The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply).
A. Remove the diaphragm immediately after intercourse.
B.
D. Do not leave the diaphragm in place longer than 8 hours after intercourse.
E. Replace the old diaphragm every 3 months.
A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take?
A. Determine the client is anxious and allow him to sleep.
B. Evaluate
B. Evaluate his blood pressure, pulse, and respiratory status.
A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority?
A. Listen to bilateral lung and bowel sounds.
B. Obtain the cli
D. Check the client's gag and swallow reflexes.
After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action shoul
A. Report the findings to the surgeon.
The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first?
A. Place a chair at a right angle to the bedside.
B. Encourage deep breathing prior to standing.
C. Help the client to sit and dangle legs
D. Allow the client to sit with the bed in a high Fowler's position.
A female client is brought to the clinic by her daughter for flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems
D. Collect further data to determine whether self-neglect is occurring.
A client with gastroesophageal reflux disease (GERD) has been experiencing sever reflux during sleep. Which recommendation by the nurse is most effective to assist the client?
A. Losing weight.
B. Decreasing caffeine intake.
C. Avoiding large meals.
D. Ra
D. Raising the head of the bed on block.
When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity?
A. A diet low in phosphates.
B. Skin inspection for bruising.
C. Exercise regimen, including swimming.
D. Elimination of hazards to home
D. Elimination of hazards to home safety.
The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session?
A. Present knowledge related to the skill of injection.
B. Intelligence
C. Willingness of the client to learn the injection sites.
Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)?
A. Hematuria.
B. 2 pounds weight gain.
C. 3+ bacteria in urine.
D. Steady, dull flank pain.
C. 3+ bacteria in urine.
What discharge instruction is most important for a client after a kidney transplant?
A. Weigh weekly.
B. Report symptoms of secondary Candidiasis.
C. Use daily reminders to take immunosuppressants.
D. Stop cigarette smoking.
C. Use daily reminders to take immunosuppressants.
A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide?
A. Estrogen deficiency causes the vaginal tissues to become dry and thinner.
B. Infrequent intercourse results in
A. Estrogen deficiency causes the vaginal tissues to become dry and thinner.
The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide?
A. Two weeks before menstruation.
B. Vaginal mucous discharge is thick.
C. Low basal temperature.
D. Fir
A. Two weeks before menstruation.
A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response?
A. Explain the effect of the follicle-stimulating and lutei
B. Discuss perimenopause and related comfort measures.
Which information about mammograms is most important to provide a post-menopausal female client?
A. Breast self-examinations are not needed if annual mammograms are obtained.
B. Radiation exposure is minimized by shielding the abdomen with a lead-lined ap
C. Yearly mammograms should be done regardless of previous normal x-rays.
What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast?
A. Observe cyst size fluctuations as a sign of malignancy.
B. Use estrogen supplements to reduce breast discomfort.
C. Notify the healthcare provider
D. Perform a breast self-exam (BSE) procedure monthly.
A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide?
A. Lymph node involvement is no
C. The tumor's estrogen receptor guides treatment options.
Which postmenopausal client's complaint should the nurse refer to the healthcare provider?
A. Breasts feel lumpy when palpated.
B. History of white nipple discharge.
C. Episodes of vaginal bleeding.
D. Excessive diaphoresis occurs at night.
C. Episodes of vaginal bleeding.
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement?
A. Give 20 mEq of potassium chloride.
B. Initiate continuous cardiac monitoring.
C. Arrange a consultation wit
B. Initiate continuous cardiac monitoring.
Which milestone indicates to the nurse successful achievement of young adulthood?
A. Demonstrates a conceptualization of death and dying.
B. Completes education and becomes self-supporting.
C. Creates a new definition of self and roles with others.
D. Dev
B. Completes education and becomes self-supporting.
Which client should the nurse recognize as most likely to experience sleep apnea?
A. Middle-aged female who takes a diuretic nightly.
B. Obese older male client with a short, thick neck.
C. Adolescent female with a history of tonsillectomy.
D. School-aged
B. Obese older male client with a short, thick neck.
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.
