A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching?A. "I will monitor my husband for coughing while he's eating."B. "I will monitor for a change in my husband's voice after he swallows."C. "I will monitor my husband for tilting his head forward when he swallows."D. "I will monitor my husband for pocketing food in his mouth.
C. I will monitor my husband for tilting his head forward when he swallows.
A nurse is assessing a client and discovers the infusion pump with the client's TPN solution is not infusing. The nurse should monitor the client for which of the following conditions?A. Excessive thirst & urinationB. Shakiness & diaphoresisC. Fever & chillsD. Hypertension & crackles
B. Shakiness & diaphoresis (at risk for hypoglycemia)
A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?A. Stress incontinenceB. Urge incontinenceC. Overflow incontinenceD. Reflex incontinence
C. Overflow incontinence
A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply)A. Genetic PredispositionB. HypercholesterolemiaC. HypertensionD. ObesityE. Smoking
B, C, D, E (hypercholesterolemia, htn, obesity, smoking)
A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended d/t which of the following findings in the client's medical hx?A. Hx of dermatitisB. Hx of Breast cancerC. Multiple hospitalizations for COPDD. Concurrent tx for GERD
B. Hx of breast cancer
A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching?A. Limit fluid intake not r/t meals.B. Chew on mint leaves to reduce indigestion C. Avoid eating w/in 3 hrs of bedtimeD. Season foods w/black pepper
C. Avoid eating w/in 3 hrs of bedtime
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid?A. Nonfat milkB. ChocolateC. ApplesD. Oatmeal
B. Chocolate
A nurse is teaching a client about the adverse effects of cisplatin. Which of the following adverse effects should the nurse include in the teaching?A. TinnitusB. ConstipationC. HyperkalemiaD. Weight Gain
A. Tinnitus
A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply)A. Check peripheral pulses in affected extremityB. Place client in High-Fowlers positionC. Measure the client's vitals q4hrD. Keep the client's hip and leg extendedE. Have the client remain in bed up to 6 hr
A, D, E (Check peripheral pulses in affected extremity, Keep the client's hip and leg extended, Have the client remain in bed up to 6 hr)
A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?A. "I will call for pain medication before the previous dose wears off"B. "I will call for pain medication as my pain starts to increase again."C. "I will wait for you to evaluate my pain before asking for more medication."D. "I will ask for less medication to avoid addiction.
A. "I will call for pain medication before the previous dose wears off.
A nurse is teaching a client about the 7 warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply)A. A nonhealing soreB. BloatingC. Change in bowel patternD. Change in molesE. Nagging cough
A, C, D, E (a nonhealing sore, change in bowel pattern, change in moles, nagging cough)
A nurse is preparing to administer TPN 1800 mL to infuse over 24 hrs. The nurse should set the iv pump the deliver how many mL/hr? (round to nearest whole #)
75 mL/hr
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?A. Pulse and BP findingsB. Behavioral indicators and effectC. Scheduled tx and client illnessD. A self-report pain rating scale
D. A self-report pain rating scale
A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in color of his urine?A. Pale pinkB. Bright yellowC. Bright redD. Dark amber
A. Pale pink
A nurse in a provider's office is reviewing the lab results of a client who takes furosemide for HTN. The nurse notes that the client's potassium level is 3.3. The nurse should monitor the client for which of the following complications?A. Cardiac dysrhythmiasB. HypoglycemiaC. SeizuresD. Neurogenic shock
A. Cardiac dysrhythmias
A nurse is collecting a medication hx from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts w/contrast material and places the client at risk for acute kidney injury?A. AtorvastatinB. MetforminC. NitroglycerinD. Carvedilol
B. Metformin
A nurse is caring for a client who has cancer and a new prescription for ondansetron to tx chemo-induced nausea. For which of the following adverse effects should the nurse monitor?A. HeadacheB. Dependent edemaC. PolyuriaD. Photosensitivity
A. Headache
A nurse is teaching a client who is starting to take methotrexate to treat RA. Which of the following instructions should the nurse include in the teaching?A. "Avoid eating foods high in vitamin K."B. "Use an alcohol-based mouthwash after each meal."C. "Take the medication daily."D. "Drink at least 2 L of water daily.
D. Drink at least 2 L of water daily
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)A. Poor skin turgorB. BradycardiaC. HypotensionD. Pale yellow urineE. Flat neck veins
A, C, E (poor skin turgor, hypotension, flat neck veins)
A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?A. "The laxative will prevent the absorption of magnesium."B. "The laxative helps eliminate the barium."C. "The laxative is a protocol at this facility."D. "The laxative makes the barium turn brown.
