Respiratory Alkalosis S/S
lethargy
lightheadedness
confusion
tachycardia
dysrhythmias related to hypokalemia
nausea
vomiting
epigastric pain
numbness and tingling of the extremities
hyperventilation (tachypnea)
A nurse is contributing to the plan of care for an older adult client who is at risk for Osteoporosis. Which intervention should the nurse include to prevent bone loss?
Encourage weight bearing exercises (such as walking because it can help maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis.)
A nurse is caring for a client who has meningococal pneumonia. Which of the following personal protective equipment should the nurse use?
Mask (this disease requires droplet precautions)
A nurse is reinforcing teaching with a client who is taking insulin Glargine. What information should the nurse include in the teaching?
This type of insulin should be given at the same time everyday. (It is released over a 24hr period)
A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. What statement by the client indicates that they are adhering to the nurse’s instructions?
“I don’t cross my legs anymore”.
A nurse is caring for a client who has a methicillin-resistant Staphlococcus aureus (MRSA) infections in a surgical wound. What information should the nurse plan to share with visitors?
Visitors must don a gown & gloves prior to entering the client’s room.
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. What should the client report to the provider?
Onset of nausea
A nurse is reinforcing discharge teaching with a client who has hearing loss. What action should the nurse take when communicating with the client?
Rephrase client instructions when not understood.
A nurse is caring for a client who is 1 day post operative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, & tacky-nearly. The nurse should recognize these findings as what complication?
Pulmonary Embolism
A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. What finding should the nurse recognize as abnormal?
Lack of sensation between the first and second toes
A nurse reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. What should the nurse include in the teaching?
Limit contact with large groups of people
A nurse is caring for a client who is 24hr postoperative following abdominal surgery & has an NG tube. What action should the nurse plan to take to decrease the risk of postoperative complications?
Encourage the client to use an incentive spirometer every hour while awake
A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. What finding should the nurse expect related to hyperkalemia?
Bradycardia
A nurse is assisting in the care of a client who has manifestations of sepsis. What provider prescriptions should the nurse implement first?
Initiate oxygen at 4 L/min via nasal cannula
A nurse is caring for a client who has terminal pancreatic cancer. The client states, “I don’t think I can go on any longer.” What response should the nurse make?
“Tell me more about the way you are feeling.”
A nurse is collecting data from a client who has hypokalemia. What finding should the nurse identify as the priority?
Dysrhythmia
A nurse is caring for a client who is in Buck’s traction. What intervention should the nurse perform to reduce skin breakdown?
Keep the skin dry and free of perspiration
A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infections and is on contract isolation precautions. What action should the nurse take?
Have a designated stethoscope in the client’s room
A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. What action should the nurse perform first?
Stop the infusion
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as what?
Hyperactive bowel sounds
A nurse is preparing to administer furosemide to a client who has heart failure. What should the nurse report before administering the medication?
Decreased potassium
A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. What information should the nurse include in the teaching?
Apply cold packs to the joints
A nurse is collecting data from a client who has hypothyroidism. What manifestation should the nurse expect?
Bradycardia
A nurse is reinforcing teaching with an older adult client who has osteoporosis. What instructions should the nurse include in the teaching?
Take the calcium supplements with meals
A nurse is reviewing the medical record for an older adult client who is experiencing nausea & vomiting. Based on the client data, what action should the nurse take?
(Na 142 mEq, K+ 4.2 mEq/L, BUN 36 mg/dL, Creatinine 1.4 mg/dL)
Notify the charge nurse of the client’s BUN level
A nurse is admitting a client who is suspected having active tuberculosis (TB). What action should should the nurse take first?
Institute airborne precautions
A nurse is monitoring a client who has a wrist cast and reports intense itching underneath the cast. What action should the nurse take?
Blow cool air into the cast using a blow dryer on a cool setting
A nurse is planning care for a group of clients after receiving change-of-shift report. What client should the nurse see first?
A client who is dehydrated, has mental confusion, & was found getting out of bed several times during the night.
A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. What action should the nurse take?
Administer oxygen via nasal cannula
A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily. While taking the client’s apical pulse, the nurse notes a rate of 58/ min. What action should the nurse take?
Withhold the dose
A nurse is caring for a client who has an intestinal obstruction & reports a new onset of nausea. The client has an NG tube set at low intermittent suction & is receiving continuous IV infusion of 0.9% sodium chloride. What action should the nurse take first?
Check for kinks in the NG tube
A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. What instructions should the nurse include in the teaching?
Maintain hip flex ion to 90 or less when sitting
A nurse is caring for a client who is 24hr postoperative following an abdominal surgery. What finding requires immediate attention from the nurse?
Oxygen saturation of 88%
A nurse is caring for a client following a gastrectomy. What action should the nurse take to decrease episodes of dumping syndrome?
Place the client in the supine position after meals
A home health nurse is caring for a client who has COPD. The client tells the nurse that he becomes short of breath while eating despite the use of home oxygen. What instructions should the nurse include?
Drink beverages at the end of meals
A nurse is reinforcing teaching with a client who has chronic kidney disease about management. What statement by the client indicates an understanding of the teaching?