A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history?
A. Jewish European ancestry.
B. H. pylori bowel infection.
C. Family history of irritable bowel syndrome.
D. Age between 25 and 55 years.
A. Jewish European ancestry.
In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer?
A. A 35-year-old multipara who never breastfed.
B. A 50-year-old whose mother had unilateral breast cancer.
C. A 55-year-old whose mother-in-
B. A 50-year-old whose mother had unilateral breast cancer.
During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What should be the correct interpretation if the nurse hears the spoken words "99" very clear
C. May indicate pneumonia.
A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?
A. Position the head of the bed (HOB) flat.
B. Withhold intravenous fluids.
C. Administer a bolus of IV fluids.
D. Give an antihyperte
D. Give an antihypertensive medications.
Which symptoms should the nurse expect a client to exhibit who is known to have a pheochromocytoma?
A. Numbness, tingling, and cramps in the extremities.
B. Headache, diaphoresis, and palpitations.
C. Cyanosis, fever, and classic signs of shock.
D. Nausea
B. Headache, diaphoresis, and palpitations.
The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first?
A. Potassium of 6.0 mEq
B. Daily urine output of 400mL
C. Peripheral neuropathy
D. Uremic fetor
A. Potassium of 6.0 mEq
The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain?
A. If suctioning will be n
D. If the client's wound is infected.
The client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E.coli, Klebsiella, Pseudomonas, and Proteus) is very poor because
A. The occur in the lowe
B. Gram-negative organisms are more resistant to antibiotic therapy.
Which assessment finding by the nurse during a client's clinical breast examination requires follow-up?
A. Newly retracted nipple.
B. A thickened area where the skin folds under the breast.
C. Whitish nipple discharge.
D. Tender lumpiness noted bilaterall
A. Newly retracted nipple.
A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide?
A. Stay out of direct sunlight.
B. Restrict intake of high protein foods.
C. Schedul
C. Schedule extra rest periods.
The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply)
A. Remove the diaphragm immediately after intercourse.
B.
D. Do not leave the diaphragm in place longer than 8 hours after intercourse.
E. Replace the old diaphragm every 3 months.
The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit?
A. A decreased total lung capacity.
B. Normal arterial blood gasses.
C. Normal skin coloring.
D. An a
C. Normal skin coloring.
How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring?
A. Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line.
B. Positive polarity left shoulder, negative polari
D. Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line.
A 32-year-old female client complains of severe abdominal pain each month before her mensural period, painful intercourse, and painful defecation. Which additional history should the nurse obtain is consistent with the client's complaints?
A. Frequently u
B. Inability to get pregnant.
The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia?
A. Sweating, trembling, tachycardia.
B. Polyuria, pol
A. Sweating, trembling, tachycardia.
Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client?
A. Apply sequential compression devices (SCDs) bilaterally.
B
D. Advise the client to remain in bed with the leg elevated.
The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instructions from the healthcare provider is the client's
A. Serum digoxin level is 1.5
B. Blood pressure is 104/68.
C. Serum potassium
C. Serum potassium level is 3.
When preparing a client who has had a total laryngectomy for discharge, what instruction is most important for the nurse to include in the discharge teaching?
A. Recommend that the client carry suction equipment at all times.
B. Instruct the client to hav
C. Tell the client to carry a medic alert card stating that he is a total neck breather.
A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority?
A. Listen to bilateral lung and bowel sounds.
B. Obtain the cli
D. Check the client's gag and swallow reflexes.
A client who is receiving a chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia?
A. "Chemotherapy affects the cells of the body that grows rapidly, both normal an
A. "Chemotherapy affects the cells of the body that grows rapidly, both normal and malignant.
When teaching diaphragm breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide?
A. Place a small book or magazine on the abdomen and make it rise while inhaling deeply.
B. Purse the lips while i
A. Place a small book or magazine on the abdomen and make it rise while inhaling deeply.
During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide?