B. The laxative helps eliminate the barium
A nurse is reviewing lab values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?A. Serum CreatinineB. Blood urea nitrogen (BUN)C. Serum SodiumD. Urine-Specific Gravity
A. Serum creatinine
A nurse is caring for a client who is 1 day postop following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply)A. Add the amount of bladder irrigation to the total outputB. Use sterile technique when preparing the irrigation systemC. Ensure the drainage tubing is patent and without obstructionD. Contact the surgeon if the client reports a continual need to voidE. Notify the surgeon if the urine is bright red in appearance or has large clots
B, C, E (use sterile technique when preparing the irrigation system, Ensure the drainage tubing is patent and without obstruction, and notify the surgeon if the urine is bright red in appearance or has large clots)
A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link w/Crohn's disease. Which of the following information should the nurse include?A. Both are inflammatoryB. Both begin in the rectumC. Both manifest fistula formationD. Both require frequent surgery
A. Both are inflammatory
A nurse is planning care for a client who has immunosuppression following chemo. Which of the following interventions should the nurse include in the plan of care?A. Insert an indwelling catheter to monitor sediment in the urineB. Take the client's temperature once per shiftC. Provide the client with fresh fruit to avoid constipationD. Limit the amount of healthcare workers entering the room
D. Limit the amount of healthcare workers entering the room
A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated w/early menopause?A. Urinary retentionB. Decreased BPC. Dryness w/intercourseD. Elevation in body temp above 37.8C (100F)
C. Dryness w/intercourse
A nurse is caring for a client who has cancer and is receiving TPN. Which of the following lab values indicates the tx is effective?A. Hct 43%B. WBC 8,000C. Albumin 4.2D. Calcium 9.4
C. Albumin 4.2
The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action?A. Notify the provider of the client's allergyB. Attach a wristband indicating the client's allergyC. Ask the client if any other foods cause such a reactionD. Notify the dietary department of the client's allergy
A. Notify the provider of the client's allergy
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?A. Decrease in the respiratory rate from 20 to 16B. Decrease in the urinary output from 50 mL to 30 mL per hourC. Increase in the temp from 37.5C (99.5F) to 38.6C (101.5F) D. Increase in HR from 88 to 110
D. Increase in HR from 88 to 110
A nurse is planning care for a client who is 2hr postop following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?A. Restrict the client's oral fluid intakeB. Remind the client he might feel constant urge to voidC. Monitor the client's urine output q 6 hrD. Weight the client every evening
B. Remind the client he might feel constant urge to void
A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation therapy for the tx of lung cancer. Which of the following should the nurse plan to include in the teaching?A. Bottled water is an appropriate choice to increase fluid intakeB. The salad bar is a healthy choice when dining outC. Soft-boiled eggs are an appropriate source of proteinD. Eating at a buffet is a good choice to increase calorie intake
A. Bottled water is an appropriate choice to increase fluid intake
A nurse remains with a client to observe for any adverse reactions for initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?A. FebrileB. HemolyticC. AllergicD. Bacterial
B. Hemolytic
A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching?A. Hx of smokingB. ObesityC. Hx of htnD. Race
D. Race
A nurse is providing teaching to a client about measures to prevent UTIs. Which of the following client statements indicates a need for further teaching?A. "I will need to wipe my perineal area from back to front after urination."B. "I will need to empty my bladder regularly and completely"C. "I will need to drink apple cider vinegar each day."D. "I need to drink 8 cups of liquid each day.
A. I will need to wipe my perineal area from back to front after urination
A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication?A. Decreased BPB. Increase of HDL cholesterolC. Prevention of bipolar manic episodesD. Improved sexual function
A. Decreased BP
A nurse in the ED is assessing a client who is having a suspected acute MI. Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply)A. OrthopneaB. HeadacheC. NauseaD. TachycardiaE. Diaphoresis
C, D, E (nausea, tachycardia, diaphoresis)
A nurse is talking with a client whose thyroid-stimulating hormone (TSH) level will be measured. Which of the following statements by the nurse explains the purpose of this test? A. This test measures the amount of thyroid hormone that attaches to a protein in your bloodB. This test detects antithyroid antibodies in your bloodC. This test measures the absorption of iodine and how it relates to the thyroid glandD. This test determines whether your thyroid gland is overactive, appropriately active, or underactive
D. This test determines whether your thyroid gland is overactive, appropriately active, or underactive
A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?A. A reddened area over the sacrumB. Stiffness in the lower extremitiesC. Difficulty moving the upper extremitiesD. Difficulty hearing some type of sounds
A. A reddened area over the sacrum
A nurse is teaching a client who is to begin long-term therapy w/ prednisone to treat RA. The nurse should instruct the client to take which of the following supplements while taking this medication?A. Calcium and Vitamin DB. Biotin and Vitamin B2C. Folic Acid and Vitamin CD. Pantothenic acid and Vitamin B6
A. Calcium and Vitamin D
A nurse is admitting a client who is about to undergo surgery for BPH. The client states, "I don't know what I'll do if they find cancer." Which of the following responses should the nurse make?A. "Why do you think you might have cancer when your diagnosis is a benign condition?"B. "I'm looking at your chart here, and I don't see any reason for you to worry about that."C. "I think that's something you need to discuss w/ your provider."D. "I'm hearing that you're concerned that it might turn out that you have cancer.
