A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan
A. Provide the client with a means of communication
B. Maintain the head of the client’s bed in a flat position
C. Suction the client’s endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr
A
Use electronic tablet computer, programmable speech generating device, alphabet board, pencil and paper, etc
—
B, keep head of bed higher than 30 degrees to prevent aspiration and ventilator associated pneumonia. Turn the client q 2hr to prevent complications related to immobility
C, assess the need to suction q 2-4 hr, but not perform routine suctioning. Base the need for suctioning on assessments, not a schedule. Unnecessary suctioning can cause bronco spasms and injury tracheal mucosa
D, oral hygiene should be performed q 2 hr to decrease the risk of ventilator associated pneumonia
A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration. Which of the following laboratory results indicates effectiveness of the treatment
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62%
C
Within the expected range of 1.005-1.030
—
A, sodium range is 136-145
B, potassium range is 3.5-5
D, Hct range is 37%-52%
A nurse is monitoring the laboratory findings for a client who is postoperative following a total hip arthroplasty 6 hr ago. Which of the following values indicates that the client has an increased risk for bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million
C
platelet range is 150,000-400,000
—
A, PT range is 11-12.5
B, aPTT range is 30-40 seconds
D, RBC range is 4.2-6.1 million. A low RBC can indicate that bleeding has occurred, but it does not indicate that the client is at risk for bleeding
A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle crash. Which of the following interventions is the nurse’s priority while caring for this client
A. Change the client’s position every 2 hours
B. Pad pressure points at the edges of the client’s cervical collar
C. Palpate the client’s abdomen for bladder distention
D. Assist the client with quad coughing
D
The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the priority is to ensure the client can clear their airway. Apply abdominal pressure as the client coughs (quad coughing)
A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings indicates that the client is experiencing transfusion-associated circulatory overload
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia
C
Dyspnea is an indication of possible transfusion associated circulatory overload, leading to hypertension, bounding pulses, and confusion. Dyspnea can also indicate transfusion related acute lung injury to an anaphylactic response, which also causes wheezing, chest tightness, cyanosis, and low BP
—
A, nausea can indicate an acute hemolytic transfusion reaction
B, transfusion reactions include acute hemolytic, febrile, mild allergic, and anaphylactic
D, bradycardia is not an indication
A nurse is assessing a client who has lung cancer and is undergoing radiation therapy to the chest. Which of the following indicates an adverse effect of the therapy
A. Hair loss on the scalp
B. Sweating at the treatment site
C. Altered taste sensations
D. Intolerance to cold
C
Altered taste is a result of the release of metabolites by dead cells
—
A, client may have hair loss at the treatment site on the chest
B, client might have skin changes, such as dryness and increased sensitivity
D, avoid heat exposure
A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Which of the following actions should the nurse plan to take (select all that apply)
A. Obtain pre-transfusion temperature
B. Prime the IV tubing with lactated Ringer’s
C. Instruct an assistive personnel to monitor the client during the transfusion
D. Verify the client’s blood type with a second nurse
E. Use a 20 gauge IV needle for venous access
A, D, E
—
A, complete assessment prior to transfusion
B, prime tubing with a solution that does not cause hemolysis of PRBCs. No LR or 5% dextrose!
C, nurse should remain with pt for first 15 minutes of transfusion
D, verify identification, blood compatibility, and expiration of product with second nurse
E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk of cell hemolysis and obstruction of flow
A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the following BUN levels should the nurse expect
A. 3.6 mg/dl
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL
D
Normal range is 10-20, and elevated levels indicates renal disease, dehydration, shock, excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other conditions in which blood is reabsorbed from injured tissues
—
A low BUN level can indicate malnutrition, malabsorption, liver disease, fluid overload, or nephrotic syndrome
A nurse is reviewing ECG strips for several clients. Which of the following images should the nurse identify as atrial fibrillation
(cannot insert pictures, read description)
A. multiple irregular and variable waves at the baseline and irregular R to R intervals
B. a rate of 140-180/min
C. a tachycardia with no identifiable P wave and is determined to originate somewhere other than the ventricles. Rate between 100-280/min
D. a P wave for every QRS, rate is 60-100/min
A
—
B, Vtach
C, SVT
D, normal sinus
A nurse is preparing to admit a client who has a new tracheostomy from the operating room. Which of the following items is the priority for the nurse to have available in the client’s room upon admission
A. Obturator
B. Hydrogen peroxide
C. Sterile gloves
D. Inner cannula
A
The obturator can be inserted in the stoma in the even of dislodgment or decannulation to maintain an airway until a new trach tube can be placed. For the first 72 hr following the insertion of a trach, dislodgement or decannulation is considered an emergency
—
B, used for trach care, but not priority
C, sterile gloves for suctioning or for dressing change, but not priority
D, inner cannula in case it needs to be replaced, but not priority
A nurse is caring for a client who had a below the knee amputation due to a traumatic injury 2 days ago. Which of the following statements should the nurse use to assess how the client is coping with this change in their body image
A. “Tell me how the changes to your leg make you feel”
B. “What potential changes do you think you’ll need to make when doing your job”
C. “Let’s discuss how you can adjust once you have a prosthesis”
D. “What are some possible issues that you foresee when completing self-management tasks”
A
A nurse is teaching a client how to administer a medication using an inhaler with a spacer. Which of the following instructions should the nurse include
A. “Wait at least 5 minutes between puffs from the same inhaler”
B. “Breathe in rapidly when inhaling the medication”
C. “Clean the plastic inhaler cap weekly with cold water”
D. “Shake the inhaler vigorously prior to use”
D
Thoroughly shake the inhaler to disperse the medication because the medication in the inhaler can separate easily
—
A, wait at least 30 to 60 seconds between puffs of the medication. Wait 2-5 min between using different medications from separate inhalers
B, breathe in slowly and deeply to distribute the medication evenly throughout the bronchiole tissue. If the spacer makes a whistling noise, they are breathing too rapidly
C, clean the spacer weekly and the plastic cap of the inhaler at least once daily by rising them in warm water
A nurse in an endoscopy clinic is providing teaching to a client who is to undergo a colonoscopy for colon cancer screening. Which of the following information should the nurse provide
A. “You should have nothing to eat or drink for 3 hours prior to the procedure”
B. “You should drink the bowel preparation slowly to prevent nausea”
C. “You will have no discomfort following the procedure”
D. “You will need someone to drive you home after your procedure”
D
Do not drive for 12-18 hours following the procedure, because during a colonoscopy, the pt receives moderate sedation
—
A, begin a clear diet the day before the procedure. The pt should have nothing to eat or drink for 4-6 hr prior to the procedure
B, drink the bowel prep quickly to minimize nausea
C, it is typical to have cramping and a feeling of fullness after a colonoscopy d/t the instillation of air into the bowel during the procedure
A nurse is monitoring a client who is receiving moderate sedation with midazolam. Which of the following findings requires immediate intervention by the nurse
A. Oxygen saturation 90%
B. No response to verbal stimuli
C. Occasional premature ventricular contractions (PVCs)
D. Nausea
B
using urgent vs non-urgent approach, this is the priority. During moderate sedation, the pt should be able to provide a response to questions and commands. No response to verbal stimuli can indicate a loss or consciousness or oversedation