A. Long-term relationships with he
C. Insurance coverage of employees is less expensive to employers.
Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)?
A. Tinnitus, vertigo, and hearing difficulties.
B. Sudden, stabbing, severe pain over the lip and chin.
C. Facial weakness and paralysis.
D.
B. Sudden, stabbing, severe pain over the lip and chin.
A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client?
A. Stage II.
B. Invasive infiltrating ductal carcinoma.
C. T1N0M0.
D. I
D. Inflammatory with peau d'orange.
An adult client is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remember about full-thickness burns?
A. Regene
A. Regenerative function of the skin is absent because the dermal layer has been destroyed.
A 49-year-old female client arrives at the clinic for an annual exam and ask the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response?
A. Explain the effect of the follicle-stimulating and lutein
B. Discuss perimenopause and related comfort measures.
The nurse is assessing a client's lab values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)?
A. A serum PTT of 10 seconds
B. Serum calcium of 5mg/dL
C. Oxygen
B. Serum calcium of 5mg/dL
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit?
A. Lower left quadrant pain and a low-grade fever
B. Severe pain at McBurney's point and nausea.
A. Lower left quadrant pain and a low-grade fever
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?
A. Use a laryngoscope to check for a foreign body lodged in the esophagus.
B. Reposition the head to validate
B. Reposition the head to validate that the head is in the proper position to open the airway.
A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg every 12 hours IV is prescribed. What is the priority nursing diagnosis for this client?
A. Impaired communication related to paral
A. Impaired communication related to paralysis of skeletal muscles.
The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the healthcare provider if the client's
A. Serum digoxin level is 1.5
B. Blood pressure is 104/68
C. Serum potassium le
C. Serum potassium level is 3
After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples?
A. 15 minutes before and 15 minutes after the next dose.
B. One hour befo
C. 5 minutes before and 30 minutes after the next dose.
A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client?
A. Facial f
D. Feelings of dizziness.
A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the
A. Propanolol (Inderal).
In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important?
A. Genetic counseling.
B. Twelve-step recovery program.
C. Clinical nutritionist.
D. Smoking cessa
D. Smoking cessation program.
Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma?
A. Numbness, tingling, and cramps in the extremities.
B. Headache, diaphoresis, and palpations
C. Cyanosis, fever, and classic signs of shock
D. Nausea, v
B. Headache, diaphoresis, and palpations
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?
A. Sodium.
B. Antidiuretic hormone.
C. Potassium.
D. Glucose.
C. Potassium.
A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed di
A. He visits his diabetic brother who just had surgery to amputate an infected foot.
The nurse is taking a history of a newly diagnosed type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note?
A. A history of obesity.
B. An allergy to sulfa drugs
C. Cessation of smoking three years
B. An allergy to sulfa drugs
A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client?
A. Avoid high carbohydrate foods.
B. Decrease intake of fat soluble vitamins.
C. Decrease caloric intake.
D. Restrict salt and fluid intake.
A female client receiving IV vasopressin (Pitressin) for esophageal varieties rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate?
A. Start an IV nitroglycerin infusi
A. Start an IV nitroglycerin infusion.
A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide?
A. "Diagnosis of AIDS is made when you have 2 positive ELISA test results."
B. "Diagnosis is made when both the ELISA and the
D. "AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual.
Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation?
A. Maintain the residual limb on three pillows at all times.
B. Place a large tourniquet at the client's bedside.
C. A
B. Place a large tourniquet at the client's bedside.
The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms would this client most likely exhibit?
A. Loss of short-term memory, facial expression, and tremors of the head.
B. Shuffling gait, mask-like faci
B. Shuffling gait, mask-like facial expression, and tremors of the head.
The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question should provide information relevant to the client's plan of care?
A. Have you ever experienced any paralysis of your arms or le
C. Have you ever been 'frozen' in one spot, unable to move?
The nurse is interviewing a make client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)?
A. Diabetes mellitus
B. Hypothyroidism
C. Parkinson's disea
A. Diabetes mellitus
The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those o
C. Notify surgeon that the ECG is over two years old.
What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina?