D. I'm hearing that you're concerned that it might turn out that you have cancer
A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations?A. Sensitivity to coldB. ConstipationC. Frequent mood changesD. Weight gain of 4.5 kg (10lb) in 3 wks
C. Frequent mood changes
A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is priority?A. Pupil reactionB. Urine outputC. Bowel soundsD. Respiratory Rate
D. Respiratory Rate
A nurse is caring for a client whose pap test cytology results are abnormal. Which of the following procedures should the nurse anticipate?A. Rectovaginal palpation by the providerB. Dilation and curettage C. Human chorionic gonadotropin (hCG) testD. Colposcopy
D. Colposcopy
A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous iv infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?A. "It actually takes heparin 2-3 days to reach a therapeutic blood level."B. "A pharmacist is the person to answer the question."C. "Heparin does not dissolve clots, it stops new clots from forming."D. "The oral medication you take after this IV will dissolve the clot.
C. Heparin does not dissolve clots, it stops new ones from forming
A nurse is providing teaching to a client who is postoperative following a coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?A. It decreases the clients level of anxietyB. It facilitates the clients deep breathing.C. It enhances the clients ability to sleepD. It reduces the clients BP
B. It facilitates the clients deep breathing
A nurse is caring for a 2-year-old child who is hospitalized and throws a tantrum when his parent leaves. Which of the following toys should the nurse provide to alleviate the child's stress?A. Set of building blocksB. Toy hammer and pounding boardC. Picture book about hospitalsD. Stuffed animal
B. Toy hammer and pounding board
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?A. Avoiding covering sores and bandagesB. Avoiding handwashing after eatingC. Avoids foods prepared w/ tapwaterD. Avoid eating meat
C. Avoid foods prepared w/tapwater
A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching (Select all that apply)A. BacteriaB. DiureticsC. AgingD. ObesityE. Smoking
C, D, E (aging, obesity, smoking)
A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?A. Intracranial pressureB. Serum electrolytesC. TemperatureD. Respiratory status
D. Respiratory status
A nurse is planning care for a client who has viral hepatitis. Which of the following actions should the nurse include in the plan of care?A. Provide a high carb dietB. Administer acetaminophen for painC. Encourage eating 3 large meals dailyD. Include high protein snacks
A. Provide a high carb diet
A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client?A. Soy milkB. Cheddar cheeseC. Low-fat yogurtD. Cottage cheese
A. Soy milk
A nurse is caring for a 1-month old infant who weighs 3500 g and is prescribed a dose of cephazolin 50 mg/kg by intermittent IV bolus 3x daily. How many mg should the nurse administer per dose (round to nearest tenth)
175 mg
A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching?A. "The procedure will be canceled if the urinalysis indicates the presence of RBCs."B. "High frequency sound waves will be used to identify renal system structures."C. "You will be able to resume your regular diet as soon as the test is complete."D. "After the procedure, you will be encouraged to drink plenty of fluids.
D. "After the procedure, you will be encouraged to drink plenty of fluids.
A nurse is caring for a client who has Crohn's disease and is receiving parenteral nutrition. Which of the following interventions should the nurse include in the care of this client?A. Remove the parenteral nutrition solution from the refrigerator 2 hr before infusionB. Remove unused parenteral nutrition after 12 hr of useC. Monitor daily lab values and report as neededD. Monitor the flow rate of the parenteral nutrition carefully and increase the rate as needed if it falls behind
C. monitor daily lab values and report as needed
A nurse is reviewing a client's lab values. Which of the following should the nurse report to the provider?A. Hct 45%B. WBC 1700C. Hgb 14.7D. Platelets 160,000
B. WBC 1700
A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?A. Drink 3 L of fluid every dayB. Take 3,000 mg of vitamin C dailyC. Restrict calcium intake to one serving dailyD. eat 12 oz of animal protein daily
A. Drink 3 L of fluid every day
A nurse is assessing a client who has Grave's Disease. The nurse should expect which of the following lab results?A. Decreased TSH levelB. Decreased T3 levelC. Decreased T4 levelD. Decreased TSI percentage
A. Decreased TSH level
A nurse is reviewing the lab values of a client who had a MI 3 hrs ago. The nurse should expect which of the following lab values to be elevated?A. ASTB. Unconjugated BilirubinC. Troponin ID. Serum amylase
D. Serum amylase
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?A. Diagnosis of DMB. Family Hx of cardiac diseaseC. Increasing ageD. Cigarette smoking
D. cigarette smoking
A nurse is assessing a client 1 day postop following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take?A. Have the client lie flat in bedB. Use sterile gauze to place gentle pressure on the exposed organsC. Cover the area w/ saline-soaked sterile dressingsD. Apply an abdominal binder
C. Cover the area w/ saline-soaked sterile dressings
A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?A. A weight loss program can decrease my LDL cholesterol levelB. Exercising regularly will increase my HDL cholesterol levelsC. Adding foods w/omega-3 fatty acids to my diet can lower my riskD. Increasing my intake of foods containing trans-fatty acids can lower my risk
D. Increasing my intake of foods containing trans-fatty acids can lower my risk
A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include?A. Sleep on your left sideB. Drink milk to soothe your stomachC. Eat four small meals each dayD. Wait to go to bed 1 hr after eating