A nurse is reviewing the laboratory findings for a client who has heart failure and is taking furosemide. The nurse should identify which of the following findings as an adverse effect of the medication
A. Sodium 142 mEq/L
B. Metabolic acidosis
C. Potassium 3.2 mEq/L
D. Hypoglycemia
C
Loop diuretics remove excessive extracellular fluid through the kidneys, causing an increased excretion of potassium. Monitor for dysrhythmias
—
A, monitor for hyponatremia (sodium < 136)
B, furosemide can cause metabolic alkalosis, monitor for cramping, twicthing, and increased HR
D, furosemide can cause hyperglycemia
A nurse is caring for a client who is in Buck’s traction. Which of the following actions should the nurse take? (select all that apply)
A. Monitor peripheral pulses in the affected extremity
B. Position weights against the foot of the bed
C. Adjust the prescribed weights every 24 hrs
D. Examine the skin under the traction bood
E. Assess the temperature of the affected extremity
A, D, E
—
A, closely monitor the neurovascular integrity. Circulation can be compromised from the fracture as well as the traction device
B, weights should hang freely away from the foot of the bed to promote proper traction and healing. Hanging freely provides counter traction that diminishes muscle spasms
C, Buck’s is a short term treatment with weights ranging 2.3-4.5 kg (5-10lb). Nurse does not adjust the weight without a prescription from the provider
D, monitor skin integrity at least every 8 hr
E, Circulation can be compromised from the fracture as well as the traction device. Check and document color, temperature, distal pulses, capillary refill, movement, and sensation during neurovascular assessment. Monitor 6 P’s: pain, pallor, pulselessness, pressure, paresthesia, and paralysis
A nurse is reviewing safety measures with the caregiver of a client who has Alzheimer’s disease. Which of the following instructions should the nurse include in the teaching
A. Lock doors leading to stairways
B. Instruct the client not to use the stove
C. Place a throw rug in front of the toilet
D. Provide a darkened room for the client to sleep
A
This pt is at an increased risk for falls d/t difficulty with balance and an inability to recognize dangerous situations due to brain damage from the disease
—
B, learning and memory are loss impaired, so it is unrealistic to expect this pt to remember instructions long term. Caregiver should remove the knobs or controls on the stove so the pt cant turn it on
C, at a high risk for falls, rugs increase risk for slipping
D, loss of cognition and recognition of environment. Keeping the room dark will further decrease the ability of the client to gain their bearings and places the client at risk for falls. Use a night-light
A nurse is developing a plan of care for a client who has meningitis. Which of the following interventions should the nurse include in the plan
A. Keep the client’s room dark and quiet
B. Perform a vascular assessment for the client every 6 hr
C. Maintain the head of the client’s bed at 15 degrees at all times
D. Place the client on contact precautions
A
Meningitis often causes photophobia and phonophobia. Reduce stimuli
—
B, risk of thrombotic or embolic complications, perform a vascular assessment at least every 4 hours or more often as needed
C, head of bed should be elevated to 30 degrees at all times. Remain on bedrest until activity is tolerated
D, meningitis needs droplet precautions for the first 24 hr of antibiotic therapy to prevent transmission. If viral meningitis is confirmed diagnosis, the precautions may be removed
A nurse is caring for a client who has a right subclavian central venous catheter. Which reconnecting a new intravenous infusion administration set, which of the following actions should the nurse take
A. Ask the client to exhale slowly
B. Turn the client’s head to the right
C. Place the client in a semi fowlers position
D. use aseptic technique
D
aseptic= sterile
prevents central line related blood infections when disconnecting and reconnecting the new set
—
A, ask pt to perform the valsalva maneuver by inhaling, holding their breath, and bearing down to prevent any air from entering the catheter when disconnecting and reconnecting the new set
B, turn clients head to the left to facilitate access to the clients catheter, which is located in the right subclavian vein
C, the client should lie flat to ensure the catheter exit site is at or below the level of the heart when disconnecting and reconnecting the new set
A nurse is educating an older adult client about immunizations. Which of the following immunizations should the nurse include in the recommendation for the client
A. Recombinant herpes zoster
B. Human papillomavirus
C. Live attenuated influenza
D. Varicella
A
herpes zoster= shingles
Older adults can get either the live or recombinant herpes zoster immunization
—
B, the HPV vaccine is recommended only for pt < 26 years old
C, live attenuated influenza vaccine is recommended only for pt <49 years old. Older adults should receive inactivated or recombinant influenza immunization
D, varicella is recommended only for pt born after 1980
A nurse is caring fro a client who has continuous bladder irrigation following a transurthral resection of the prostate (TURP). Which of he following actions should the nurse take
A. Place the indwelling urinary catheter tubing so it lies freely between the client’s legs
B. Irrigate the indwelling urinary catheter using sterile water
C. Subtract the amount of irrigation solution from the indwelling urinary catheter output
D. Flush the indwelling urinary catheter with 30mL of irrigation solution to clear an obstruction
C
Determine an accurate urinary output by subtracting the amount of irrigation solution from the total output in the urinary drainage bag
—
A, fasten the drainage tube securely to the client’s thigh
B, use sterile 0.9% sodium chloride irrigation, which is an isotonic solution, for bladder irrigation. Sterile water is hypotonic and can be absorbed if used as an irrigation solution, causing fluid shifts and dilutional hyponatremia
D, irrigate with 50 mL of irrigation solution to free an obstruction in the catheter
A nurse is administering epinephrine IV to a client who is having an anaphylactic reaction. Which of the following findings should the nurse identify as a therapeutic response to the medication
A. Hypoglycemia
B. Thickened bronchial secretions
C. Regular heart rate with hypotension
D. Non itchy skin wheals
D
A pt in anaphylactic shock can experience intensely itchy skin with wheals or hives that can merge to form large red blotches. Epi blocks the release of histamine and decreases erythema, angioedema, and hives. This finding indicates a therapeutic response to the epi
—
A, hyperglycemia is an adverse effect of epi. Hypoglycemia from the administration of epi does not indicate a therapeutic response to the medication
B, a client in anaphylactic shock can have an increase in congestion, tongue and larynx swelling, and increased mucus production. Decreased bronchial secretions and a clear airway indicate and therapeutic response to epi
C, a client in anaphylactic shock can have hypotension and a rapid, weak, irregular pulse from vasodilation of vessels and extensive capillary leaks. Absence of hypotension and an elevated HR indicate an therapeutic response to epi
A nurse is assisting in selecting foods for lunch with a client who has diverticulosis. Which of the following foods should the nurse recommend as the best source of fiber
A. 1 slice of rye bread
B. 1/2 cup cooked navy beans
C. 1/2 cup cooked asparagus
D. 1/2 cup watermelon
B
navy beans contain 5g of fiber per 1/2 cup
—
A, 1 slice of rye bread has 1g of fiber
C, 1/2 cup of asparagus has 1g fiber
D, 1/2 cup of watermelon has 0.3 g fiber
A nurse is providing teaching to a client who has venous insufficiency. Which of the following statements by the client indicates an understanding of the teaching
A. “I will wear my graduated compression stockings while sleeping”
B. “I will elevate my legs for 10 minutes 3 times per day”
C. “I will limit the time I spend sitting down during the day”
D. “I will cross my legs at my knees when sitting”
C
Avoid prolonged periods of sitting or standing, which keeps the legs from being in a dependent position and helps prevent venous stasis
—
A, wear graduated compression stockings during the day and evening, remove stockings at bedtime
B, elevate legs for at least 20 minutes 4 or 5 times per day. When lying down, elevate the legs above the level of their heart
D, do not cross legs when sitting
A nurse is providing teaching to a client who is undergoing radiation therapy and wants to go for a walk outside. Which of the following recommendations should the nurse include in the teaching?