I will limit my daily intake of protein
A nurse is caring for a client who has dementia due to Alzheimer’s disease. What action should the nurse take to reduce the client’s confusion?
Encourage reminiscence of past experiences
A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. What information should the nurse include in the teaching?
The virus can be transmitted without lesions present
A nurse is reinforcing teaching with a client who has coronary artery disease and is taking a statin medication to lower cholesterol levels. What instruction should the nurse include in the teaching?
Add oily fish to your diet
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. What instructions on preparing the insulin should the nurse include?
Withdraw the regular insulin before withdrawing the NPH insulin
A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. What instructions should the nurse include to promote comfort?
Sleep on a firm mattress
A nurse is assisting in the plan of care for a client who has a recent left hemispheric stroke. What action should the nurse include in the plan?
Use simple verbal cues when directing tasks
A nurse is reinforcing teaching with a client who is taking Levothyroxine. What statement by the client indicates an understanding of the teaching?
The medication should be taken before I eat breakfast every morning
A nurse is reviewing medical record of a client who is postoperative. What finding should the nurse identify as a complication of surgery?
WBC count of 15,000/ mmm3
A nurse is reviewing the medication administration record of a client who has osteoarthritis. What analgesic prescription should the the nurse expect to administer when the client reports pain?
Acetaminophen
A nurse is assisting with an educational program for clients who have newly diagnosed with diabetes mellitus. What instruction should the nurse include in the program regarding insulin?
Opened insulin can be stored on a cool countertop away from light
A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from PACU following a right total knee arthroplasty. What interventions should the nurse include in the plan?
Assist the client to change position every 2hr
A nurse is reinforcing teaching with a client who has circulatory comprise in the lower extremities due to peripheral vascular disease. What action should the nurse take?
Educate the client about choosing low-fat, low cholesterol foods
A nurse is caring for a client who is post operative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. What prescription should the nurse expect the provider to order?
Irrigate the urethral catheter with 0.9% sodium chloride
A nurse is caring for a client who has a new cast on her left forearm and report severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. What fracture complication should the nurse suspect?
Compartment syndrome
A nurse is reviewing the plan of care for an older adult client who is 1 day post operative following a total hip arthroplasty. What interventions should the nurse contribute to the plan of care?
Keep an abduction pillow between the client’s legs
A nurse is caring for four clients. What conditions should the nurse identify as a risk for developing vascular disease?
Diabetes mellitus
A nurse is caring for a female client who is being treated for dehydration due to nausea & vomiting. What finding should the nurse report to the provider?
Heart rate 120/ min
A nurse is reinforcing teaching to a client about preventing osteoporosis. What statement indicates an understanding of the teaching?
I will limit my coffee intake
A nurse is contributing to the plan of care for a client who has tuberculosis (TB). What intervention should the nurse include?
Place the client in a negative pressure airflow room
A nurse is contributing to the plan of care for a client who has pericarditis. What position should the nurse plan to place the client to decrease plan?
Upright, leaning forward
Pregbalin (Lyrica)
This can be used to treat fibromyalgia, postherpetic neuropathy, and diabetic neuropathy:
Iron deficiency symptoms
Anemia: weakness, fatigue, headaches; impaired work performance; impaired immunity; pale skin, nail beds, mucous membranes, and palm creases; concave nails; inability to regulate body temperature; pica
Hypothyroidism S/S
Same as hypometabolism ie,
tired,
sluggish
Cold intolerant
obese
decreased hr, p, rr
McBurney’s point
Pain in RLQ with appendicitis
Large bowel obstruction
-Differs in that manifestation may be constipation for months, slow progression
-Pain less severe
-Eventually, abdominal distention and fecal vomiting occurs
-Diagnostics and treatment similar
Hyperthyroidism symptoms
heat intolerance, weight loss, sweating, anxiety, irritability, hyperactive reflexes, palpitations
Malabsorption S/S
FTT
Bulk, foul stools (stetorrhea)
Abdominal pain
protrubent abdomen
Pallor
Fatigue
High purine foods
Alcoholic beverages, some seafood/fish…some meats like turkey, bacon, liver
celiac disease symptoms
-Malabsortive diarrhea
-Flatulence
-Steatorrhea (greasy, bulky stool)
-Weight loss
-Abd distention
-Weakness and growth retardation
-Iron deficiency
-Bone pain or Bone weakness
-Amenorrhea
-Fertility problems
-Dermatitis herpetiformis (blisters on extensor surface)
Foods high in iron
Meats, eggs, legumes, whole grains, green leafy vegetables , and dried fruits
Foods high in potassium
- Avocado
- Bananas
- Cantaloupe
- Carrots
- Fish
- Mushrooms
- Oranges
- Potatoes
- Pork, Beef, Veal
- Raisins
- Spinach
- Strawberries
- Tomatoes
Foods high in calcium
Cheese
Collard greens
Milk and soy milk
Rhubarb
Sardines
Spinach
Tofu
Yogurt
Low calcium diet
This diet includes: Peas, carrots, fruit, meat, fish.