C. Eat 4 small meals each day
A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions?A. LiverB. MilkC. BeansD. Eggs
C. Beans
A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?A. Oxygen saturationB. Abdominal dressingC. Urinary outputD. Pain level
A. O2 saturation
A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, "I don't understand why my child is so upset. I've never seen my child act this way around others before." Which of the following statements should the nurse make?A. This is normal, expected reaction for a child this age.B. This is a response to an overstimulating environmentC. This is a common reaction to an overexposure of caregiversD. This is a typical reaction for a child who is sick
A. This is a normal, expected reaction for a child this age
A nurse is caring for a client who has HTN and asks the nurse about a prescription for propranolol. The nurse should inform the client that the medication is contraindicated in clients who have a hx of which of the following conditions?A. AsthmaB. GlaucomaC. DepressionD. Migraines
A. Asthma
A nurse is caring for a client who has Cushing's Syndrome. The nurse should recognize that which of the following manifestations of Cushing's Syndrome?A. AlopeciaB. TremorsC. Moon faceD. Purple striationsE. Buffalo Hump
C,D,E (moon face, purple striations, buffalo hump)
While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following?A. A systolic murmurB. A third heart sound (S3)C. An expected heart soundD. A fourth heart sound (S4)
A. A systolic murmur
A nurse is providing preop teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postop complications should the nurse include in the teaching?A. Teaching the client how to use the PCA pumpB. Instruct the client about the use of sequential compression deviceC. Discuss the visitation policyD. Review the pain scale
B. Instruct the client about the use of sequential compression device
A nurse at a provider's office is providing teaching to a client who is taking chemo and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (Select all that apply)A. Top fruits w/yogurtB. Add cream to soupsC. Use milk instead of water in recipesD. Increase fluids during mealsE. Dip meats in eggs/bread crumbs before cooking
A, B, C, E (top fruits w/yogurt, add cream to soups, use milk instead of water in recipes, and dip meats in eggs/bread crumbs before cooking)
A nurse is completing dietary teaching on consuming a low fiber diet w/a client who has ulcerative colitis. Which of the following foods should be eliminated in the client's diet?A. Cooked cabbageB. Dried apricotsC. Ripe bananasD. Ice cream
B. Dried apricots
A nurse is the clinic is reviewing lab values for a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following lab values?A. TSHB. Free T4C. Serum T4D. Serum T3
A. TSH
A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?A. eat plenty of fresh fruits and vegetablesB. Avoid crowdsC. Perform mild exercise, such as gardeningD. Take temp weekly
B. Avoid crowds
A nurse is assessing a client who returned to the unit 4 hr ago after a partial colectomy. Which of the following findings should the nurse attend to first?A. A moderately saturated dressingB. Report of severe incisional painC. A distended bladderD. SAO2 of 95%
B. Report of severe incisional pain
A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider?A. I drink at least 2 quarts of fluid every dayB. The last time I voided it was painful and red-tingedC. My period ended two days agoD. I don't eat shellfish because it gives me hives
D. I don't eat shellfish because it gives me hives
A nurse is caring for a client who has a new onset of chest pressure severe epigastric distress. The physician prescribes monitoring of creatinine kinase (CK) isoenzymes. When should the nurse anticipate the CK isoenzymes will begin to rise if the client has had a MI? (Select all that apply)A. 1 hrB. 2 hrC. 3 hrD. 24 hr
C, D?? (3, 24)
A nurse is preparing a client for a radiation tx who is postop following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the tx?A. AlopeciaB. DiarrheaC. FatigueD. Anorexia
C. Fatigue
A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering the dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication?A. UtilitarianismB. NonmaleficenceC. FidelityD. Veracity
B. Nonmaleficence
A nurse is providing teaching to a client who has stomatitis. Which of the following statements by the client indicates the need for further teaching?A. I will drink liquids through a strawB. I will season foods w/dried spices before cookingC. I will rinse my mouth w/baking soda and water frequentlyD. I will eat frozen bananas as a snack
B. I will season foods w/dried spices before cooking
A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?A. Encourage brief exercise before meals to promote appetiteB. Place food in affected side of the mouthC. Encourage the client to take small bitesD. Place the client w/ the head reclined back to facilitate swallowing
C. Encourage client to take small bites
A nurse is providing instruction for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?A. Don't worry; most clients dislike the prep more than the procedure itselfB. Before the exam, the provider will give you a sedative that will make you sleepyC. I know you're anxious, but this procedure is recommended for people your ageD. After you have signed the consent form, we can talk more about this
B. Before the exam, the provider will give you a sedative that will make you sleepy
A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?A. You may donate blood 6 months after completing the medication regimenB. Consume a high-protein dietC. Rest frequently throughout the dayD. Take acetaminophen q 4hrs PRN for discomfort
C. Rest frequently throughout the day
A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?A. Review the client's electrolyte valuesB. Check the client's perianal skin integrityC. Investigate the client's emotional concernsD. Obtain a dietary hx from the client