A. “Try to avoid sun exposure by waiting until after sunset to go outdoors”
B. “Gently was the irradiated area to remove the markings before going outside”
C. “Protect exposed skin with an over the counter sunscreen”
D. “Wear form sitting clothing when going outside”
A
Protect the skin from exposure to sunlight during treatment and for 1 year after the last treatment. Stay in the shade, go outside in the early morning or evening to avoid the more intense sun rays to allow the pt to stay outside for a longer period
—
B, do not remove any temporary ink markings when cleaning the skin until the entire course of radiation is complete
C, apply only lotions that he provider prescribes. Chemical agents in sunscreen can cause irritation to the radiated skin
D, wear loose fitting clothing over the treated area of skin. No buckles, belts, straps, or anything that binds or rubs the skin at the site
A nurse in an emergency department is monitoring a client who reports angina. Which of the following findings should indicate to the nurse that the client might have experienced a myocardial infarction (MI)
A. Increased troponin
B. Decreased creatinine kinase MB
C. Cholesterol 300 mg/dL
D. C- reactive protein 1.2 mg/dL
A
Troponin is a myocardial muscle protein released into the blood stream as a result of injury to the heart muscle. Troponin levels increase within 2-3 hr following an MI
—
B, creatinine kinase MB elevates when there is injury to brain tissue, myocardial muscle, or skeletal muscle
C, elevated cholesterol increases the risk for cardiovascular disease, but does not diagnose an MI
D, this is within the expected reference range
A nurse is preparing to obtain blood cultures from a client’s central venous catheter (CVC). Which of the following actions should the nurse take when accessing the catheter
A. Flush the lumen with heparin solution before each use
B. Aspirate for blood return prior to each use
C. Perform a 5 second scrub to the catheter hub before accessing the catheter
D. Apply firm pressure to the syringe plunger when flushing the lumen
B
—
A, flush the lumen of any CVC with 0.9% sodium chloride. The nurse can flush an implanted port with 5mL heparin 10 units / mL to prevent clots
C, 15 second scrub
D, apply slow, even pressure to the syringe plunger to flush the lumen, and immediately stop if there is resistance. Use a 10mL syringe when flushing central catheters
A nurse on a medical surgical unit has received shift report for a group of clients. Which of the following interventions should the nurse plan to complete first
A. Perform a dressing change on a client who is 24 hr postoperative following abdominal surgery and has sanguineous drainage on the dressing
B. Replace an infiltrated IV for a client who has pneumonia and has scheduled IV antibiotics due in 30 minutes
C. administer a prescribed opioid pain medication to a client who is reporting back pain as a 5 on a numeric pain scale of 0 to 10
D. Assess a client who is 4hr postoperative following thoracic surgery and has a respiratory rate of 7/min
D
Using the ABC approach, this is the priority. A RR of 7 indicates hypoventilation and can indicate respiratory failure or shock, especially in pt who is postop.
A nurse on a medical unit is planning care for a client who has COPD. Which of the following actions should the nurse include in the plan
A. Suction the client’s airway every 4 hours
B. Limit the client’s fluid intake to control secretions
C. Provide the client with a high protein diet
D. Administer the client’s bronchodilator following each meal
C
COPD needs a diet high in protein and calories. They should eat freuqent, small meals and should avoid drinking fluids prior to or during meals
—
A, do not suction COPD on a routine basis, only suction as necessary to clear secretions and maintain a patent airway
B, encourage the intake of fluids at least 2L/day to help thin secretions
D, administer bronchodilator 30 min prior to meals to reduce the risk of bronchospasm
A nurse is administering parenteral nutrition to a client who has a history of heart failure. Which of the following manifestations indicates to the nurse that the client is experiencing fluid overload
A. hypotension
B. flattened neck veins
C. nocturia
D. weight loss
C
when the client is recumbent, the extracellular fluid enters the vascular system and increases the blood volume filtering through the kidneys, which increases urine production
—
A, hypertension indicates fluid overload in a pt with heart failure
B, distended neck veins indicates fluid overload in a pt with heart failure
D, acute weight gain is the most reliable indicator of fluid volume overload in a client who has heart failure
A nurse is teaching the caregiver of a client who has mild alzheimer’s disease about progression of the disease. Which of the following should the nurse include as a manifestation of moderate alzheimer’s disease
A. Short term memory loss
B. misplacement of household items
C. Episodes of wandering
D. loss of mobility
C
Wandering occurs in the moderate stage of AD
—
A, short term memory loss is an early stage of AD. In moderate stage, pt has impaired cognitive function and is disoriented
B, misplacement of items is an early stage of AD. In moderate stage, pt develops a lack of awareness of their location and surroundings
D, loss of mobility is severe stage of AD. in moderate stage, pt needs more assistance with mobility and ADLs but will still have some mobility
A nurse is providing discharge teaching to a client who was admitted to the medical surgical unit due to heart failure. Which of the following statements by the client indicates an understanding of the teaching
A. “I will limit my dietary sodium intake to 4 grams per day”
B. “I should weigh myself once a week”
C. “I plan to wait 2 hours after eating to take my walk”
D. “I will take my diuretic before going to bed at night”
C
To promote exercise tolerance, the client should wait for 2 hr after eating before engaging in exercise
—
A, limit sodium to 2-3g per day to prevent fluid retention in a heart healthy diet
B, weigh daily! Report a weight gain of more than 1.4kg (3lb) in 1 day or more than 2.3 kg (5lb) per week
D, take diuretics in the morning to avoid having to get up during the night to void
A nurse is reviewing the laboratory reports of a client who has cirrhosis. Which of the following results should the nurse report to the provider immediately
A. BUN 22 mg/dL
B. Sodium 134 mEq/L
C. Platelet count 18,000 mm
D. WBC 4,500 mm
C
The greatest risk to this client is injury from hemorrhage, and 18,000 is critically lower than the range of 150,000-400,000. A level <20,000 is a critical value representing thrombocytopenia and the potential for spontaneous bleeding
A nurse is preparing to transfuse 1 unit of packed RBC to a client. Which of the following actions should the nurse take first
A. Verify the label on the blood product with 2 client identifiers
B. Check the client’s medical record to verify the provider’s prescription
C. Flush the blood tubing with 0.9% sodium chloride
D. Instruct the client to report itching or shortness of breath
B
The greatest risk to this client is injury from a transfusion reaction, so the first action is to check the medical record to verify the providers order. This reduces the risk for client injury form receiving incompatible packed RBCs
A nurse is providing discharge teaching to a client who is postoperative following glaucoma surgery. Which of the following instructions should the nurse include to prevent increased intraocular pressure
A. “Avoid straining to have a bowel movement”
B. “Avoid lying on your right side”
C. “Avoid lifting objects that weigh more than 5 pounds”
D. “Avoid sleeping with your head elevated”
A
Consume a diet high in fiber and fluids to prevent constipation and straining to have a bowel movement, which can increase intraocular pressure
B, instruct pt to lie on the unaffected side to decrease intraocular pressure
C, avoid lifting objects that weight 4.5 kg (10lb) or more
D, sleep with their head elevated. Avoid placing their head in a dependent position, as this increases intraocular pressure
A nurse is providing teaching about health promotion activities to an older adult client. Which of the following recommendations should the nurse include in the teaching
A. “Maintain your dietary fat intake at 45% of your daily caloric intake”
B. “Obtain 15 minutes of sunlight exposure 3 times per week”
C. “Exercise for 30 minutes twice per week”
D. “Decrease your fiber intake to less than 20 grams per day”
B
Instruct the client to obtain at least 10-15 min of exposure to sunlight 2-3 times per week to ensure adequate vitamin D production
—
A, metabolism slows with age, so the client should maintain a dietary fat intake between 20-35% of daily caloric intake to prevent weight gain
C, exercise 5 times per week for 30 min to improve strength and mobility
D, increase dietary fiber containing foods to between 35-50 grams per day
A nurse is caring for a client who has an above the knee amputation related to trauma and is experiencing phantom limb pain. Which of the following medications should the nurse administer to treat the client’s pain?