A. Instruct the client to look at the examiner's nose and not move his/.her eyes during the exam.
B. Set ophthalmoscope on the plus 2 to 3 lens and hol
C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client?
Assess the client's
A. Pulse rate, both apically and radially.
C. Temperature.
While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test?
A. Immediately after the exposure.
B. Within one week of the exposure.
C. Four to six weeks after
C. Four to six weeks after the exposure.
The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group?
A. The length of time each group member has resided at the nur
D. The usual activity patterns of each member of the group
The nurse knows that lab values sometimes vary for the older client. Which data should the nurse expect to find when reviewing laboratory values of an 80-year-old male?
A. Increased WBC, decreased RBC.
B. Increased serum bilirubin, slightly increased live
C. Increased protein in the urine, slightly increased serum glucose levels.
A 77-year-old male client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. Which question is a priority for the nurse to ask this client or h
D. take digitalis?
A 67-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur?
A. Failing eyesight resulting in an unsafe environment.
B. Renal osteodystroph
C. Osteoporosis resulting from hormonal changes.
During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom should t
D. Productive cough with grayish-white sputum.
An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing inter
A. Help the client to determine ways to increase his fluid intake.
An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain sh
C. Pain in the calf upon exertion which is relieved by rest and elevating the extremity.
An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom?
A. Leukocytosis and febrile.
B. Polycythemia and crackles.
C. Pharyngitis and sputum production.
D. Con
D. Confusion and tachycardia.
A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information?
A. The vaccine is given annually before the flu season to those over 50 years of age.
B.
B. The immunization is administered once to older adults or persons with a history of chronic illness.
The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli?
A. Cyanosis of the fingertips.
B. Bradycardia and bradypnea.
C. Presence and S3 and S4 heart sounds.
D. 3+ pitting e
A. Cyanosis of the fingertips.
A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse?
A. White blood count of 10,000 mm3.
B. Serum glucose of 115 mg/dl.
C. Purulent sputum.
D. Excessi
C. Purulent sputum.
The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. What information should the nurse implement?
A. Administer 30 minutes before e
D. Question the healthcare provider's prescription.
A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement?
A. Determine if the client has also experienced breast tenderness and weight gain.
B. Encourage the client to begin
C. Advise the client to notify the healthcare provider for immediate medical attention.
The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia?
A. Sweating, trembling, tachycardia
B. Polyuria, poly
A. Sweating, trembling, tachycardia
A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency?
A. K.
B. B12.
C. B6.
D. C.
A. K.
A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. What initial medication should the nurse anticipate administering to the client?
A. Xylocaine (Lidocaine).
B. Procainamide (Pronestyl).
C. Phenytoin (Dilantin).
D. D
D. Digoxin (Lanoxin).
A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client?
A. The dosage of the diuretic will be decreased.
B. The diuretic will be discontinued.
C. A po
C. A potassium supplement will be prescribed.
A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client?
A. "What dose of medication are you takin?"
B. "Are you eating foods rich in potassium?"
C. "Have you lost weight recently?"
D. "A
D. "At what time do you take your medication?
The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy?
A. An increase in abdominal girth.
B. Hypertension and a boun
D. Difficulty in handwriting.
A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity rela
C. Provide back and skin care while maintaining the traction.
A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints?
A. Prevention of deformities.
B. Avoidance of joint trauma.
C. Relief of joint infl
A. Prevention of deformities.
The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit?
A. A decreased total lung capacity
B. Normal arterial blood flow
C. Normal skin coloring
D. An absenc
C. Normal skin coloring
A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicated that infarction occurred ten. hours ago. Which lab test result would the nurse expect the client to exhibit?
A. Elevated LDH
C. Elevated CK-MB
A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. What content is most important for the nurse to include in the discharge teaching for the client?
A. Information abou
A. Information about smoking cessation.
Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?
A. Place HIV posi
B. Wear gloves when coming in contact with the blood or body fluids of any client.
A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration?
