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Terms in this set (192)A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching? A. "I will monitor my husband for coughing while he's eating." C. I will monitor my husband for tilting his head forward when he swallows. A nurse is assessing a client and discovers the infusion pump with the client's TPN solution is not infusing. The nurse should monitor the client for which of the following conditions? A. Excessive thirst & urination B. Shakiness & diaphoresis (at risk for hypoglycemia) A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? A. Stress incontinence C. Overflow incontinence A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply) A. Genetic Predisposition B, C, D, E (hypercholesterolemia, htn, obesity, smoking) A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended d/t which of the following findings in the client's medical hx? A. Hx of dermatitis B. Hx of breast cancer A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching? A. Limit fluid intake not r/t meals. C. Avoid eating w/in 3 hrs of bedtime A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid? A. Nonfat milk B. Chocolate A nurse is teaching a client about the adverse effects of cisplatin. Which of the following adverse effects should the nurse include in the teaching? A. Tinnitus A. Tinnitus A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply) A. Check peripheral pulses in affected extremity A, D, E (Check peripheral pulses in affected extremity, Keep the client's hip and leg extended, Have the client remain in bed up to 6 hr) A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control? A. "I will call for pain medication before the previous dose wears off" A. "I will call for pain medication before the previous dose wears off." A nurse is teaching a client about the 7 warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply) A. A nonhealing sore A, C, D, E (a nonhealing sore, change in bowel pattern, change in moles, nagging cough) A nurse is preparing to administer TPN 1800 mL to infuse over 24 hrs. The nurse should set the iv pump the deliver how many mL/hr? (round to nearest whole #) 75 mL/hr A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? A. Pulse and BP findings D. A self-report pain rating scale A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in color of his urine? A. Pale pink A. Pale pink A nurse in a provider's office is reviewing the lab results of a client who takes furosemide for HTN. The nurse notes that the client's potassium level is 3.3. The nurse should monitor the client for which of the following complications? A. Cardiac dysrhythmias A. Cardiac dysrhythmias A nurse is collecting a medication hx from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts w/contrast material and places the client at risk for acute kidney injury? A. Atorvastatin B. Metformin A nurse is caring for a client who has cancer and a new prescription for ondansetron to tx chemo-induced nausea. For which of the following adverse effects should the nurse monitor? A. Headache A. Headache A nurse is teaching a client who is starting to take methotrexate to treat RA. Which of the following instructions should the nurse include in the teaching? A. "Avoid eating foods high in vitamin K." D. Drink at least 2 L of water daily A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply) A. Poor skin turgor A, C, E (poor skin turgor, hypotension, flat neck veins) A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make? A. "The laxative will prevent the absorption of magnesium." B. The laxative helps eliminate the barium A nurse is reviewing lab values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function? A. Serum Creatinine A. Serum creatinine A nurse is caring for a client who is 1 day postop following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply) A. Add the amount of bladder irrigation to the total output B, C, E (use sterile technique when preparing the irrigation system, Ensure the drainage tubing is patent and without obstruction, and notify the surgeon if the urine is bright red in appearance or has large clots) A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link w/Crohn's disease. Which of the following information should the nurse include? A. Both are inflammatory A. Both are inflammatory A nurse is planning care for a client who has immunosuppression following chemo. Which of the following interventions should the nurse include in the plan of care? A. Insert an indwelling catheter to monitor sediment in the urine D. Limit the amount of healthcare workers entering the room A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated w/early menopause? A. Urinary
retention C. Dryness w/intercourse A nurse is caring for a client who has cancer and is receiving TPN. Which of the following lab values indicates the tx is effective? A. Hct 43% C. Albumin 4.2 The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action? A. Notify the provider of the client's allergy A. Notify the provider of the client's allergy A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? A. Decrease in the respiratory rate from 20 to 16 D. Increase in HR from 88 to 110 A nurse is planning care for a client who is 2hr postop following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include? A. Restrict the client's oral fluid intake B. Remind the client he might feel constant urge to void A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation therapy for the tx of lung cancer. Which of the following should the nurse plan to include in the teaching? A. Bottled