A. Meloxicam
B. Cyclobenzaprine
C. Gabapentin
D. Lidocaine
C
phantom limb pain is a type of neuropathic pain resulting from damage to peripheral and central nervous system pathways. Gabapentin is an anticonvulsant medication that helps treat neuropathic pain
—
A, meloxicam is an NSAID that helps treat mild to moderate nociceptive pain d/t tissue damage or inflammation
B, cyclobenzaprine is a skeletal muscle relaxant that helps treat muscle spasms
D, lidocaine is a topical anesthetic that provides surface anesthesia to relieve localized pain, itching and soreness
A nurse is reviewing the laboratory findings for a client who has a urinary tract infection. Which of the following laboratory findings should the nurse identify as an indication the client is in the initial stages of systemic inflammatory response syndrome (SIRS)?
A. WBC count 14,000/mm
B. Platelets 110,000/ mm
C. Lactic acid 19 mg/dL
D. C reactive protein 2.8 mg/L
A
WBC count of 14,000 is above the expected range of 5,000-10,000. SIRS overwhelms the body’s defenses, resulting in a widespread inflammation. WBCs might increase initially, but depending on the bone marrow’s ability to produce neutrophils and WBCs, the WBC count can become extremely low
—
B, slightly lower than the expected range of 150,000-400,000 , but this is an expected finding in SIRS
C, lactic acid value of 19 is within the reference range of 5-20. We would see elevated lactic acid levels in SIRS
D, 2.8 is within the expected range for C reactive protein of 1-3. Would expect it to be elevated in SIRS
A nurse is caring for a client who is receiving brachytherapy. Which of the following actions should the nurse take?
A. Limit visitation time to 2 hr per day, per visitor
B. Wear a dosimeter film badge when caring for the client
C. Open the door toe the client’s room when visitors are present
D. Double bag bed linens and remove them daily from the client’s room
B
the badge does not protect the nurse form the effects of radiation, it does record the amount of individual exposure to the radiation
—
A, limit each visitor to 30 min per day to decrease the visitors exposure to radiation. Advise visitors to stay at least 6 feet from the radiation source located internally in the client
C, keep the door closed to the pt room at all times to prevent radiation exposure to other clients and visitors
D, keep bed linens in the client’s room until the provider removes the radiation from the client. Once the client is no longer receiving radiation and all the radiation is accounted for, the nurse can remove linens using standard precautions.
A nurse is panning care for a client who has been newly diagnosed with acute pancreatitis. Which of the following interventions should the nurse include in the plan of care
A. Encourage liquid nutritional supplements
B. Administer opioid medications via a PCA
C. Assess for signs of hypercalcemia
D. Administer hypotonic IV fluids
B
pain mangement is important in the care of a client who has pancreatitis. Clients are most often started on opioid medication via PCA in the early stages of pancreatitis to mange pain
—
A, remain NPO to rest pancreas in early stages of pancreatitis
C, pacnreatitis causes hypocalcemia, monitor for chovstek’s and trousseau’s signs
D, during acute period of pancreatitis, client is at risk of hypovolemia due to NPO status. Isotonic solutions (.9 NaCl) should be given to maintain fluid balance
A nurse is reviewing the current laboratory findings for a client who has a pulmonary embolism and is receiving heparin therapy by continuous IV infusion. Which of the following prescriptions should the nurse anticipate for an aPTT of 110 seconds
A. Increase the rate of the heparin infusion
B. Stop the heparin infusion
C. Administer vitamin K to the client
D. Administer atropine to the client
B
Therapeutic range of aPTT for client on heparin is 1.5-2.5 times the normal value. A value greater than 2.5 times the expected reference range of 20-40 seconds is critical! If the aPTT is > 100 seconds, anticipate a prescription to stop or decrease the heparin infusion rate
—
C,
vitamin K= warfarin antidote
Protamine= heparin antidote
A nurse in the emergency department is caring for a client who has a traumatic brain injury (TBI). Which of the following assessment findings should the nurse recognize as a late manifestation of increased intracranial pressure (ICP) (select all that apply)
A. Tachypnea
B. Increased restlessness
C. Bradycardia
D. Asymmetric pupils
E. Widened pulse pressure
C, D, E
Late manifestations of ICP:
-Bradypnea
-Stuporous (requires painful stimuli to elicit a reaction)
-Bradycardia
-Asymmetric pupils
-Widened pulse pressure
A nurse is caring for a client who has end stage liver disease and an active upper GI bleed. After inserting an NG tube, which of the following findings should the nurse expect
A. Bright red drainage
B. Dark brown drainage
C. Off white drainage
D. Greenish yellow drainage
A
Red NG output indicates the client has an active upper GI bleed
—
B, dark brown NG output indicates intestinal obstruction
C, off white drainage is an expected finding for NG drainage when the client does not have GI bleeding
D, greenish yellow NG output contains bile and is an expected finding for NG drainage when the client does not have GI bleeding
A nurse is educating a group of clients about menopause. Which of the following information should the nurse include
A. Limit exercise to 30 min, one to two times a week to reduce fatigue
B. Hormone therapy (HT) is no longer used because of the risk of cancer
C. Vaginal bleeding after 1 year without menses should be reported to the provider
D. The use of complementary therapies to treat hot flashes should be avoided
C
Immediately report to the provider about any vaginal bleeding that occurs 1 year after menses have stopped. Vaginal bleeding after 1 year can indicate menopause has occurred, however, it can indicate a malignant process and the provider should be notified.
—
A. exercise should not be limited
B, HT is still somewhat controversial but can be used in small doses to treat moderate to severe manifestations of menopause. HT should be used for a short an amount of time as possible
D, vitamins, herbal supplements, and meditation can help treat hot flashes
A nurse is reviewing the medical record of a client who is to undergo a surgical procedure. Which of the following findings indicates that the client is at risk for developing DVT
A. BMI 38.6
B. History of asthma
C. Use of glucosamine sulfate
D. Hypothyroidism
A
A BMI of 38.6 indicates the client is obese and is at a greater risk for developing DVT as a surgical complication
—
B, does not increase risk of developing DVT
C, glucosamine increses risk for bleeding, not a DVT
D, hypothyroidism has a delayed response to healing, but not a risk for DVT
A nurse is caring for a client who has neutropenia following cyclosporine therapy. Which of the following actions should the nurse take?
A. Monitor the client’s vital signs every 8 hr
B. Keep a designated blood pressure cuff in the client’s room
C. Inspect the client’s mucous membranes daily
D. Avoid the use of alcohol based hand sanitizers prior to client care
B
Designate equipment to keep in the client’s room to limit exposing the equipment to micro-organisms from other clients. Patients with neutropenia have an increased risk for infection and sepsis due to a reduction in their leukocyte count
—
A, measure temperature at least every 4 hours to monitor for infection and sepsis
C, inspect membranes at least every 8 hours for early detection of infection or bleeding
D, proper hand hygiene is required prior to providing care or touching the client’s belongings
A nurse is completing a preoperative assessment on a client who is scheduled for surgery in the morning. Which of the following findings should indicate to the nurse that the client is at risk for increased bleeding
A. History of smoking
B. Shellfish allergy
C. Uses St John’s wort
D. Takes a garlic supplement
D
Garlic supplements increase the client’s risk for bleeding due to garlic’s ability to inhibit blood clotting by decreasing platelet aggregation
—
B, shellfish allergy indicates client is at risk for allergic reaction to povidone-iodine
C, st johns wort can reduce the effectiveness of digoxin and calcium channel blockers, but does not increase risk for bleeding
A nurse is assessing a client who has a calcium level of 12.3 mg/dL. Which of the following findings should the nurse expect
A. lethargy
B. muscle spasms
C. positive chvostek’s sign
D. shortened P-R interval
A
12.3 calcium indicates hypercalcemia (range is 9-10.5).