A. Review the client's electrolyte values
A nurse is speaking w/ a 35-year-old client who has fibrocystic disease of the breasts. At which of the following times should the nurse inform the client that manifestations are most evident?A. Before menstruation beginsB. After menstruation endsC. During cold weatherD. During hot weather
A. Before menstruation begins
A nurse is caring for a client who has PUD. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?A. Hyperactive bowel soundsB. Sudden abdominal painC. Increased BPD. Bradycardia
B. Sudden abdominal pain
A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain?A. The pain usually lasts longer than 20 minB. The pain often radiates to the jaw or backC. The pain persists w/rest and organic nitratesD. Exertion and anxiety can trigger the pain
D. Exertion and anxiety can trigger the pain
A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity?A. AnorexiaB. AtaxiaC. PhotosensitivityD. Jaundice
A. Anorexia
A nurse is teaching a client who has a new prescription for sucralfate to tx a gastric ulcer. Which of the following statements by the client indicates an understanding of the teaching?A. I will take this medication as needed to reduce the painB. I will reduce my fluid intake w/this medicationC. I will take this med w/an antacidD. I will take this med 1 hr before meals & at bedtime
D. I will take this med 1 hr before meals and at bedtime
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?A. Difficulty readingB. Inability to recognize family membersC. Right hemiparesisD. Aphasia
B. Inability to recognize family members
A nurse is teaching a client who has a new prescription for aspirin to tx RA. The nurse should include to monitor for which of the following adverse effects of the medication?A. ConstipationB. BleedingC. Blurred visionD. Insomnia
B. Bleeding
A nurse is assessing a client who is taking levothyroxine. The nurse should recognize that which of the following findings is a manifestation of levothyroxine overdose?A. InsomniaB. ConstipationC. DrowsinessD. Hypoactive DTRs
A. Insomnia
A nurse caring for a client who had a R side stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?A. Provide a nonskid mat to alleviate plate movementB. Encourage the client to use right hand when feeding C. Remind the client to look for food on the left side of the trayD. Encourage the use of wide grip utensils
C. Remind the client to look for food on the left side of the tray
A nurse is caring for a client 1 hr following subtotal thyroidectomy. In which of the following positions should the nurse place the client?A. Semi-fowlersB. Dorsal recumbentC. SupineD. Sims
A. Semi fowlers
A nurse is caring for a client 4 days postop following a right radical mastectomy. Which of the following activities should the nurse anticipate being the most difficult for this client to perform w/her right hand?A. Buttoning her blouseB. Eating her breakfastC. Combing her hairD. Brushing her teeth
C. Combing her hair
A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take?A. Offer the client a light snackB. Measure the clients BPC. Measure the clients apical pulseD. Weigh the client
C. Measure the clients apical pulse
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated w/urinary retention should the nurse expect? (Select all that apply)A. Report of feeling pressureB. Tenderness over the symphysis pubisC. Distended bladderD. Voiding 30 mL frequently E. Dysuria
A,B,C, D (report feeling pressure, tenderness over symphysis pubis, distended bladder, voiding 30 mL frequently)
A nurse is assessing who is 48 hr postop following abdominal surgery. Which of the following findings should the nurse report to the provider?A. BP 102/66B. Straw-colored urine from indwelling catheterC. Yellow-green drainage on surgical incisionD. RR 18
C. yellow-green drainage on surgical incision
A nurse in an ED is planning care for a client who is having an acute MI. The nurse should plan to administer which of the following medications after the initial acute phase to manage the clients pain/anxiety?A. NitroglycerinB. AspirinC. OxygenD. Morphine
D. Morphine
A nurse is preparing a client who is scheduled for an echocardiogram the following day. Which of the following instructions should the nurse include about the test?A. It might cause slight discomfort in the chest areaB. It takes about 5 or 10 minC. It requires lying quietly on one sideD. It is best to have no food or beverages on the day of the test
C. It requires lying quietly on one side
A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?A. Have the client lie flat in bedB. Keep the affected leg slightly flexedC. Elevate the HOB 45 degreesD. Keep the client NPO for 4 hr
A. Have the client lie flat in bed
A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching?A. Avoid eating at fast food restaurantsB. Avoid serving raw foodsC. Practice effective hand hygieneD. Wear barrier protection during vaginal intercourse
C. Practice effective hand hygiene
A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test. Which of the following statements should the nurse include in the teaching?A. A CA 125 test is used to confirm a diagnosis of ovarian cancerB. A CA 125 test is used to monitor a clients progress during tx of ovarian cancerC. A CA 125 test is used to identify a Bartholin cystD. A CA 125 test is used to measure testosterone level
B. A CA 125 test is used to monitor a clients progress during tx of ovarian cancer
A nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?A. These tests help to determine the degree of damage to the heart tissuesB. Cardiac enzymes will identify the location of the MIC. These tests will enable the provider to determine the heart structure and mobility of the heart valvesD. Cardiac enzymes assist in diagnosing the presence of pulmonary congestion
A. These tests help to determine the degree of damage to the heart tissues