water is an appropriate choice to increase fluid intake A. Bottled water is an appropriate choice to increase fluid intake A nurse remains with a client to observe for any adverse reactions for initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions? A. Febrile B. Hemolytic A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching? A. Hx of smoking D. Race A nurse is providing teaching to a client about measures to prevent UTIs. Which of the following client statements indicates a need for further teaching? A. "I will need to wipe my perineal area from back to front after urination." A. I will need to wipe my perineal area from back to front after urination A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication? A. Decreased BP A. Decreased BP A nurse in the ED is assessing a client who is having a suspected acute MI. Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply) A. Orthopnea C, D, E (nausea, tachycardia, diaphoresis) A nurse is talking with a client whose thyroid-stimulating hormone (TSH) level will be measured. Which of the following statements by the nurse explains the purpose of this test? A. This test measures the amount of thyroid hormone that attaches to a protein in your blood D. This test determines whether your thyroid gland is overactive, appropriately active, or underactive A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? A. A reddened area over the sacrum A. A reddened area over the sacrum A nurse is teaching a client who is to begin long-term therapy w/ prednisone to treat RA. The nurse should instruct the client to take which of the following supplements while taking this medication? A. Calcium and Vitamin D A. Calcium and Vitamin D A nurse is admitting a client who is about to undergo surgery for BPH. The client states, "I don't know what I'll do if they find cancer." Which of the following responses should the nurse make? A. "Why do you think
you might have cancer when your diagnosis is a benign condition?" D. I'm hearing that you're concerned that it might turn out that you have cancer A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations? A. Sensitivity to cold C. Frequent mood changes A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is priority? A. Pupil reaction D. Respiratory Rate A nurse is caring for a client whose pap test cytology results are abnormal. Which of the following procedures should the nurse anticipate? A. Rectovaginal palpation by the provider D. Colposcopy A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous iv infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give? A. "It actually takes heparin 2-3 days to reach a therapeutic blood level." C. Heparin does not dissolve clots, it stops new ones from forming A nurse is providing teaching to a client who is postoperative following a coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? A. It decreases the clients level of anxiety B. It facilitates the clients deep breathing A nurse is caring for a 2-year-old child who is hospitalized and throws a tantrum when his parent leaves. Which of the following toys should the nurse provide to alleviate the child's stress? A. Set of building blocks B. Toy hammer and pounding board A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation? A. Avoiding covering sores and bandages C. Avoid foods prepared w/tapwater A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching (Select all that apply) A.
Bacteria C, D, E (aging, obesity, smoking) A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority? A. Intracranial pressure D. Respiratory status A nurse is planning care for a client who has viral hepatitis. Which of the following actions should the nurse include in the plan of care? A. Provide a high carb diet A. Provide a high carb diet A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client? A. Soy milk A. Soy milk A nurse is caring for a 1-month old infant who weighs 3500 g and is prescribed a dose of cephazolin 50 mg/kg by intermittent IV bolus 3x daily. How many mg should the nurse administer per dose (round to nearest tenth) 175 mg A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching? A. "The procedure will be canceled if the urinalysis indicates the presence of RBCs." D. "After the procedure, you will be encouraged to drink plenty of fluids." A nurse is caring for a client who has Crohn's disease and is receiving parenteral nutrition. Which of the following interventions should the nurse include in the care of this client? A. Remove the parenteral nutrition solution from the refrigerator 2 hr before infusion C. monitor daily lab values and report as needed A nurse is reviewing a client's lab values. Which of the following should the nurse report to the provider? A. Hct 45% B. WBC 1700 A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching? A. Drink 3 L of fluid every day A. Drink 3 L of fluid every day A nurse is assessing a client who has Grave's Disease. The nurse should expect which of the following lab results? A. Decreased TSH level A. Decreased TSH level A nurse is reviewing the lab values of a client who had a MI 3 hrs ago. The nurse should expect which of the following lab values to be elevated? A. AST D. Serum amylase A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor? A. Diagnosis of DM D. cigarette smoking A nurse is assessing a client 1 day postop following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take? A. Have
the client lie flat in bed C. Cover the area w/ saline-soaked sterile dressings A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching? A. A weight loss program can decrease my LDL cholesterol level D. Increasing my intake of foods containing trans-fatty acids can lower my risk
A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include? A. Sleep on your left side C. Eat 4 small meals each day A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions? A. Liver C. Beans A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority? A.