Manifestations of hypercalcemia: muscle weakness, decreased deep tendon reflexes, generalized weakness, fatigue, lethargy, confusion, weight loss, bone pain, cardiac dysrhythmias (shortened QT interval) and kidney stones
Manifestations of hypocalcemia: muscle spasms, cramps, tetany, positive chvostek’s sign (tap on clients face below and in front of ear, positive sign is twitching on one side of face)
A nurse in the ICU is caring for a client who is reporting heart palpitations. The nurse notes ventricular tachycardia on the ECG monitor. Which of the following actions should the nurse take
A. Defibrillate the client
B. Prepare the client for cardioversion
C. Initiate CPR
D. Administer digoxin
B
cardioversion is a synchronized countershock that uses a pulse to help convert vtach back to sinus rhythm for a client who is STABLE AND RESPONSIVE
—
A, defibrillation does not have a synchronized current and is not appropriate for a client who has stable Vtach and is responsive
C, the nurse needs to assess ABCS and level of consciousness before beginning CPR. Because this patient is stable in vtach and is responsive, the pt does not need CPR
D, the nurse should give an anti-dysrhythmic agent (amiodarone) to treat Vtach. Digoxin increases ventricular irritability and would increase the clients risk of vfib after cardioversion
A nurse is providing discharge teaching to a client who has lithotripsy for calcium phosphate renal calculi. Which of the following instructions should the nurse give to the client
A. Limit intake of animal protein to 6 oz per day
B. Increase fluid intake to 1.5L/ day
C. Expect pain in the kidneys and bladder
D. Expect difficulty urinating for up to 1 week
A
To prevent further kidney stones, the client should limit animal protein intake to 5 servings per week. Animal protein contains purine, which produces uric acid that can accumulate as stones in the kidney
—
B, client should increase fluid intake to 3L/day
C, pain in the kidneys and bladder is a manifestation of infection or formation of a stone
D, blood in the urine is expected for 4-5 days, but any dysuria should be reported to the provider
A nurse is reviewing the ABG results of a client who is receiving total parenteral nutrition. The nurse notes a pH of 7.25, a bicarbonate of 18 mEq/L, and PaCO2 of 43 mm Hg. Which of the following acid base imbalances is the client experiencing
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
C
Low pH (acidosis)
Normal PaCO2
Low bicarb (metabolic)
A nurse is caring for a client who is in the progressive stage of hypovolemic shock. Which of the following findings should the nurse expect
A. Acidosis
B. Bradycardia
C. Hypertension
D. Hypokalemia
A
In the progressive stage, compensatory mechanisms have failed. Decreased perfusion to the tissues results in anaerobic metabolism and the accumulation of metabolites, causing metabolic acidosis
—
B, the tissues lack perfusion and body compensates by increasing HR (tachycardia)
C, heart cannot deliver enough blood, resulting in hypotension
D, the lack of perfusion that occurs in the progressive stage of hypovolemic shock results in anaerobic metabolism and the accumulation of lactic acid. The build up of lactic acid raises potassium levels (hyperkalemia)
A nurse is caring for a client who is prescribed bedrest following a stroke. Which of the following interventions should the nurse implement to prevent foot drop
A. Maintain the client’s feet in plantar flexion
B. Tuck the bed sheet tightly over the client’s feet
C. Support the feet with toes pointed upwards using padded splits
D. Position and abductor pillow between the client’s legs
C
Position the client’s feet in a dorsiflexion position using a firm surface, such as a footboard, padded splints, or orthotics. The nurse should pad the splints to prevent areas of pressure on clients skin
—
A, when foot drop occurs, the clients feet are fixed in a plantar flexion position with toes pointed downward
B, avoid downward pressure on the clients feet, which occurs when sheets are tucked
D, use an abductor pillow to prevent hip displacement following a total hip arthroplasty. This does not help prevent foot drop
A nurse in a postanesthesia care unit is performing a postoperative assessment on a client who is recovering from a lumbar laminectomy and has a surgical drain. Which of the following findings should the nurse identify as a complication of the procedure
A. Clear drainage on the surgical dressing
B. Pain level of 5 on a scale from 0 to 10
C. Reports discomfort when log rolling
D. Drainage output 30m: during the first hour
A
Clear fluid on or around the surgical dressing following a laminectomy is an indication of CSF leak. Place the client flat to prevent a spinal headache and notify provider immediately
A nurse is caring for a client who has gastroenteritis with nausea and vomiting. Which of the following findings should the nurse identify as the most accurate indication of the client’s fluid status
A. The client’s intake and output
B. The client’s skin turgor
C. The client’s blood pressure
D. The client’s daily weight
D
The most accurate indication of fluid loss is the measurement of the client’s weight.
*1 kg (2.2 lb) of weight loss= approx 1 L of fluid loss
A nurse is reviewing laboratory reports for a client who has HIV. Which of the following laboratory values should the nurse report to the provider immediately
A. Positive enzyme linked immunosorbent assay (ELISA) test
B. CD4 T cell count 175
C. Positive western blot test
D. WBC count 4,8000
B
A CD4 cell count of < 200 indicates the client is severely immunocompromised and is in stage 3 of the disease (AIDS). This indicates the client is at greatest risk for infection
—
A, ELISA test is a specific screening test that detects the presence of antibodies of HIV and indicates that the client is at risk for immunosuppression and has HIV
C, a western blot test is a specific screening test that detects the presence of antibodies of HIV and indicates that the client is at risk for immunosuppression and has HIV
D, a WBC of <3,500 is expected for a client who has AIDS
A nurse is caring for a client who is receiving intermittent peritoneal dialysis. Which of the following actions should the nurse take
A. Warm the dialysate in the microwave
B. Weigh the client before and after each dialysis treatment
C. Place the drainage bag at the level of the client’s dialysis catheter
D. Wear clean gloves when providing peritoneal catheter care
B
This determines the amount of fluid removed
—
A, cold dialysate causes discomfort, so it should be warmed by wrapping the bag with a heating pad or using a warming chamber
C, place the drainage bag below the level of the peritoneal catheter to allow for gravity drainage
D, wear sterile gloves and use aseptic (sterile) technique when providing peritoneal dialysis catheter care to prevent infection
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which of the following actions should the nurse take to prepare the client for the procedure
A. Advise the client that a chest xray will be necessary following the procedure
B. Inform the client that the procedure requires general anesthesia
C. Place the client in a supine position
D. Instruct the client to take deep breaths during the procedure
A
chest X ray verifies that a pneumothorax or a mediastinal shift has not occurred
—
B, local anesthetic is sufficient for the procedure
C, place client in an upright position with their arms and shoulders raised and supported on pillows or an overbed table to facilitate the removal of fluid. An upright position also allows the provider access to the pleural space
D, avoid moving during the procedure, including taking deep breaths. Deep breaths can result in damage to the lungs
A nurse is caring for a client who has developed a pulmonary embolus (PE). Which of the following assessment findings should the nurse expect
A. bradycardia
B. lethargy
C. sharp chest pain
D. petechiae over lower extremities
C
A PE is a medical emergency
PE manifestations: tachycardia, sharp chest pain, petechiae over the chest and axillae, feeling of apprehension, restlessness, sense of impending doom, tachypnea, dyspnea, crackles, low grade fever
A nurse on an ICU is caring for a client who has developed ventricular fibrillation. Which of the following actions is the nurses priority
A. Defibrillate the client
B. Apply oxygen for the client
C. Provide chest compressions for the client
D. Administer epinephrine to the client
A
Vfib is a lethal rhythm, ventricles are quivering and has no cardiac output and must be defibrillated! If Vfib continues after one shock, then deliver CPR and airway mangement
Shockable rhythms: pulseless Vtach, vfib
Nonshockable rhythms: PEA, asystole