Foods high in protein include
Meats, dairy, nuts and beans
Glucosamine contraindications
shellfish allergy, diabetes, bleeding disorders
Glucosamine side effects
GI upset, nausea, diarrhea, constipation
Small bowel obstruction is a condition characterized by which finding?
A) Severe fluid and electrolyte imbalances.
B) Metabolic acidosis.
C) Ribbon-like stools.
D) Intermittent lower abdominal cramping.
A) Severe fluid and electrolyte imbalances
obstipation
severe constipation, which may be caused by an intestinal obstruction
vaso-occlusive crisis
visual disturbance, hematuria, painful swelling extremities, fever, tachy, PAIN
left hemisphere of brain
controls right side of the body and is logical, contains mathamatics, lauguage, & speech
right hemisphere of brain
controls left side of the body and contains creativity and the arts
peripheral neuropathy
damage to nerves in lower legs and hands as result of diabetes mellitus; symptoms include either extreme sensitivity or numbness and tingling
Teaching for a client who has a new dx of hyperlipidemia
- focus on lifestyle modification for the first six months (management of identified CVD risk factors can be done in a primary care)
- Offer nutrition support and lifestyle counseling.
- If lifestyle modifications fail to reduce the lipids to the desired level in patients with extreme lipid disorders, pharmacotherapy is recommended
hyperlipidemia
excessive fat in the blood
Gestational Diabetes risks
macrosomia, hypoglycemia, hypocalcemia, hyperbilirubinemia, and polycythemia
Hypothermia treatment
remove wet clothing, wrap victim in blanket, protect from weather, provide food and drink to conscious victims if they aren’t nauseas, do not massage to warm body, place unconscious victim in recovery position, place in warm bath if available
hypothermia symptoms
Pale, cold skin, dilated pupils, poor coordination, slurred speech, incoherent thinking, unconsciousness, muscle rigidity, weak pulse, labored breathing, irregular heart beat
sepsis s/s
o Fever
o Chills
o Rapid breathing and heart rate
o Rash
o Confusion
o Disorientation
A nurse is planning to administer the first dose of iron dextran. What actions should the nurse plan to take?
Administer a small test dose before giving the full dose.
Infuse the medication over 30 seconds
Monitor the client closely for hypertension after the infusion.
Administer cyanocobalamin as an antidote if iron dextran toxicity occurs.
Hearing Loss: Conductive
deafness; occurs when sound waves are not conducted to the inner ear
Hearing Loss: Sensorineural
damage to structures of inner ear
Hearing Loss Manifestations
Asking to speak up/repeat
Answering questions inappropriately
Not responding when looking away
Straining to hear
Cupping hand around ear
functional hearing loss
a condition in which persons do not respond appropriately to speech or other sound and there does not appear to be an abnormality or lesion in their ears, auditory nerves, or CANS. also referred to as psychogenic hearing loss, pseudohypacusis, and idiopathic sudden deafness
metabolic acidosis
low pH, low HCO3
causes:
DKA, severe diarrhea, renal failure, shock
metabolic alkalosis
high pH, high HCO3
causes:
severe vomiting, excessive GI suctioning, diuretics, excessive NaHCO3
respiratory acidosis
low pH, high CO2
causes:
(1) COPD
(2) Pneumonia.
(3) Atelectasis.
respiratory alkalosis
high pH, low CO2
lethargy
lightheadedness
confusion
tachycardia
dysrhythmias related to hypokalemia
nausea
vomiting
epigastric pain
numbness and tingling of the extremities
hyperventilation (tachypnea)
A nurse in an emergency department is preparing to perform an ocular irrigation for a client. Which of the following actions should the nurse plan to take?
a. Assess the client’s visual acuity prior to irrigation
b. Have the client turn their head toward the unaffected eye
c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
d. Perform the irrigation with sterile water for irrigation
d. Perform the irrigation with sterile water for irrigation
A nurse is preparing to administer lactated ringer’s via continuous IV infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min should the nurse set the IV pump to administer? Round to near whole number
33 gtt/min
A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching?
a. I can keep my medications for 1 year before replacing it
b. I should lie down when I take this medication
c. I should discontinue this medication if I develop a headache
d. I can take up to five tablets in 15 minutes before seeking medical attention
b. I should lie down when I take this medication
A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
a. Clean the incision daily with hydrogen peroxide
b. You can cross your legs the ankles when sitting down
c. You should use an incentive spirometer every 8 hours
d. Install a raised toilet seat in your bathroom
d. Install a raised toilet seat in your bathroom
A nurse is planning care for a client following a cardiac catheterization. Which of the following actions should the nurse take?
a. Keep the client on bed rest for 24 hours
b. Limit the client’s fluid intake to 1 l per day
c. Maintain the client’s affected extremity in extension
d. Change the client’s dressing every 8 hour
c. Maintain the client’s affected extremity in extension
A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change?