A nurse at a rehab center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 wks ago. Which of the following goals should the nurse include in the clients rehab program?A. Establish the ability to communicate effectivelyB. Compensate for loss of depth perception C. Learn to control impulsive behaviorD. Improve left-sided motor function
A. establish the ability to communicate effectively
A nurse in a providers clinic is caring for a client who reports erectile dysfunction and requests a prescription for slidenafil. Which of the following medications currently prescribed for the client is a contraindication to take slidenafil?A. IsosorbideB. PhenytoinC. MetronidazoleD. Prednisone
A. Isosorbide
A nurse is assessing a client who is admitted for hyperthyroidism. The client reports a weight loss of 5.4 kg (12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis?A. Provide a quiet, low-stimulus environmentB. Administer aspirin as prescribed for any sign of hyperthermiaC. Keep the client NPOD. Observe the client carefully for signs hypocalcemia
A. Provide a quiet, low-stimulus environment
A nurse is teaching a client who has a new prescription for pancrealipase to aid in digestion. The nurse should inform the client to expect which of the following gastrointestinal changes?A. Decreased mucus in stoolsB. Decreased black tarry stoolsC. Decreased watery stoolsD. Decreased fat in stools
D. Decreased fat in stools
A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?A. ExophthalmosB. PalpitationsC. Weight gainD. Diaphoresis
C. Weight gain
A nurse is providing discharge teaching for a client who is postop following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?A. Do not apply heat to the area of irradiationB. Do not wash the area of irradiationC. Use an antibiotic ointment to treat skin breakdownD. Lubricate the skin lubricated w/ hypoallergenic lotion
A. Do not apply heat to the area of irradiation
A nurse is caring for an older adult client who has a WBC count of 2,000 after three rounds of chemo. Which of the following actions should the nurse take?A. Humidify the clients roomB. Serve cooked fruit w/mealsC. Clean dentures in a denture cupD. Replace the water in flower vases w/fresh water daily
B. Serve cooked fruit w/meals
A nurse is providing dietary teaching to a client who has calcium oxalate kidney stones. Which of the following statements indicates an understanding of the teaching?A. I can have almonds as a snackB. I can use soy milk w/my cerealC. I may eat a sweet potato for dinnerD. I may eat a banana w/my breakfast
D. I may eat a banana w/my breakfast
A nurse is caring for a client who has a postop ileus and an NG tube that has drained 2500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?A. elevated sodium levelB. decreased potassium levelC. elevated magnesium levelD. decreased calcium level
B. decreased potassium level
A nurse is teaching a client who has a UTI and is taking ciprofloxacin. Which of the following instructions should the nurse give to the client?A. If the medicine causes an upset stomach, take an antacid at the same timeB. Limit your daily fluid intake while taking your medicationC. This medication can cause photophobia, so be sure to wear sunglasses outdoorsD. You should report any tendon discomfort you experience while taking this medication
D. You should report any tendon discomfort you experience while taking this medication
A nurse is providing teaching to a client who has a new prescription for hydroxychloroquine to tx mild manifestations for RA. Which of the following information should the nurse include in the teaching?A. This medication should be taken between mealsB. This medication can turn skin an orange colorC. Wear sunglasses when out in bright sunshineD. Avoid crushing the medication
C. Wear sunglasses when out in bright sunshine
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the clients ability to safely ambulate?A. Observe for the presence of kernigs signB. Perform a rombergs testC. check the function of cranial nerve VD. Inspect for the presence of clubbing
B. Perform a rombergs test
A nurse is caring for an older adult client who has RA and is taking aspirin 650 mg q 4hrs. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?A. WBC countB. Rheumatoid factorC. Antinuclear antibodyD. Erythrocyte sedimentation rate
D. Erythrocyte sedimentation rate
A nurse is caring for a client who has BPH. Which of the following medications should the nurse plan to administer?A. DanazolB. FinasterideC. FluoxymesteroneD. Methyltestosterone
B. Finasteride
A nurse is assessing a client who has PUD. Which of the following findings should the nurse identify as the priority?A. Epigastric discomfortB. DyspepsiaC. Epigastric discomfortD. Hematemesis
D. Hematemesis
A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply)A. Lubricate lips w/water soluble ointmentB. Brush teeth w/soft toothbrushC. Blow nose gentlyD. Limit fruit consumptionUse a straight edge razor to shave
A,B,C (lubricate lips w/water soluble ointment, brush teeth w/soft toothbrush, blow nose gently)
A nurse is shopping and finds a woman who has collapsed w/right-sided weakness and slurred speech. Which of the following action should the nurse take?A. Provide the client w/water to test the gag refluxB. Perform carotid massageC. Notify emergency management servicesD. Drive the client to the nearest medical facility
C. Notify emergency management services
A nurse is reviewing a medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition?A. Hx of bulimiaB. Hx of NSAID useC. Drinks green teaD. Has a glass of wine and dinner each day
B. Hx of NSAID use
A nurse is caring for a client who is receiving cisplatin for tx of ovarian cancer. The clients most recent CBC is shown in the table. It is important for the nurse to consider which of the following for the client?WBC 1400 RBC 4.3 X 10^12Hgb 12.1Hct 36.5%Platelets 170,000Albumin 4.5 gA. The client has increased risk for bleedingB. The client should receive a diet w/increased proteinC. The client has increased risk of infectionD. The client should receive an erythropoiesis stimulating agent