Oxygen saturation A. O2 saturation A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, "I don't understand why my child is so upset. I've never seen my child act this way around others before." Which of the following statements should the nurse make? A. This is normal,
expected reaction for a child this age. A. This is a normal, expected reaction for a child this age A nurse is caring for a client who has HTN and asks the nurse about a prescription for propranolol. The nurse should inform the client that the medication is contraindicated in clients who have a hx of which of the following conditions? A. Asthma A. Asthma A nurse is caring for a client who has Cushing's Syndrome. The nurse should recognize that which of the following manifestations of Cushing's Syndrome? A. Alopecia C,D,E (moon face, purple striations, buffalo hump) While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? A. A systolic murmur A. A systolic murmur A nurse is providing preop teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postop complications should the nurse include in the teaching? A. Teaching the client how to use the PCA pump B. Instruct the client about the use of sequential compression device A nurse at a provider's office is providing teaching to a client who is taking chemo and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (Select all that apply) A. Top fruits w/yogurt A, B, C, E (top fruits w/yogurt, add cream to soups, use milk instead of water in recipes, and dip meats in eggs/bread crumbs before cooking) A nurse is completing dietary teaching on consuming a low fiber diet w/a client who has ulcerative colitis. Which of the following foods should be eliminated in the client's diet? A. Cooked cabbage B. Dried apricots A nurse is the clinic is reviewing lab values for a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following lab values? A. TSH A. TSH A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching? A. eat plenty of fresh fruits and vegetables B. Avoid crowds A nurse is assessing a client who returned to the unit 4 hr ago after a partial colectomy. Which of the following findings should the nurse attend to first? A. A moderately saturated dressing B. Report of severe incisional pain A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? A. I drink at least 2 quarts of fluid every day D. I don't eat shellfish because it gives me hives A nurse is caring for a client who has a new onset of chest pressure severe epigastric distress. The physician prescribes monitoring of creatinine kinase (CK) isoenzymes. When should the nurse anticipate the CK isoenzymes will begin to rise if the client has had a MI? (Select all that apply) A. 1 hr C, D?? (3, 24) A nurse is preparing a client for a radiation tx who is postop following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the tx? A. Alopecia C. Fatigue A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering the dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication? A. Utilitarianism B. Nonmaleficence A nurse is providing teaching to a client who has stomatitis. Which of the following statements by the client indicates the need for further teaching? A. I will drink liquids through a straw B. I will season foods w/dried spices before cooking A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? A. Encourage brief exercise before meals to promote appetite C. Encourage client to take small bites A nurse is providing instruction for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? A. Don't worry; most clients dislike the prep more than the procedure itself B. Before the exam, the provider will give you a sedative that will make you sleepy A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching? A. You may donate blood 6 months after completing the medication regimen C. Rest frequently throughout the day A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? A. Review the client's electrolyte values A. Review the client's electrolyte values A nurse is speaking w/ a 35-year-old client who has fibrocystic disease of the breasts. At which of the following times should the nurse inform the client that manifestations are most evident? A. Before menstruation begins A. Before menstruation begins A nurse is caring for a client who has PUD. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation? A. Hyperactive bowel sounds B. Sudden abdominal pain A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain? A. The pain usually lasts longer than 20 min D. Exertion and anxiety can trigger the pain A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity? A. Anorexia A. Anorexia A nurse is teaching a client who has a new prescription for sucralfate to tx a gastric ulcer. Which of the following statements by the client indicates an understanding of the teaching? A. I will take this medication as needed to reduce the pain D. I will take this med 1 hr before meals and at bedtime A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Difficulty reading B. Inability to recognize family members A nurse is teaching a client who has a new prescription for aspirin to tx RA. The nurse should include to monitor for which of the following adverse effects of the medication? A. Constipation B. Bleeding A nurse is assessing a client who is taking levothyroxine. The nurse should recognize that which of the following findings is a manifestation of levothyroxine overdose? A. Insomnia A. Insomnia A nurse caring for a client who had a R side stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? A. Provide a nonskid mat to alleviate plate movement C. Remind the client to look for food on the left side of the tray A nurse is caring for a client 1 hr following subtotal thyroidectomy. In which of the following positions should the nurse place the client? A. Semi-fowlers A. Semi fowlers A nurse is caring for a client 4 days postop following a right radical mastectomy. Which of the following activities should the nurse anticipate being the most difficult for this client to perform w/her right hand? A. Buttoning her blouse C. Combing her hair A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take? A. Offer the client a light snack C. Measure the clients apical pulse A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated w/urinary retention should the nurse expect? (Select all that apply) A. Report of feeling pressure A,B,C, D (report feeling pressure, tenderness over symphysis pubis, distended bladder, voiding 30 mL frequently) A nurse is assessing who is 48 hr postop following abdominal surgery. Which of the following findings should the nurse report to the provider? A. BP 102/66 C. yellow-green drainage on surgical incision A nurse in an ED is planning care for a client who is having an acute MI. The nurse should plan to administer which of the following medications after the initial acute phase to manage the clients pain/anxiety? A. Nitroglycerin D. Morphine A nurse is preparing a client who is scheduled for an echocardiogram the following day. Which of the following instructions should the nurse include about the test? A. It might cause slight discomfort in the chest area C. It requires lying quietly on one side A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take? A. Have the client lie flat in bed
A. Have the client lie flat in bed A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? A. Avoid eating at fast food restaurants C. Practice effective hand hygiene A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test. Which of the following statements should the nurse include in the teaching? A. A CA 125 test is used to confirm a diagnosis of ovarian cancer B. A CA 125 test is used to monitor a clients progress during tx of ovarian cancer A nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? A. These tests help to determine the degree of damage to the heart tissues A. These tests help to determine the degree of damage to the heart tissues A nurse at a rehab center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 wks ago. Which of the following goals should the nurse include in the clients rehab program? A. Establish the ability to communicate effectively A. establish the ability to communicate effectively A nurse in a providers clinic is caring for a client who reports erectile dysfunction and requests a prescription for slidenafil. Which of the following medications currently prescribed for the client is a contraindication to take slidenafil? A. Isosorbide A. Isosorbide A nurse is assessing a client who is admitted for hyperthyroidism. The client reports a weight loss of 5.4 kg (12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis? A. Provide a quiet, low-stimulus environment A. Provide a quiet, low-stimulus environment A nurse is teaching a client who has a new prescription for pancrealipase to aid in digestion. The nurse should inform the client to expect which of the following gastrointestinal changes? A. Decreased mucus in stools D. Decreased fat in stools A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?