a. I will need to have my partner take over shopping for groceries and cooking the meals for us
b. These crutches will make it impossible to care for my child
c. I feel bad that I have to ask my partner to keep the house clean
d. Its going to be difficult to tell my parents I cant take them to their appointments anymore
a. I will need to have my partner take over shopping for groceries and cooking the meals for us
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
a. Pitting, dependent edema
b. Distended jugular veins
c. Increased BP
d. Decreased BP
d. Decreased BP
A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client’s urinary output was 4,000 ml over the past 24 hour. The nurse should anticipate a prescription for which of the following IV medication?
a. Desmopressin
b. Epinephrine
c. Furosemide
d. Nitroprusside
a. Desmopressin
A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports a nagging dry cough. Which of the following responses by the nurse is appropriate?
a. “your cough may require that you stop or change your medication”
b. “Increasing your daily fluid intake may eliminate your cough”
c. “sucking on lozenge may reduce the frequency of your cough”
d. You cough should go away in time”
a. “your cough may require that you stop or change your medication”
A nurse is taking an admission history from a client who reports Raynaud’s disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations
of Raynaud’s?
a. Eating a strict vegetarian diet
b. A history of herpes zoster
c. Taking amiodipine for hypertension
d. Using a nicotine transdermal patch
d. Using a nicotine transdermal patch
A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following
actions should the nurse take first?
a. Perform an ECG
b. Obtain ABG values
c. Turn the client to his left side
d. Clamp the catheter
d. Clamp the catheter
A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client’s skin is intact. Which of the following interventions should the nurse include in the plan of care?
a. Turn and reposition the client every 4 hr
b. Apply an occlusive dressing
c. Support bony prominences with pillows
d. Massage the reddened areas three times a day
c. Support bony prominences with pillows
A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take?
a. Discuss recommendations for eating and swallowing techniques
b. List strategies for family coping when dealing with possible role changes
c. Review the use of adaptive grooming devices to promote client independence
d. Give the client information about the local national multiple sclerosis society
a. Discuss recommendations for eating and swallowing techniques
A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? Exhibit
a. Obtain a sputum sample for culture
b. Administer ondansetron
c. Initiate airborne precautions
d. Prepare the client for a chest x-ray
c. Initiate airborne precautions
A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client’s risk?
a. History of Crohn’s disease
b. BMI of 24
c. Diet high in fiber
d. Age 46 years
a. History of Crohn’s disease
A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, “I’m not sure I want to have a mastectomy.” Which of the following statements should the nurse make?
a. “I can give you a list of other people who had the same procedure”
b. “You will be cancer-free if you have the procedure”
c. “I can give you additional information about the procedure”
d. “You should should get a second opinion regarding the procedure”
c. “I can give you additional information about the procedure”
A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow.
e. Remain with the client for the first 15 to 30 min of the infusion
a. Obtain venous access using 19-gauge needle
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
b. Obtain the unit of packed RBCs from blood bank
a. Obtain venous access using 19-gauge needle
b. Obtain the unit of packed RBCs from blood bank
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
e. Remain with the client for the first 15 to 30 min of the infusion
A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?
a. “rinse your mouth with hydrogen peroxide”
b. “brush your teeth for 60 seconds twice daily”
c. “wear your dentures only during meals”
d. “floss your teeth following each meals”
d. “floss your teeth following each meals”
A critical care nurse is assessing a client who has severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow Coma Scale scores should the nurse assign the client?
a. 5
b. 2
c. 13
d. 10
a. 5
A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?
a. “I can season my foods with garlic and onion salts”
b. “I can have mayonnaise on my sandwiches”
c. “I can have a frozen fruit juice bar for dessert”
d. “I can drink vegetable juice with a meal”
c. “I can have a frozen fruit juice bar for dessert”
A nurse is preparing to perform ocular irrigation for a client following chemical splash to the eye. Which of the following actions should the nurse plan to take first?
a. Instill 0.9% sodium chloride solution into the affected eye
b. Administer proparacaine eyedrops into the affected eye
c. Collect information about the irritant that caused the injury
c. Collect information about the irritant that caused the injury
A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately?
a. Rhonchi
b. SaO2 92%
c. Sore throat
d. Stridor
d. Stridor
A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
a. Elevated serum calcium
b. Elevated blood glucose
c. Decreased serum amylase
d. Decreased erythrocyte sedimentation rate
b. Elevated blood glucose
A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?
a. Hypothermia
b. Urine specific gravity 1.001 (<1.005)
c. Elevated blood pressure
d. BUN 15 mg/dl
b. Urine specific gravity 1.001 (<1.005)
A nurse is planning care for a client who has pulmonary embolism. Which of the following interventions should the nurse include?
a. Initiate a continuous IV heparin infusion
b. Instruct the client to massage the lower extremities
c. Position the client on the left side
d. Measure vital signs every 4 hour
a. Initiate a continuous IV heparin infusion
A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include?
a. Avoid extremely hot or cold temperatures
b. Limit fluids to 1.5 L per day
c. Limit alcohol intake to one drink per day
d. Avoid getting a flu vaccination
a. Avoid extremely hot or cold temperatures
A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first?