C. The client has increased risk of infection
A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat-soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following?A. Vitamin AB. Vitamin B1C. Vitamin CD. Vitamin B12
A. Vitamin A
A nurse is assisting with obtaining an ECG for a client who has a-fib. Which of the following actions should the nurse take? (select all that apply)A. Keep the client NPO after midnightB. Inspect the electrode padsC. Wash the skin w/plain water before placing the electrodesD. Instruct the client not to talk during the testE. Administer an analgesic prior to the procedure
B, D (Inspect the electrode pads, Instruct the client not to talk during the test)
A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparins effects?A. Vitamin KB. Protamine SulfateC. AcetylcysteineD. Deferasirox
B. Protamine sulfate
A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?A. Review lab test results for low hemoglobinB. Observe for signs of infectionC. Monitor the mouth for signs of xerostomia D. Examine the skin for generalized urticaria
B. Observe for signs of infection
A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident. The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?A. Perhaps you could call your children to see how they are doingB. Don't worry. We'll take good care of your parent while you're gone.C. You are feeling drawn in two separate directions.D. There's nothing you can do here. You should go home to your children.
C. You are feeling drawn in two separate directions
A nurse is teaching about adverse effects of anastrozole w/a client who has advanced breast cancer and is postmenapausal. Which of the following adverse effects should the nurse recommend the client report to the provider?A. Weight gainB. StomatitisC. CoughD. Musculoskeletal pain
D. Musculoskeletal pain
A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate w/the client. Which of the following responses by the nurse is appropriate?A. Incorporate nonverbal cues in the conversationB. Ask multiple choice questions as part of the conversationC. Use a higher-pitched tone of voice when speakingD. Use simple childlike statements when speaking
A. Incorporate nonverbal cues in this conversation
A nurse is caring for a client who is 1 day postop following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?A. Refusing to look at the dressing or surgical incisionB. After for pain medication q 3hrsC. Asking questions about the info on her postop care pamphletD. Performing arm exercises once or twice a day
A. Refusing to look at the dressing or surgical incision
A nurse is caring for a client who has R.sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?A. Place sandbags to maintain right plantar flexionB. Position soft pillows against the bottom of the feetC. Apply a protective boot to the right ankleD. Splint the right lower extremity to maintain proper alignment
C. Apply a protective boot to the right ankle
A nurse is caring for a client who is 1 day postop following a mastectomy. Which of the following exercises should the nurse assist the client to perform on the affected side? (select all that apply)A. Squeezing a rolled washclothB. Flexing and extending her handC. Flexing and extending her elbowD. Rotation of her shoulderE. Hand wall climbing
A,B,C (squeezing a rolled washcloth, flexing/extending her hand, flexing/extending her elbow)
A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia maybe associated w/changes to the T-wave. On the graphic, point and click on the area of the ECG that represents the T-wave
Far right box
A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24 hr. Which of the following actions is the nurse's priority?A. Monitor intake and outputB. Strain the urineC. Administer pain medicineD. Administer an antiemetic
C. Administer pain medicine
A nurse is monitoring the urinary output of an adult client who had a colon resection. Which of the following 24 hr output totals indicates oliguria?A. 720 mLB. 550 mLC. 380 mLD. 600 mL
C. 380 mL
A nurse is reviewing a medical record of a client who has been on levothyroxine for several months. Which of the following findings indicates a therapeutic response to the medication?A. Decrease in level of thyroxine (T4)B. Increase in weightC. Increase in hr of sleep per nightD. Decrease in level of TSH
D. Decrease in level of TSH
A nurse is teaching a client who has a hx of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia?A. Dietary iron restrictionsB. Intestinal malabsorption syndromeC. Chronic blood lossD. Intestinal parasites
C. Chronic blood loss
A nurse is reviewing the lab results for a client who has a hx of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet?A. I flavor my meat w/lemon juiceB. I eat two eggs for breakfast each morningC. I cook my food w/canola oilD. I take an omega-3 supplement daily
B. I eat two eggs for breakfast each morning
A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?A. HypermagnesemiaB. HypokalemiaC. HyperkalemiaD. Hypomagnesemia
B. Hypokalemia
A client who has a hx of MI is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?A. AnalgesicB. Anti-inflammatoryC. Antiplatelet aggregateD. Antipyretic
C. Antiplatelet aggregate
A nurse is evaluating a client's lab results. The nurse should recognize that an increase in the client's prostate specific antigen (PSA) lab value is indicative of which of the following diagnoses?A. Breast cancerB. Colon cancerC. Liver cancerD. Prostatic cancer
D. Prostatic cancer
A nurse is caring for a 12-month old toddler who is hospitalized and confined to a room w/ a contact precaution in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client?A. Large building blocksB. Hanging crib toysC. Modeling clayD. Crayons and a coloring book
A. Large building blocks
A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side.