Capstone Med Surg Assessment 1. A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea. Which of the following information should the nurse include in the teaching?It delivers a present amount of airway pressure throughout the breathing cycle2. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? Shortness of breath might be an indication of transplant rejection3. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3 % sodium chloride via continuous IV. Which of the following laboratory finding should the nurse identify as an indication that the SIADH is resolving?Urine specific gravity 1.0204. A nurse is teaching a client about fecal occult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching? You should avoid taking corticosteroids prior to testing5. A nurse is preparing a client for a colonoscopy. Which of the following medications should the nurse anticipate the provider to prescribe as an anesthetic for the procedure? Propofol6. A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the clients plan? Select all that apply.Monitor blood glucose levels Maintain NPO status until pain-freeManage acute pain
- A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the client to include in their diet? 3 oz of chicken breast8. A nurse is reviewing the medical record of a client who has unstable angina.Which of the findings should the nurse report to the provider?Breath Sounds9. A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching? I will limit activities that require bending at the waist.10. A nurse at a provide office is interviewing a client who has multiple sclerosis and has been taking dantrolone for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective? I don’t have muscle spasms as frequently 11.A nurse is assessing a client who reports a possible exposure to HIV. Whichof the following finding should the nurse identify as an early manifestation of HIV infection? Fatigue 12.A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia .which of the following statements by the client indicates an understanding of the teaching?I can drink 4 ounces of soda if my blood sugar is low 13.A nurse is providing discharge teaching to a client who has heart failure anda prescription for furosemide 20 mg PO two times daily. Which of the following instructions should the nurse include in the teaching? Increase intake of high-potassium foods
14.A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance .Which of the following statements should the nurse make?It could be helpful for you to attend a support group for people who have burn injuries.15.A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine .Which of the following interventions should the nurse include in the plan?Monitor the client skin under the halo vest.16.A nurse is caring for a client who has a traumatic brain injury. Which of the following finding should indicate to the nurse the need for immediate intervention? Respiratory rate 30/min17.A nurse is assessing a client who has meningitis. The nurse should identify which of the following finding as a positive Kerning s sign? After stroking the lateral area of the foot, the client’s toes contract and draw together.After hip flexion, the client is unable to extend their leg completely without pain18.A nurse is teaching a group of assistive personnel (AP) about caring for client who have Alzheimer’s disease. Which of the following information should the nurse include in the teaching?Provide supervision to prevent a client from becoming injured or lost.19.A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching? Keep a padded tongue blade near the bedside. Place a pillow under the client’s head while in bed during a seizure. Administer diazepam orally at the onset of seizures.
Position the client on their side during a seizure.20.A nurse is contributing to the plan of care for a client who has pyelonephritis. Which of the following interventions should the nurse include? Encourage the client to consume caffeinated beverages Avoid the use of acetaminophen for discomfort Monitor the clients the urine for color changes Begin antibiotic therapy after culture and sensitivity results are obtained21. Nurse is assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect?The client reports relief from pain when lying in the prone position.The client reports that her low-back pain radiates upward toward one scapula.The client reports tingling and a burning sensation in one foot.The client reports decreased pain when the affected leg is raised and straightened22.A nurse is caring for a client who has acute gastritis and is NPO. The client has a new prescription to resume oral intake. Which of the following items should the nurse offered the client?LemonadeTomato soupGelatinBlack coffee23.A triage nurse nds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min,is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?
RedYellowGreenBlack24.A nurse is teaching a client who has a new diagnosis of polycystic kidney disease. Which of the following statements should the nurse include in the teaching?”Take aspirin as needed to reduce your pain.””Reduce your dietary beer intake.””Apply dry heat to your abdomen when needed.””Check your weight once per week.”25. A nurse is assessing a client who has right lower lobe pneumonia. Which ofthe following findings should the nurse expect? Dull percussion sounds Increased anterior posterior chest diameter Distended neck veins Pitting edema26.A nurse is providing teaching to the caregivers of a client who has Alzheimer’s disease. Which of the following instructions should the nurse give? (Select all that apply.) Install safety locks and alarm systems. Place nightlights throughout the home. Replace carpeted flooring with tile. Establish a predictable daily routine for the client. Remind the client of scheduled activities 1 day in advance.27.A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50, PaCO 29 mm Hg, and HCO 25 mEq/L. The nurse
should recognize that the client has which of the following acid-base imbalances? 2 3 – Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis28.A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include? Eat three large meals daily. Consume high-calorie foods. Limit caffeinated drinks to two per day. Drink fluids during mealtime29.A nurse is caring for a client who has a right-sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly? Gentle bubbling in the suction chamber Crepitus around the insertion site Constant bubbling in the water seal chamber Absence of breath sounds on the right side30.A nurse is caring for client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to present transmission of the disease?Contact precautions Airborne precautionsDroplet precautionsProtective environment
Recommended for you
Document continues below
1
Botox treatment sheet – For beginngers
Botox treatment sheet – For beginngers
Nursing Fundamentals
94% (32)
2
Mod 1 The Friedman Family Assessment Form
Mod 1 The Friedman Family Assessment Form
Nursing
100% (12)
31
HESI RN PEDS Actual
HESI RN PEDS Actual
Nursing
94% (17)
45
WGU D220 Exam Questions with correct Answers
WGU D220 Exam Questions with correct Answers
Nursing Fundamentals
71% (14)
31.A nurse is planning care for a client who has Ménière’s disease and is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan? Maintain strict bed rest. Restrict uid intake to the morning hours. Administer aspirin. Provide a low-sodium diet.32.A nurse reviewing laboratory reports for client who is taking NSAISs for rheumatoid arthritis. Which of the following results should the nurse recognize as a possible adverse effect of NSAID therapy?Increased erythrocyte sedimentation rate Elevated creatinine clearance Increased serum potassiumPositive fecal occult blood test33.A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing a hemolytic transfusion reaction.HypertensionReport of urticarialDistended neck veinsReport of chest pain34.A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first?Determine the time the last dose of pain medication was administered.Reposition the client to assist with reduction of pain.Ask the client to describe the pain and rate it on a scale of 0 to 10. Para miCheck the client’s medical record for type of PRN pain medication.
35.A nurse is teaching strategies to prevent carpal tunnel syndrome to a group of oce workers. Which of the following instructions should the nurse include? (Select all that apply.)”Raise your chair height so that you lean over to type.””Use a wrist rest when working at a computer station.””Stretch your ngers and wrists periodically while working.””Position your keyboard at shoulder height.””Take breaks from the repetitive activity.”36.A nurse is assessing a client who has a tension pneumothorax following blunt chest trauma. Which of the following findings should the nurse expect?Tracheal deviation to the unaffected sidePleural friction rubFrothy, pink-tinged sputumIncreased breath sounds on the affected side37.A nurse is caring for an adult client who asks about vaccinations against communicable diseases. The nurse should inform the client that which of the following vaccines are available? (Select all that apply)Hepatitis A vaccineHepatitis B vaccinePneumococcal vaccineHepatitis C vaccineHelicobacter pylori vaccine38.A nurse is teaching a client who has angina pectoris about nitroglycerin sublingual tablets. Which of the following statements should indicate to the nurse that the client understands the teaching?”I will keep the tablets in the original container.””I should keep the container in my shirt or pants pocket.””I should begin to feel relief within 20 minutes of taking the medication.””I will drive myself to the emergency room if three nitroglycerin tablets do not relieve my pain.”