a. Obtain a blood specimen for type and crossmatch
b. Insert a large-bore IV catheter
c. Administer IV therapy
d. Monitor urine output
b. Insert a large-bore IV catheter
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
a. Dilated appearance of the graft
b. Absence of a bruit
c. Normotensive blood pressure
d. Palpable thrill
d. Palpable thrill
A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia?
a. Oliguria
b. Hypertension
c. Muscle weakness
d. Positive chvostek’s sign (CHEEK)
c. Muscle weakness
A nurse is caring for a client who has a full-thickness burn injury covering 15% of their body. Which of the following actions should the nurse take?
a. Weigh the client once per week
b. Provide the client with a protein intake of 1g/kg/day
c. Maintain a daily count of the client’s calorie intake
d. Place the client on a low-carb diet
c. Maintain a daily count of the client’s calorie intake
A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?
a. “I will expect my stools to be loose”
b. “I will eat a high fiber diet’
c. “I will take a laxative when I’m constipated”
d. “I will empty my bag when it is full”
a. “I will expect my stools to be loose”
A nurse is caring for a client who is receiving total parental nutrition through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take?
a. Switch the infusion to a 10% dextrose solution
b. Discontinue the infusion and flush the line
c. Decrease the rate of infusion to last until the new bag is available
d. Start an infusion of 0.45% sodium chloride solution
a. Switch the infusion to a 10% dextrose solution
A nurse is caring for a client who is 6 hr postoperative following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of the following electrolyte imbalances?
a. Hypocalcemia
b. Hypokalemia
c. Hypermagnesemia
d. Hypernatremia
a. Hypocalcemia
A nurse is caring for a client who is caregiver for a relative who has chronic disease. Which of the following statements indicates the client is adapting to the role change?
a. “I had to reschedule my doctor’s appointment last week”
b. “I have lunch with my friends once a week”
c. “I’ve lost 15 pounds in the past 2 months”
d. “I need to get my blood pressure medicine refilled”
d. “I need to get my blood pressure medicine refilled”
A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?
a. “I should withhold my metoprolol if my heart rate is above 100 bpm”
b. “I should take my daily aspirin on an empty stomach”
c. “I should lie down before taking dose of isosorbide dinitrate”
d. “I should place a nitroglycerin tablet under my tongue every 10 minutes for up to four doses”
c. “I should lie down before taking dose of isosorbide dinitrate”
A nurse in the post-anesthesia care unit is assessing a client following an appendectomy and finds a 2-cm (3/4in) area of blood on the postoperative dressing. Which of the following actions should the nurse take?
a. Apply pressure
b. Loosen the dressing
c. Circle the drainage
d. Apply a new dressing
c. Circle the drainage
A nurse is caring for a client who is receiving mechanical ventilation. Which of following interventions should the nurse implement?
a. Empty water from the ventilator tubing daily
b. Suction the client’s airway every 4 hour
c. Maintain the client in supine position
d. Perform oral care every 2 hour
a. Empty water from the ventilator tubing daily
A nurse is a planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include?
a. Apply new gloves when alternating between wound care sites
b. Provide a diet of fresh fruits and vegetables for the client
c. Limit visitation time for the client’s children to 40 min per day
d. Clean the equipment in the client’s room once per week
a. Apply new gloves when alternating between wound care sites
A nurse is providing teaching for a client who has tuberculosis and a new prescription for pyrazinamide. The nurse should instruct the client to notify the provider if which of the following adverse effects occurs?
a. Hair loss
b. Polyuria
c. Weight gain
d. Jaundice
d. Jaundice
A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care?
a. Position the bedside table on the client’s left side
b. Place the plate guard on the client’s meal tray
c. Provide the client with a short handled reacher
d. Remind the client to use a cane on left side while ambulating
b. Place the plate guard on the client’s meal tray
A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take?
a. Use a cool fluid for irrigation
b. Insert the tip of the syringe 2.5cm (1in) into the ear canal
c. Tilt the client’s head 45 degrees
d. Point the tip of the syringe toward the top of the ear canal
d. Point the tip of the syringe toward the top of the ear canal
A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
a. Ondansetron
b. Sertraline
c. Methylprednisolone
d. Diphenhydramine
a. Ondansetron
- A nurse is preparing to discharge a client who has halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider?
a. Increase intake of fiber-rich foods
b. May place a small pillow under head when sleeping
c. May operate a motor vehicle when no longer taking analgesics
d. Take a tub bath instead of showers
c. May operate a motor vehicle when no longer taking analgesics
A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following information should the nurse include in the teaching?
a. “You should wear an N95 respirator mask when you are at home”
b. “you will need to return in 2 weeks to provide a sputum specimen”
c. “You can drink alcohol after the first 6 weeks of treatment”
d. “Your provider will discontinue your medications after 3 months of therapy”
b. “you will need to return in 2 weeks to provide a sputum specimen”
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
a. Flushed skin
b. Frothy sputum/Hacking cough
c. Jugular vein distention
d. Bradycardia
b. Frothy sputum/Hacking cough
A nurse is planning care for a client who has osteoarthritis of the knees. Which of the following interventions should the nurse include in the plan?