A. Exophthalmos C. Weight gain A nurse is providing discharge teaching for a client who is postop following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? A. Do not apply heat to the area of irradiation A. Do not apply heat to the area of irradiation A nurse is caring for an older adult client who has a WBC count of 2,000 after three rounds of chemo. Which of the following actions should the nurse take? A. Humidify the clients room B. Serve cooked fruit w/meals A nurse is providing dietary teaching to a client who has calcium oxalate kidney stones. Which of the following statements indicates an understanding of the teaching? A. I can have almonds as a snack D. I may eat a banana w/my breakfast A nurse is caring for a client who has a postop ileus and an NG tube that has drained 2500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for? A. elevated sodium level B. decreased potassium level A nurse is teaching a client who has a UTI and is taking ciprofloxacin. Which of the following instructions should the nurse give to the client? A. If the medicine causes an upset stomach, take an antacid at the same time D. You should report any tendon discomfort you experience while taking this medication A nurse is providing teaching to a client who has a new prescription for hydroxychloroquine to tx mild manifestations for RA. Which of the following information should the nurse include in the teaching? A. This medication should be taken between
meals C. Wear sunglasses when out in bright sunshine A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the clients ability to safely ambulate? A. Observe for the presence of kernigs sign B. Perform a rombergs test A nurse is caring for an older adult client who has RA and is taking aspirin 650 mg q 4hrs. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication? A. WBC count D. Erythrocyte sedimentation rate A nurse is caring for a client who has BPH. Which of the following medications should the nurse plan to administer? A. Danazol B. Finasteride A nurse is assessing a client who has PUD. Which of the following findings should the nurse identify as the priority? A. Epigastric discomfort D. Hematemesis A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply) A. Lubricate lips w/water soluble ointment A,B,C (lubricate lips w/water soluble ointment, brush teeth w/soft toothbrush, blow nose gently) A nurse is shopping and finds a woman who has collapsed w/right-sided weakness and slurred speech. Which of the following action should the nurse take? A. Provide the client w/water to test the gag reflux C. Notify emergency management services A nurse is reviewing a medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition? A. Hx of bulimia B. Hx of NSAID use A nurse is caring for a client who is receiving cisplatin for tx of ovarian cancer. The clients most recent CBC is shown in the table. It is important for the nurse to consider which of the following for the client? C. The client has increased risk of infection A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat-soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following? A. Vitamin A A. Vitamin A A nurse is assisting with obtaining an ECG for a client who has a-fib. Which of the following actions should the nurse take? (select all that apply) A. Keep the client NPO after midnight B, D (Inspect the electrode pads, Instruct the client not to talk during the test) A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparins effects? A. Vitamin K B. Protamine sulfate A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take? A. Review lab test results for low hemoglobin B. Observe for signs of infection A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident. The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make? A. Perhaps you could call your children to see how they are doing C. You are feeling drawn in two separate directions A nurse is teaching about adverse effects of anastrozole w/a client who has advanced breast cancer and is postmenapausal. Which of the following adverse effects should the nurse recommend the client report to the provider? A. Weight gain D. Musculoskeletal pain A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate w/the client. Which of the following responses by the nurse is appropriate? A. Incorporate nonverbal cues in the
conversation A. Incorporate nonverbal cues in this conversation A nurse is caring for a client who is 1 day postop following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast? A. Refusing to look at the dressing or surgical incision A. Refusing to look at the dressing or surgical incision A nurse is caring for a client who has R.sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop? A. Place sandbags to maintain right plantar flexion C. Apply a protective boot to the right ankle A nurse is caring for a client who is 1 day postop following a mastectomy. Which of the following exercises should the nurse assist the client to perform on the affected side? (select all that apply) A. Squeezing a rolled washcloth A,B,C (squeezing a rolled washcloth, flexing/extending her hand, flexing/extending her elbow) A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia maybe associated w/changes to the T-wave. On the graphic, point and click on the area of the ECG that represents the T-wave Far right box A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24 hr. Which of the following actions is the nurse's priority? A. Monitor intake and output C. Administer pain medicine A nurse is monitoring the urinary output of an adult client who had a colon resection. Which of the following 24 hr output totals indicates oliguria? A. 720 mL C. 380 mL A nurse is reviewing a medical record of a client who has been on levothyroxine for several months. Which of the following findings indicates a therapeutic response to the medication? A. Decrease in level of thyroxine (T4) D. Decrease in level of TSH A nurse is teaching a client who has a hx of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia? A. Dietary iron restrictions C. Chronic blood loss A nurse is reviewing the lab results for a client who has a hx of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet? A. I flavor my meat w/lemon juice B. I eat two eggs for breakfast each morning A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor? A. Hypermagnesemia B. Hypokalemia A client who has a