assess which item based on priority? 1. Anxiety level of the client and family 2. Presence of a MedicAlert card for the client to carry 3. Knowledge of restrictions on postdischarge physical activity 4. Activation status of the device, HR cutoff, and number of shocks it is programmed to deliver

4. Activation status of the device, HR cutoff, and number of shocks it is programmed to deliver

The nurse is caring for a client admitted to the ED with DKA. In the acute phase, the nurse plans for which priority intervention? 1. Correct the acidosis 2. Administer 5% dextrose IV 3. Apply a monitor for an ECG 4. Administer short-duration insulin IV

4. Administer short-duration insulin IV

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? 1. Monitoring the temp 2. Monitoring complaints of heartburn 3. Giving warm gargles for a sore throat 4. Assessing for the return of the gag reflex

4. Assessing for the return of the gag reflex

A client is admitted to the hospital with a diagnosis of BPH, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the HCP? 1. Red, bloody urine 2. Pain rated 2/10 3. Urinary output of 200 mL higher than intake 4. BP, 100/50; pulse 130 bpm

4. BP, 100/50; pulse 130 bpm

The nurse performing an assessment on a client suspected diagnosis of cataract. Which clinical manifestations of the nurse expect to know in the early stages of cataracts formation? 1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision

4. Blurred vision

The nurse is reviewing an ECG rhythm strip The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 bpm. WHich action should the nurse take? 1. Check vital signs 2. Check lab test results 3. Notify the HCP 4. COntinue to monitor for any rhythm changes

4. COntinue to monitor for any rhythm changes

The nurse is assisting to defib a client in v fib. After placing the pad on the client's chest and before discharge, which intervention is a priority? 1. Ensure that the client has been intubated 2. Set the defib to the synchronize mode 3. Administer an amiodarone bolus IV 4. Confirm that the rhythm is actually v fib

4. Confirm that the rhythm is actually v fib

The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully? 1. Gets angry with family if they interrupt a task 2. Experiences bouts of depression and irritability 3. Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self

4. Consistently uses adaptive equipment in dressing self

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? 1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear 3. Cranial nerve III, oculomotor 4. Cranial nerve VII, facial nerve

4. Cranial nerve VII, facial nerve

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply 1. Diarrhea 2. Black ,tarry stools 3. Hyperactive bowel sounds 4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. LUQ pain with radiation to the back

4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. LUQ pain with radiation to the back

The client newly diagnosed with CKD recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? 1. HTN, tachy, and fever 2. hTN, brady, and hypothermia 3. Restlessness, irritability, and generalized weakness 4. HA, deteriorating level of consciousness, and twitching

4. HA, deteriorating level of consciousness, and twitching

A week after kidney transplant, a client develops a temp of 101F, the BP is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The xray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? 1. ANtibiotic therapy 2. Peritoneal dialysis 3. Removal of the transplanted kidney 4. Increased immunosuppression therapy

4. Increased immunosuppression therapy

A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply 1. Peritoneal dialysis 2. Analysis of the urinary stone 3. IV opioid analgesics 4. Insertion of a nephrostomy tube 5. Placement of a ureteral stent with ureteroscopy

4. Insertion of a nephrostomy tube 5. Placement of a ureteral stent with ureteroscopy

An external insulin pump is prescribed for a client with DM. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? 1. It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals 2. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels 3. It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream. 4. It administers a small continuous dose of short-duration insulin subQ. The client can self-administer an additional bolus dose from the pump before each meal

4. It administers a small continuous dose of short-duration insulin subQ. The client can self-administer an additional bolus dose from the pump before each meal

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action? 1. Immobilize the affected extremity 2. Remove jewelry and constricting clothing from the victim 3. Place the extremity in a position so that it is below the level of the heart 4. Move the victim to a safe area away from the snake and encourage the victim to rest.

4. Move the victim to a safe area away from the snake and encourage the victim to rest.

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action? 1. Monitor the client 2. Elevate the head of the bed 3. Assess the fistula site and dressing 4. Notify the HCP

4. Notify the HCP

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1. Slow, deep breathing 2. Rapid, deep breathing 3. Paradoxical respirations 4. Pain, especially on exhalation

4. Pain, especially on exhalation

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication? 1. Warmth, redness, and pain in the left hand 2. Ecchymosis and audible bruit over the fistula 3. Edema and reddish discoloration of the left arm 4. Pallor, diminished pulse, and pain in the left hand

4. Pallor, diminished pulse, and pain in the left hand

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 1. Intact skin 2. Full-thickness skin loss 3. Exposed bone, tendon, or muscle 4. Partial thickness skin loss of the dermis

4. Partial thickness skin loss of the dermis

While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? 1. Call the HCP 2. Reinsert the implant into the vagina 3. Pick up the implant with gloved hands and flush it down the toilet 4. Pick up the implant with long-handled forceps and place it in a lead container

4. Pick up the implant with long-handled forceps and place it in a lead container

A clienth in sinus brady, with a heart rate of 45 bpm, complains of dizziness and has a BP of 82/60 mmHg. Which prescription should the nurse anticipate will be prescribed? 1. Administer digoxin 2. Defibrillate the client 3. Continue to monitor the client 4. Prepare for transcutaneous pacing

4. Prepare for transcutaneous pacing

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination

4. Promote carbon dioxide elimination

A client with a hip fracture asks the nurse about Buck's traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? 1. Allows bony healing to begin before surgery and involves pins and screws 2. Provides rigid immobilization of the fracture site and involves pulleys and wheels 3. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws 4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

The client is admitted to the hospital with a diagnosis of GB syndrome. Which past medical history finding makes the client most at risk for this disease? 1. Meningitis or encephalitis during the last 5 years 2. Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or GI infection during the previous month

4. Respiratory or GI infection during the previous month

The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation? 1. Fever 2. Fatigue 3. Weight loss 4. SOB

4. SOB

A client with DM has had a right BKA. Given the client's history of DM, which complication is the client most at risk for after the surgery? 1. Hemorrhage 2. Edema of the residual limb 3. Slight redness of the incision 4. Separation of the wound edges

4. Separation of the wound edges

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? 1. SItting up in bed 2. Side-lying in bed 3. Sitting in a recliner chair 4. Sitting up and leaning on an overbed table

4. Sitting up and leaning on an overbed table

The nurse witnessed a vehicle hit a pedestrian. THe victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? 1. Try to reduce the fracture maually 2. Assist the victim to get up and walk to the sidewalk 3. Leave the victim for a few moments to call an ambulance 4. Stay with the victim and encourage him or her to remain still

4. Stay with the victim and encourage him or her to remain still

A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder? 1. Soft and swollen prostate gland 2. Swollen and boggy prostate gland 3. Tender and edematous prostate gland 4. Tender indurated prostate gland that is warm to the touch

4. Tender indurated prostate gland that is warm to the touch

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply 1. Presence of striae 2. Palpable radial pulses 3. Absence of any ecchymosis on the extremities 4. Thinner and decrease number of reddish papules 5. Scarce amount of silvery-white scaly patches on the arms

4. Thinner and decrease number of reddish papules 5. Scarce amount of silvery-white scaly patches on the arms