a. Avoid using a topical salicylate cream
b. Administer acetaminophen for pain management
c. Place a large pillow under the client’s knees when resting
d. Apply an ice pack directly to client’s knees
b. Administer acetaminophen for pain management
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse first take?
a. Increase the client’s fluid intake
b. Reposition the client in bed
c. Check the client’s urine output
d. Administer PRN pain medication
c. Check the client’s urine output
A nurse is caring for a client who has Parkinson’s disease and is prescribed a level 1 dysphagia diet. Which of the following items should the nurse remove from the client’s tray?
a. Vanilla milkshake
b. Peanut butter
c. Chocolate pudding
d. Applesauce
b. Peanut butter
A nurse in a provider’s office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include?
a. “eat a light meal 1 hour before bedtime”
b. “sleep with head of your bed elevated 6 inches”
c. “increase your caloric intake by 250 calories per day”
d. “lie down for 30 min after each meal”
b. “sleep with head of your bed elevated 6 inches”
A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
a. Client report of pain at the incision site
b. High-pitched sound on inspiration
c. Hypoactive bowel sounds
d. Loose tracheal secretions
b. High-pitched sound on inspiration
A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?
a. “the elastic bandage will prevent a post-op wound infection”
b. “the elastic bandage will prevent excessive edema”
c. “the elastic bandage will keep the sutures from loosening”
d. “the elastic bandage will keep you from seeing the surgical site”
b. “the elastic bandage will prevent excessive edema”
A nurse is planning care for a client who is 8 hour post-op following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?
a. Examine the surgical incision for drainage
b. Auscultate breath sounds
c. Palpate pulses distal to the graft donor site
d. Measure the client’s core body temperature
b. Auscultate breath sounds
A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?
a. “you will need cryotherapy for 1 to 2 weeks”
b. “you will need to take an antiviral medication for 6 months”
c. “you will need 3 follow-up blood tests within 24 month period”
d. “you will need to be monitored for 15 minutes after receiving each medication dose”
c. “you will need 3 follow-up blood tests within 24 month period”
A nurse is caring for a client who has hypotension, cool clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?
a. Reverse Trendelenburg
b. Feet elevated
c. High fowlers’
d. Side lying
b. Feet elevated
A nurse is teaching a client how to use a quad cane for ambulation following a right-hemispheric stroke. Which of the following client actions indicates an understanding of the teaching?
a. Client takes a step before advancing the cane
b. Client holds the cane with the left hand
c. Client moves the cane 2 feet ahead
d. Client advances the weaker leg forward first
d. Client advances the weaker leg forward first
A nurse is providing discharge teaching for a client who has new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?
a. “ill remove the soiled tracheostomy ties prior to cleansing my stoma”
b. “ill cut a slit in a clean gauze pad to use as a stoma dressing”
c. “ill insert the obturator after cleaning my stoma”
d. “ill cleanse the cannula with half-strength hydrogen peroxide”
c. “ill insert the obturator after cleaning my stoma”
A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as contraindications for receiving the medications?
a. BUN 18 mg/dl
b. Creatinine 0.8 mg/dl
c. Potassium 3.2 mEq/l
d. Sodium 136 meEq/l
c. Potassium 3.2 mEq/l
A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse?
a. Bilateral pupil diameter changes from 4 to 2 mm
b. WBC count changes from 9,000 to 16,000/mm3
c. Pulse pressure changes from 30 to 20 mm Hg
d. Glasgow Coma Scale score changes from 14 to 9
d. Glasgow Coma Scale score changes from 14 to 9
A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?
a. “I have a hard time with brushing my hair”
b. “I would rather be in a wheelchair than use a walker to get around”
c. “I’ve been having problems with bladder control”
d. “I have difficulty swallowing food”
a. “I have a hard time with brushing my hair”
A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following information should the nurse include regarding needle disposal?
a. “secure the cap tightly over the needle before you discard it”
b. “remove the needle from the syringe before you place it in the trash”
c. “you can discard needles in an empty bleach bottle with a lid”
d. “place your storage container in a recycle bin when it is full”
c. “you can discard needles in an empty bleach bottle with a lid”
A nurse is assessing a client who has arteriovenous (AV) graft in the left forearm. Which of the following findings should indicate to the nurse a complication of vascular access?
a. 2+ left radical pulse
b. Absence of a bruit
c. Presence of a palpable thrill
d. Dilated appearance of the AV site
b. Absence of a bruit
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
a. Familiarize themselves with commonly used sign language
b. Ask a family member to be present during the admission
c. Obtain a board that uses colored pictures as communication
d. Request an interpreter during the initial assessment
d. Request an interpreter during the initial assessment
A nurse is planning care for a client who has unrepaired intertrochanteric fracture and has Buck’s traction placed to the affected leg. Which of the following interventions should the
nurse include?
a. Situate the client’s heel in the heel of the traction boot
b. Apply weights of the traction to total 9.1 kg (20lb)
c. Place the footplate against the foot of the bed
d. Remove the boot for skin inspection every 12 hours.