A. Serum creatinine.
B. Blood urea nitrogen (BUN)
C. Sedimentation rate
D. Urine sp
A. Serum creatinine.
What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode?
A. Vasodilators and hormones.
B. Analgesics and sedatives.
C. Anticoagulants and expectorants.
D. Bronchodilators and steroids.
D. Bronchodilators and steroids.
Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing painting the house with the client. The nurse suggests that the edge of the steps should be painted which color?
A. Black.
D. Medium yellow.
Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder?
A. Describe proper administration of vaginal suppositories and cream.
B. Encourage the client to perform Kegel exercises 10 times daily.
C. Explai
B. Encourage the client to perform Kegel exercises 10 times daily.
The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema?
A. She sustained an insect bite to her left arm yester
A. She sustained an insect bite to her left arm yesterday.
In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.)
A. Set the infusion pump to infuse the albumin within four hours.
B. Compare the client's blood type with the
A. Set the infusion pump to infuse the albumin within four hours.
D. Administer through a large gauge catheter.
E. Monitor hemoglobin and hematocrit levels.
F. Assess for increased bleeding after administration.
The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What action should the nurse implement?
A. Prepare the client for transcutaneous pacemaker
B. Shock the client with 200 joules per hospital policy.
A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?
A.
D. "The test you are having tomorrow requires that you have nothing by mouth tonight.
A client is admitted for further testing to confirm sarcoidosis. Which diagnostic test provides definitive information that the nurse should report to the healthcare provider?
A. Lung tissue biopsy.
B. Positive blood culture.
C. Magnetic resonance imaging
A. Lung tissue biopsy.
During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first?
A. Notify the healthcare provider for reinsertion.
B. Attempt to reinsert the trac
B. Attempt to reinsert the tracheostomy tube.
When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide?
A. Place a small book or magazine on the abdomen and make it rise while inhaling deeply.
B. Purse the lips whi
A. Place a small book or magazine on the abdomen and make it rise while inhaling deeply.
The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most important for the nurse to include?
A. Safely precautions during activity.
B. Assess for changes in size of lymph nodes.
C. Maintain a fluid
C. Maintain a fluid intake of 3 to 4 L per day.
The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care?
A. Flush the tube with 50mL of water Q8 hours.
B. Check for tube placemen
B. Check for tube placement and residual volume Q4 hours.
A client with a 16-year-old history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal in
B. Nocturia
A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client?
A. Fluid and electrolyte balance.
B. Prevention of water toxicity.
C. Reduced glucose in the urine.
D. Adequate cellular nourishment.
D. Adequate cellular nourishment.
The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client.
B. Disabled family coping related to dissonant coping style of significant person.
The nurse formulates the nursing diagnosis of, "urinary retention related to sensorimotor deficit" for a client with multiple sclerosis. Which nursing intervention should the nurse implement?
A. Teach the client techniques of intermittent self-catheteriza
A. Teach the client techniques of intermittent self-catheterization.
A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer?
A. Osteoporosis is progressive genetic disease with no effective
B. Calcium loss from bones can be slowed by increasing calcium intake and exercise.
The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints?
A. Increase the amount of calcium intake in the diet.
C. Initiate a weight-reduction diet to achieve a healthy body weight.
A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?
A. "Check it again in one month, and if it is still there schedule an appointment."
B. "Most lumps are benign, but i
B. "Most lumps are benign, but it is always best to come in for an examination.
A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful dedication. Which additional history should the nurse obtain that is consistent with the client's complaints?
A. Freque
B. Inability to get pregnant.
A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain?
A. Amount of weight gain or weight loss during the previous year.
B. An accurate menstrual cycle diary for t
B. An accurate menstrual cycle diary for the past 6 to 12 months.
A client who is sexually active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide?
A. Using an IUD offers no protection against sexually transmitted disease (STD), which incre
A. Using an IUD offers no protection against sexually transmitted disease (STD), which increase the risk for pelvic inflammatory disease (PID).