39.A nurse is preparing to administer epoetin to a client who has anemia due tochemotherapy. Which of the following actions should the nurse plan to take?Review the client’s Hgb level prior to administration.Use the Z-tract method when administering the medication.Shake the vial for 30 seconds prior to withdrawing the medication.Ensure the client is not taking iron supplements while on this medication.40.A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately?Decreasing leg strengthDecreasing voice volumeDecreased deep tendon reflexesDecreased sensation in the arm41. A nurse is assessing a client who has Addison’s disease. Which of the following manifestations should indicate to the nurse that the client is experiencing an Addisonian crisis?HypothermiaIncreased deep tendon reflexesHypotensionErythema of the neck and chest42.A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse’s priority?Provide assistance with ambulation.Facilitate retention of facts by repeating instructions.Place the client in a darkened room.Speak slowly and clearly.43.A nurse is providing teaching to a newly licensed nurse about caring for a client who is receiving a ealed radioactive implant. Which of the following information should the nurse include in the teaching?Place soiled linens in a lead container. •Allow children who are over 10 years old to visit.
Limit visitors to 1 hr per day.Wear a lead apron during care44.A nurse is assessing a client who is postoperative following a kidney transplant. Which of the following findings indicates the client is experiencing a transplant rejection?Polyuria •HypothermiaHypertensionHypovolemia45.A nurse is providing teaching to a client who is scheduled for a bone marrow biopsy taken from the iliac crest. Which of the following information should the nurse include?”Avoid taking warm baths following the procedure.” •”You will lie on your back during the procedure.””You will receive general anesthesia for the procedure.””Take acetaminophen as prescribed for pain relief after the procedure.”46.A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the following dietary modications should the nurse include?Provide a snack at bedtime. •Choose decaeinated coee.Restrict intake of fried foods.Avoid drinking liquids with meals47.A nurse is assessing a client following a hypophysectomy. Which of the following findings indicates the client might be developing diabetes insipidus?Urine ketonesHyperglycemia •Halo or ring-shaped dressing drainageLow urine specic gravity
48.A nurse is assessing a client who has a history of migraine headaches with aura and reports feeling “a migraine coming on.” The nurse should expect the client to report which of the following manifestations?Visual disturbances •PhotophobiaNasal congestionPhonophobia49.A nurse is reviewing laboratory values for a client who has Cushing’s disease. Which of the followingvalues should the nurse expect?Blood glucose 65 mg/dL •Serum calcium 12.2 mg/dLPotassium 5 mEq/LSodium 150 mEq/L50.A nurse is assessing a client who has had a left-hemisphere stroke. Which ofthe following findings should the nurse expect?Expressive aphasia •Poor impulse controlLeft hemiparesisDisorientation to place51.A nurse is assessing a client who has a mild traumatic brain injury. The nurse should report which of the following findings as a complication of this injury? (Select all that apply.)BradycardiaVomiting Drainage from the ear para miUnequal pupilsPruritus52.A nurse is providing discharge teaching to a client who has multiple sclerosis. Which of the following instructions should the nurse include in the teaching?
“It is important to engage in a strenuous aerobic exercise program to build strength and endurance.””It is important with this disease to relax muscles in a hot tub or spa.””It is important to engage in social activity, and volunteering to read to schoolchildren will keep you active.””It is important to develop a daily schedule that reduces fatigue and conserves energy.”53.A nurse is caring for a client who is postoperative immediately following a pheochromocytoma removal. Which of the following actions is the nurse’s priority?Increase hydration.Monitor blood pressure. •Measure urine output.Provide a calm environment.54.A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the following information should the nurse include?”Notify the provider if you experience a stinging sensation following administration.” Para mi”Watch for a decreased heart rate while using this medication.””You can expect to develop a harmless darkening of the iris.” •”This medication can cause the lashes of the affected eye to lengthen.”55.A nurse is providing teaching to a client who has a new onset of genital herpes. Which of the following statements should the nurse include in the teaching?”You are not contagious when lesions are healed.””This infection is spread through the air.””Stress can activate an outbreak.””Antiviral drugs will cure the infection.”56.A nurse is instructing a client’s caregiver on how to position the client before administering tube feedings in the home. Which of the following statements by the caregiver demonstrates an understanding of the teaching?
“I will allow him to assume a position of comfort.””I will elevate the head of the bed 10 degrees.””I will place him in a left side-lying position.””I will sit him up in bed.”57.A nurse is teaching a client who has asthma about using a peak ow meter. When a yellow zone meter reading appears, the nurse should instruct the client to take which of the following actions?Take another peak ow meter reading in 15 min.Take prescribed relief medication.Call for emergency transport to a hospital.Inhale through pursed lips.58.A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client’s bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence?StressUrgeFunctionalOverow59.A nurse is assessing a client who has tuberculosis and is taking rifampin. Which of the following findings should the nurse report as an adverse effectof the medication? Alopecia Yellowing of the sclera Report of constipation Report of insomnia60.A nurse is caring for a client who has a cervical spinal cord injury. Which ofthe following interventions should the nurse include in the plan of care to prevent autonomic dyslexia? Monitor bowel movement regularity.Use a fan to promote air circulation in the client’s room
Tuck the top bedsheet tightly around the client’s torso. Monitor for cerebrospinal fluid leakage61.A nurse is caring for a client who is using a ventilator when the low-pressure ventilator alarm sounds. Which of the following actions should the nurse take? Suction secretions from the endotracheal tube.Check the ventilator tubing connections.Administer intravenous sedation and analgesia.Reassure the client and instruct them not to bite on the tube.62.A nurse is caring for a client who has renal calculi. Which of the following prescriptions by the provider is the priority action for the nurse to take?Strain all urine.Schedule a retrograde pyelography.Monitor intake and output.Schedule a kidney ultrasound.63.A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching?”When I’m exercising, I’ll include bent-leg raises.””I’ll use my reaching device to help me pick up objects I drop on the oor.””I can stop physical therapy when I quit using my walker.” •”I’ll sleep on my back with my knees close together.”64.A nurse is providing teaching for a client who has Parkinson’s disease and a new prescription for selegiline. Which of the following statements should the nurse include?”You might experience joint pain while taking this medication.””The medication cannot be combined with other antiparkinsonian agents.””Avoid eating aged cheeses or smoked meats while taking this medication.””It will take up to 2 weeks for the medication to work.”
65.A nurse is caring for a client who has renal failure. Which of the following arterial blood gas (ABG) results should the nurse expect?pH 7.25, HCO3 20 mEq/L, PaCO 35 mm Hg -2pH 7.30, HCO3 22 mEq/L, PaCO 50 mm Hg -2pH 7.50, HCO3 32 mEq/L, PaCO 45 mm Hg -2pH 7.55, HCO3 28 mEq/L, PaCO 31 mm Hg66.A nurse is reviewing a client’s medical record prior to administering furosemide via IV bolus to a client who has heart failure. For which of the following ndings should the nurse withhold the medication and notify the provider?HypokalemiaHypernatremiaHypoglycemiaHypermagnesemia67.A nurse is initiating a plan of care for a client who has COPD. Which of the following interventions should the nurse include?Request a prescription for an antibiotic.Educate the client on pursed-lip breathing.Place the client in airborne precautions.Initiate a referral for gene therapy.68.A nurse is receiving report on a group of clients. Which of the following clients should the nurse assess first?A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10A client who received parenteral cephalosporin and reports urticaria and edemaA client who is being admitted with bilateral Stage 3 pressure injuries on both heelsA client who has a systemic infection and an oral temperature of 39.1° C (102.4° F)
69.A nurse is discussing risk factors for hepatitis A with a newly licensed nurse. Which of the following clients should the nurse identify as being at an increased risk for hepatitis A?A client who is hepatitis B positiveA client who had a kidney transplant in 1990A client who has a history of intravenous street drug useA client who has recently done volunteer work in a developing country70.A nurse is providing education regarding the prevention of urinary tract infections (UTIs) to a client who has a history of cystitis. Which of the following statements by the client indicates that the teaching has been effective? “I will limit my fluid intake to 1 liter per day to prevent frequency and urgency.””I will empty my bladder every 2 to 3 hours throughout the day.””I will use an antiseptic vaginal deodorant spray twice a day to reduce the bacterial growth.””I will take a hot bath after sexual intercourse.”71.A nurse is providing instructions to a newly licensed nurse about NG intubation for a client who is postoperative following a colectomy. Which of the following statements should the nurse include?”Tube drainage should be rust-colored.””Nutrition will be provided through the tube.” Para mi”The tube decreases pressure within the stomach.””The tube should be irrigated with sterile water.”72.A nurse is caring for a client who has a history of tonic-clonic seizures. Which of the following precautions should the nurse take? (Select all that apply.)Keep a suction apparatus at the bedside.Keep a padded tongue blade next to the bed.Keep the bed in the lowest position.Keep oxygen equipment at the bedside.Keep safety restraints near the bedside.