a. Situate the client’s heel in the heel of the traction boot
A nurse is caring for a client who sustained a spinal cord injury in a diving accident. Which of the following actions should the nurse take?
a. Assess the client’s neurological status every 8 hour
b. Monitor urine output hourly
c. Provide the client with a low-fiber diet
d. Log roll the client every 4 hour
b. Monitor urine output hourly
A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care?
a. Flush the catheter using a 10ml syringe
b. Change the dressing every 24 hour
c. Use clean technique when changing the dressing
d. Cleanse the site with povidone-iodine
a. Flush the catheter using a 10ml syringe
A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following actions should the nurse take first?
a. Check the color of the client’s skin
b. Remove all of the client’s clothing
c. Administer an opioid analgesic
d. Prepare the client for periorbital lavage
a. Check the color of the client’s skin
A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?
a. Check the client’s gag reflex
b. Inform the client they might experience a low-grade fever
c. Instruct the client to report bleeding
d. Provide the client with sips of water
a. Check the client’s gag reflex
A nurse is developing a plan of care for a client who is returning from the PACU following a left below-the-knee amputation. Which of the following interventions should the nurse include in the plan?
a. Provide the client with a firm mattress
b. Wrap the client’s residual limb with elastic bandage in a distal to proximal direction
c. Place the client’s residual limb in a dependent position when possible
d. Keep the client in a supine position for 48 hours
a. Provide the client with a firm mattress
A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick-day rules. Which of the following statements by the client indicates an understanding of
the teaching?
a. “I will monitor my blood glucose every 8 hours”
b. “I will consume 250 grams of carbs daily while I’m sick”
c. “I will not take my diabetes medications while I am sick”
d. “I will check urine for ketones if my blood glucose is greater than 240 mg/dl
d. “I will check urine for ketones if my blood glucose is greater than 240 mg/dl
A nurse is reviewing ABG results for a client who has COPD. Which of the following findings should the nurse expect?
a. pH 7.38
b. PaO2 85 mm Hg
c. PaCO2 48 mm Hg
d. HCO3- 25 mEq/l
c. PaCO2 48 mm Hg
A nurse is admitting a client to a medical unit following placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse?
a. Sneezing
b. Hiccups
c. Presence of a sharp spike prior to the QRS complex on the ECG
d. Presence of intrinsic P waves following a QRS complex on the ECG
b. Hiccups
A nurse is caring for a client who experienced extensive burns to the arms and torso. Which of the following actions should the nurse take regarding the client’s oral nutritional intake?
a. Adhere to scheduled meal times three times daily
b. Encourage the client to eat as many calories as possible
c. Limit the client’s fluid intake to 1,500 ml/day
d. Avoid the use of supplemental feedings throughout the day
b. Encourage the client to eat as many calories as possible
A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of
care?
a. Place pillows under the client’s knees
b. Apply compression stockings to the lower extremities
c. Avoid use of anticoagulants
d. Discourage leg exercises while in bed
b. Apply compression stockings to the lower extremities
A nurse is caring for a client who has duodenal ulcer. Which of the following actions should the nurse take? Exhibit
a. Restrict the client’s fluid intake to 1,000 ml/day
b. Infuse packed RBCs
c. Administer the client’s naproxen prescription
d. Offer a snack before bedtime
b. Infuse packed RBCs
A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse’s priority?
a. “I can’t seem to get reading materials far enough away to see the words”
b. “I’m having more difficulty telling the difference between blues and greens”
c. “I’ve noticed that there is a gray ring around the colored part of my eye”
d. “In the last day, I have had a severe headache and pain around my right eye”
d. “In the last day, I have had a severe headache and pain around my right eye”
A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse anticipate?
a. BUN 8 mg/dl
b. Hgb 20 g/dl
c. Potassium 6.8 mEq/l
d. Creatinine 0.4 mg/dl
c. Potassium 6.8 mEq/l
A nurse is planning care for an older adult client who has Meniere’s disease. Which of the following interventions should the nurse include in the plan?
a. Perform range-of-motion exercises to the client’s neck every 4 hour
b. Limit the client’s fluid intake to 1,500 ml/day
c. Encourage the client to change positions slowly
d. Administer aspirin if the client reports a headache
c. Encourage the client to change positions slowly
A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations?
a. Upper left abdomen (THIS ONE IS A DIAGRAM CHOOSE THE POINT ON THE TOP LEFT OF
ABDOMEN)
A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure?
a. Initiate beta blocker therapy
b. Insert a urinary catheter
c. Prepare the client for an intravenous pyelogram
d. Administer IV fluids to the client
d. Administer IV fluids to the client
A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following actions should the nurse plan to take?
a. Administer through a 22-gauge IV catheter
b. Prime the IV tubing with 0.45% sodium chloride
c. Complete the transfusion within 2 hour
d. Slow the transfusion rate if the client reports itching
c. Complete the transfusion within 2 hour
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
a. Increase phosphorus intake
b. Decrease protein intake
c. Increase potassium intake
d. Decrease carbohydrate intake
b. Decrease protein intake
A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client’s abstract thinking?
a. “can you count backwards from 100 intervals of 7?”
b. “what is meant by the saying, don’t beat around the brush?
c. “what do you understand about your condition?”
d. “can you tell me the state where you were born?”
b. “what is meant by the saying, don’t beat around the brush?