hx of MI is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? A. Analgesic C. Antiplatelet aggregate A nurse is evaluating a client's lab results. The nurse should recognize that an increase in the client's prostate specific antigen (PSA) lab value is indicative of which of the following diagnoses? A. Breast cancer D. Prostatic cancer A nurse is caring for a 12-month old toddler who is hospitalized and confined to a room w/ a contact precaution in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client? A. Large building blocks A. Large building blocks A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side. Bottom right box (left pedal pulse) A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex? Left box A nurse is caring for a client who is 5 hr postop following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? A. Notify the provider B. Check the tubing for kinks After radiation tx, a client reports dryness, redness, and scaling of his skin occurring w/in the designated radiation tx markings. The nurse should instruct the client to take which of the following actions? A. Apply hydrating lotions A. Apply hydrating lotions A nurse is caring for a client who is postop following a TURP. Which of the following complications is the priority for the nurse to monitor for? A. Hemorrhage A. Hemorrhage A nurse is providing discharge instructions to a client who has RA and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication? A. Take the medication between meals C. take medication w/milk A nurse is assessing a client who is on long term omeprazole therapy. Which of the following findings should indicate to the nurse the medication is effective? A. Increased appetite D. Reduced dyspepsia A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? A. Perform passive ROM on each extremity C. Suction saliva from the client's mouth A nurse is caring for a female client who has RA and asks the nurse if it is safe for her to take aspirin. The nurse should recognize which of the following findings in the client's hx is a contraindication to this medication? A. Report of recent migraine headaches B. Hx of gastric ulcers A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect? A. Diarrhea B. Facial edema A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium? A. Bananas A. Bananas A nurse is caring for a client following an esophagogastrodudenoscopy (EGD). Which of the following assessments is the nurse's priority? A. Pain C. Gag reflex A nurse is caring for an older adult client who has a UTI. Which of the following manifestations should the nurse identify as a finding specifically associated w/this client? A. Urinary retention D. Confusion A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a MI? A. Check the client's BP C. Perform a 12-lead ECG A client who has chronic lymphocytic leukemia is starting chemo tx and asks if she needs to make any dietary changes. Which of the following statements should the nurse make? A. You should avoid drinking liquids an hour before tx A. You should avoid drinking liquids an hour before tx A nurse is planning care for a client who is postop following a thyroidectomy. Which of the following interventions should the nurse include in the plan? A. Instruct the client to deep breathe q 4hr B. Check the client's voice every 2 hr A nurse in a provider's office is assessing a client who has RA. Which of the following findings is a late manifestation of this condition? A. Anorexia B. Knuckle deformity A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? A. Serum cardiac enzyme levels B. MRI of the chest A nurse is caring for a client who is rescheduled for an exercise stress test. Which of the following comments made by the client should indicate to the nurse that the client requires further teaching? A. I will not smoke prior to my test B. Ill take my heart medications the morning of the test A nurse is caring for a client who is postop following a right-sided mastectomy and has a drain connected to a portable drainage evacuator. Which of the following actions should the nurse take? A. Dangle the operative limb for 5 min every hour D. Take Bps on the client's non-affected arm A nurse is teaching a client about the side effects of chemo medication. Which of the following nursing statements should the nurse include in the teaching? A. Most clients do not experience nausea B. Hair loss is common and includes eyebrows and eyelashes A nurse is caring for a client who has new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor? A. Hypocalcemia C. Family history A nurse is teaching for a client who is to begin taking tamoxifen to tx breast cancer. The nurse should instruct the client to expect which of the following findings as an adverse effect of the medication? A. Tinnitis D. Hot flashes
A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make? A. Perhaps you should discuss this w/ your physician D. Tell me more about your fears of dying from a heart attack A nurse is teaching a client who has BPH and has a new prescription for finasteride. Which of the following instructions should the nurse include in the teaching? A. Avoid drinking grapefruit juice when taking this medication C. Decreased libido is an adverse effect of the medication A nurse is reviewing discharge instructions with a client who has Raynaud's disease. Which of the following client statements indicates an understanding of the teaching? A. I plan to use nicotine gum to help me quit smoking B. I am going to take a stress management class A nurse is caring for a client who is 1 day postop following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of drainage seeping from the nasal packing. Which of the following should be the nurse's initial action? A. Document the amount of drainage C. Check the drainage for glucose A nurse is providing dietary teaching to a client who has frequent kidney stones. Which of the following instructions should the nurse include in the teaching? A. Limit your intake of dairy products C. Avoid eating tree nuts, such as almonds A nurse is reviewing the health hx for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the hx should the nurse report to the provider? A. A client has a hx of hypothyroidism B. Client has a hx of bronchial asthma A nurse is caring for a client who is receiving a unit of packed RBCs. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? A.