73.A nurse is creating a plan of care for a client who has meningitis. Which of the following interventions should the nurse include?Initiate contact isolation precautions.Keep the client’s environment dark and quiet.Restrict the client’s fluid intake.Perform neurovascular assessments once a day.74.A nurse is a caring for client who is postoperative following a below-the-knee amputation. Which of the following actions should the nurse take?Maintain a loose bandage on the residual limb.Turn the client from side to side once every 4 hr.Request a soft mattress for the client.Place the client prone for 20 min every 3 hr.75.A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig’s sign?After stroking the lateral area of the foot, the client’s toes contract and draw together.After hip exion, the client is unable to extend their leg completely without pain. Esta es la misma pregunta 17The client’s voluntary movement is not coordinated.The client reports pain and stiness when exing their neck76. A nurse is caring for a client who has rheumatoid arthritis and has been taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?Weight lossHypoglycemiaHypertensionHyperkalemia77.A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement? Place several pillows behind the client’s head.
Place the client in a Sims’ position. Keep the client’s neck in a midline position. Maintain exion of the client’s hips at a 90° angle78.A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instructions should the nurse include in the teaching? Apply an ice pack directly to the affected area. Immobilize the affected extremity with a splint. Place a tourniquet above and below the affected area. Elevate the affected extremity79.A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson’s disease. Which of the following instructions should the nurse include in the teaching? “This medication can cause your urine to turn a dark color.” “Expect immediate relief after taking this medication.” “Take the medication with a high-protein food.” “Skip a dose of the medication if you experience dizziness.”80.A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following diets should the nurse recommend? Low-potassium diet High-ber diet Low-fat diet Low-sodium diet81.A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG). Which of the following statements by the client indicates an understanding of the teaching?
“I should not wash my hair prior to the procedure.” “I will receive a sedative 1 hour before the procedure.” “I should avoid eating prior to the procedure.” “I will be exposed to ashes of light during the procedure.”82.A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching? Immunosuppressant medications need to be taken for up to 1 year. Shortness of breath might be an indication of transplant rejection. The surgical site will heal in 3 to 4 weeks after surgery. Begin 45 min of moderate aerobic exercise per day following discharge83.A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 min. After maintaining the client’s airway and turning the client on their side, which of the following medications should the nurse administer? Diazepam IV Lorazepam PO Diltiazem IV Clonazepam PO84.A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching? “I should take my medicine with orange juice.” “A bedtime snack will prevent heartburn.” “I will lie down after meals.” “I will limit activities that require bending at the waist.”
85.A nurse is caring for a client who is at high risk for iron deciency anemia. Which of the following foods should the nurse instruct the client to increasein their diet? Yogurt Apples Raisins Cheddar cheese86.A nurse is caring for a client who has a right-sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly?Gentle bubbling in the suction chamber •Crepitus around the insertion siteConstant bubbling in the water seal chamberAbsence of breath sounds on the right side87.A nurse is planning care for a client who has acute post-streptococcal glomerulonephritis. Which of the following interventions should the nurse include in the client’s plan?Encourage a high-protein diet for the client.Increase the client’s fluid intake.Administer diuretics to the client.Weigh the client twice a week.88.A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?
Inspect the pin site every 48 hr.Monitor the client’s skin under the halo vest.Ensure two personnel hold the halo device when repositioning the client.Apply powder frequently to the client’s skin under the vest to decrease itching.89.Nurse is caring for a client who is receiving total parenteral nutrition (TPN).Which of the following findings should the nurse identify as a possible complication of TPN administration?Pitting edema of bilateral lower extremitiesHypoactive bowel sounds in all four quadrantsWeight is the same as the day beforeBilateral posterior lung sounds are diminished90.A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer?LidocaineAdenosineAtropineVerapamil91.A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). Which of the following referrals should the nurse plan to initiate?Respiratory therapyHospice careOccupational therapy
Dietary services92.A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance. Which of the following statements should the nurse make?”It is okay to not want to touch the burned areas of your body.””Cosmetic surgery should be performed within the next year to be effective.””Reconstructive surgery can completely restore your previous appearance.””It could be helpful for you to attend a support group for people who have burn injuries.”93.A nurse is caring for a client who has dehydration. The client has a peripheral IV and has aprescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride toinfuse over 1 hr. Which of the following actions should the nurse take first?Teach the client to report findings of IV extravasation.Evaluate the patency of the IV.Consult with the pharmacist about the prescription.Verify the prescription with the provider94.A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?Distended, board-like abdomenWBC count 15,000/mm3 (para mi esta es la respuesta Idania)Rebound tenderness over McBurney’s pointTemperature 37.3° C (99.1° F)
95.A nurse in an emergency department is caring for a client who has sustainedmultiple injuries. The nurse observes the client’s thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries?Flail chestHemothoraxPulmonary contusionPneumothorax96.A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following ndings should the nurse expect?Decreased deep-tendon reexesPositive Trousseau’s signHypoactive bowel soundsSticky mucous membranes97.A nurse is providing teaching to a client who is scheduled for electromyography (EMG). The nurse should include which of the followinginformation in the teaching?”You will receive a xed dose of radioisotope 2 hours before the procedure.””Momentary ushing will occur at the beginning of the procedure.””You should inform your provider if you are claustrophobic.””You should expect insertion of small needle electrodes into the muscles.”98.A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?Eat three large meals daily.
Consume high-calorie foods. Limit caffeinated drinks to two per day.Drink fluids during meal time.99.A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hr ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)✓ Use an electric shaver.✓ Avoid crowds.Take temperature weekly.✓ Consume a low-residue diet.✓ Monitor for bruising.100. A nurse is planning care for a group of postoperative clients. Which ofthe following interventions should the nurse identify as the priority?Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to10.Administer oxygen to a client who has an oxygen saturation of 91%.Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises.Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery.101. A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?”Lie on your left side.””Lie on your right side.”
“Increase your fluid intake.””Decrease your fluid intake.”102. A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?”I would like to play wheelchair basketball. When I get stronger, I think I’ll look for a league.” “I’m glad I’ll only be in this wheelchair temporarily. I can’t wait to get back to running.””I’m so upset that this happened to me. What did I do to deserve this, and why am Inot gettingbetter?””I feel like I’ll never be able to do anything that I want to again. All I am is a burden to my family.”103. A nurse is caring for a client who has chronic kidney disease. Which of the following diets should the nurse anticipate the provider to prescribe?4 g sodium dietPotassium-restricted dietHigh-phosphorous dietHigh-protein diet