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
a. Keep the soiled bed linens in the client’s room
b. Instruct visitors to remain 3 feet from the client
c. Discard the radioactive device in the client’s trash can
d. Limit time for visitors to 2 hour per day
a. Keep the soiled bed linens in the client’s room
A nurse is preparing a client for a lumbar puncture. Which of the following images indicates the position should the nurse assist the client into for this procedure?
a. Side-lying (THIS IS A DIAGRAM CHOOSE THE PERSON IN A FETAL POSITION)
A nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of the following actions should the nurse take?
a. Place long-handled forceps at the client’s bedside
b. Attach a dosimeter badge to the client’s gown
c. Leave unused equipment in the client’s room until discharge
d. Move the client’s soiled linens to a designated container outside the room
a. Place long-handled forceps at the client’s bedside
A nurse is teaching a client who has Graves’ disease about recognizing the manifestations of the thyroid storm. Which of the following findings should the nurse include in the teaching?
a. Increased temperature
b. Decreased HR
c. Hypotension
d. Lethargy
a. Increased temperature
A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
a. Serosanguineous drainage
b. Muscle twitching
c. Client report of nausea
d. Client report incisional pain
b. Muscle twitching
A nurse is reviewing ECG rhythm strips for a group of clients. The nurse should identify that which of the following rhythms indicates bradycardia?
pick the brady strip
A nurse is caring for a client who is receiving epidural analgesics. Which of the following assessment findings in the nurse’s priority?
a. Bladder distention
b. Hypoactive bowel sounds
c. Hypotension
d. Weakness to lower extremities
c. Hypotension
A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse’s priority to include?
a. Turn the client to the lateral position during seizure activity
b. Provide the client oxygen at 6 l/min using a nasal cannula
c. Administer phenytoin IV bolus to the client
d. Administer diazepam intravenously to the client
a. Turn the client to the lateral position during seizure activity
A nurse is caring for a client following a below-the knee amputation. The client states. “my life is over.” Which of the following responses should the nurse make?
a. “you are upset. We can talk about this later?”
b. “would you like to meet with another client who is an amputee?”
c. “why do you think your life is over?”
d. “most people can adjust following this surgery”
b. “would you like to meet with another client who is an amputee?”
A nurse in a clinic is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adults after the age of 60? Select All That Apply
a. Herpes zoster
b. Influenza
c. Meningococcal
d. Human papillomavirus
e. Pneumococcal polysaccharide
a. Herpes zoster
b. Influenza
e. Pneumococcal polysaccharide
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?
a. Turn off all lights in the client’s room at night
b. Place the client’s bed at the lowest height
c. Request a prescription for a nightly sedative
d. Assist the client with toileting at least once every 4 hour
b. Place the client’s bed at the lowest height
A nurse is assessing a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings indicates that the client is experiencing hypoglycemia?
a. Abdominal cramping
b. Increased perspiration
c. Dehydration
d. Fruity odor to breath
b. Increased perspiration
A nurse in the PACU is assessing a client who is postoperative following general anesthesia. Which of the following findings is the priority to address?
a. Vomiting upon arousal
b. Decreased body temperature
c. Indistinct, rambling speech
d. Piloerection of the skin
a. Vomiting upon arousal
A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding?
a. Bradycardia
b. Hypotension
c. Loss of skin turgor
d. Weight gain
d. Weight gain
A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? Select All That Apply
a. Take a warm bubble bath daily
b. Void every 6 hour during the day
c. Drink low-fructose cranberry juice
d. Wipe the perineal area from front to back after urinating
e. Drink 3L of fluids daily
c. Drink low-fructose cranberry juice
d. Wipe the perineal area from front to back after urinating
e. Drink 3L of fluids daily
A nurse is caring for a client following a cardiac catheterization who has hives and urticaria following administration of IV contrast dye. Which of the following medications should the nurse plan to administer?
a. Spironolactone
b. Desmopressin
c. Metoclopramide
d. Diphenhydramine
d. Diphenhydramine
A home care nurse is planning to use nonpharmacological pain relief measures for an older adult client who has severe chronic back pain. Which of the following guidelines should the nurse use?
a. Discontinue opioids before trying nonpharmacological methods of pain relief
b. Use imagery with clients who have difficulty with focus and concentration
c. Distraction changes the client’s perception of pain, but does not affect the cause
d. Pain relief from the use of heat and cold continues for several hours after removal of the
stimulus
c. Distraction changes the client’s perception of pain, but does not affect the cause
A nurse is caring for a female client who is receiving total parental nutrition without fat emulsion. Which of the following findings should the nurse report?
a. Crackles in the bilateral lung bases
b. Weight gain of 1.3 kg (3lb) over the past 7 days
c. Triglyceride 110 mg/dl
d. Bowel sounds absent in lower quadrants
a. Crackles in the bilateral lung bases