Febrile D. Hemolytic A nurse is assessing a client who has hypokalemia as a result of N/V/D. Which of the following findings should the nurse expect? A. Hyperactive reflexes C. Weak, irregular pulse A nurse is caring for a client who has nausea and a prescription for metoclopramide intermittent IV bolus every 4 hrs as needed. The client asks the nurse how much metoclopramide will relieve her nausea. Which of the following explanations should the nurse provide? A. The medication relieves nausea by promoting gastric emptying A. The medication relieves nausea by promoting gastric emptying A nurse is assisting a client who has hypothyroidism w/meal planning. Which of the following foods should the nurse recommend that the client add to her diet? A. Ripe bananas C. Whole grains A nurse is providing discharge teaching to a client who has gastroesophogeal reflux disease. Which of the following statements by the client indicates an understanding of the teaching? A. The type of foods I eat does not affect this condition D. I will sleep w/my head of bed elevated A nurse is caring for a client who has chemo-induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms? A. Extremities that turn blue when exposed to cold B. Tinging feeling in extremities A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the clients apical pulse. Bottom (right on for me) Left on them A nurse in a providers office is reviewing the lab findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse? A. BUN 15 Platelet count 60,000 A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching? A. Pyelonephritis increases a pregnant womens risk for preterm labor A. Pyelonephritis increases a pregnant womens risk for preterm labor A nurse is assessing a client for early manifestations of RA. Which of the following changes is an early manifestation of RA? A. Morning stiffness B. Fatigue A nurse is caring for a client who is on warfarin therapy for a fib. The clients INR is 5.2. Which of the following medications should the nurse prepare to administer? A. Epinephrine D. Vitamin K A nurse is reinforcing teaching w/a client regarding reduction of risk factors for CAD. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply) A.
i must stop smoking A, D, E (I must stop smoking, I need to monitor my weight, I am limiting my intake of fast foods) A nurse is instructing a client how to decrease the nausea associated w/chemo and radiation. Which of the following statements indicates an understanding of the teaching? A. I will eat smaller meals if I feel nauseated B. I will eat foods that are served at room temp A community health nurse is developing a pamphlet about breast self-exam for a local health fair. Which of the following instructions should the nurse include? A. Expect some breast dimpling or discharge w/age D. breasts can be examined in the shower w/soapy hands A nurse is assessing a clients cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers? A. The left 2nd intercostal space A. the left 2nd intercostal space A nurse is providing dietary teaching for a client who has Cushings disease. Which of the following recommendations should the nurse include in the teaching? A. Limit intake of potassium-rich foods B. restrict sodium intake A nurse is taking a health hx of a client who reports occasionally taking several otc medications, including an H2 receptor antagonist. Which of the following outcome indicates the H2RA is therapeutic? A. Relief of heartburn A. relief of heartburn A nurse is caring for a client who has DVT and is receiving IV fluid that contains 10,000 units of heparin in 500 mL infusing at 1,000 units/hr. When calculating I&O, how much should the nurse document as intake from this infusion in 8-hr shift? (nearest whole #) 400 mL A nurse is planning care for a client being tx w/chemo and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the clients plan of care? A. All visitors from entering clients room B. fresh flowers and potted plants in room A female middle adult client tells the nurse that she tested positive for a mutant BRCA1 gene. The nurse should recognize that the client is at an increased risk for which of the following situations? A. Delivering a child who has downs syndrome C. Developing breast cancer A nurse is teaching a client who has a new prescription for ranitidine to tx PUD. Which of the following statements by the client indicate an understanding of the teaching? (select all that apply) A. I can take this w/ or w/o food A, F (I can take this with or without food, I will eat 5 small meals/day) A nurse is reviewing the EKG strip for a client who has prolonged vomiting. Which of the following abnormalities on the clients EKG strip should the nurse interpret as a sign of hypokalemia? A. Abnormally prominent U
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A nurse is caring for a client who is 4 days postoperative following a right radical mastectomy
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