Bottom right box (left pedal pulse)
A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex?
Left box
A nurse is caring for a client who is 5 hr postop following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?A. Notify the providerB. Check the tubing for kinksC. Adjust the rate of the bladder irrigantD. Irrigate the catheter
B. Check the tubing for kinks
After radiation tx, a client reports dryness, redness, and scaling of his skin occurring w/in the designated radiation tx markings. The nurse should instruct the client to take which of the following actions?A. Apply hydrating lotionsB. Apply moist heatC. Sit in the sun for 10 min per dayD. Wash w/plain soap and water
A. Apply hydrating lotions
A nurse is caring for a client who is postop following a TURP. Which of the following complications is the priority for the nurse to monitor for?A. HemorrhageB. InfectionC. Urinary retentionD. Pain
A. Hemorrhage
A nurse is providing discharge instructions to a client who has RA and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?A. Take the medication between mealsB. Take the medication w/orange juiceC. Take the medication w/milkD. Take the medication on an empty stomach
C. take medication w/milk
A nurse is assessing a client who is on long term omeprazole therapy. Which of the following findings should indicate to the nurse the medication is effective?A. Increased appetiteB. Regular bowel movementsC. Absence of headacheD. Reduced dyspepsia
D. Reduced dyspepsia
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?A. Perform passive ROM on each extremityB. Monitor the client's electrolyte levelsC. Suction saliva from the client's mouthD. Record the client's intake and output
C. Suction saliva from the client's mouth
A nurse is caring for a female client who has RA and asks the nurse if it is safe for her to take aspirin. The nurse should recognize which of the following findings in the client's hx is a contraindication to this medication?A. Report of recent migraine headachesB. Hx of gastric ulcersC. Current diagnosis of glaucomaD. Prior reports of amenorrhia
B. Hx of gastric ulcers
A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect?A. DiarrheaB. Facial edemaC. TachycardiaD. Heat intolerance
B. Facial edema
A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium?A. BananasB. Cooked carrotsC. Cheddar cheeseD. 2% milk
A. Bananas
A nurse is caring for a client following an esophagogastrodudenoscopy (EGD). Which of the following assessments is the nurse's priority?A. PainB. NauseaC. Gag reflexD. Level of consciousness
C. Gag reflex
A nurse is caring for an older adult client who has a UTI. Which of the following manifestations should the nurse identify as a finding specifically associated w/this client?A. Urinary retentionB. Low back painC. IncontinenceD. Confusion
D. Confusion
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a MI?A. Check the client's BPB. Auscultate heart tonesC. Perform a 12-lead ECGD. Determine if pain radiates to the left arm
C. Perform a 12-lead ECG
A client who has chronic lymphocytic leukemia is starting chemo tx and asks if she needs to make any dietary changes. Which of the following statements should the nurse make?A. You should avoid drinking liquids an hour before txB. Eating low-calorie foods helps prevent nauseaC. Foods that are higher in fat are usually more appealingD. Raw fruits and vegetables will be easier for your body to digest
A. You should avoid drinking liquids an hour before tx
A nurse is planning care for a client who is postop following a thyroidectomy. Which of the following interventions should the nurse include in the plan?A. Instruct the client to deep breathe q 4hrB. Check the client's voice every 2 hrC. Place the head of client's bed in the flat positionD. Hyperextend the client's neck
B. Check the client's voice every 2 hr
A nurse in a provider's office is assessing a client who has RA. Which of the following findings is a late manifestation of this condition?A. AnorexiaB. Knucle deformityC. Low-grade feverD. Weight loss
B. Knuckle deformity
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?A. Serum cardiac enzyme levelsB. MRI of the chestC. Physical therapyD. Low-sodium diet
B. MRI of the chest
A nurse is caring for a client who is rescheduled for an exercise stress test. Which of the following comments made by the client should indicate to the nurse that the client requires further teaching?A. I will not smoke prior to my testB. Ill take my heart medications the morning of the testC. Ill get 8 hrs of sleep the night before the testD. Ill skip my coffee the morning of the test
B. Ill take my heart medications the morning of the test
A nurse is caring for a client who is postop following a right-sided mastectomy and has a drain connected to a portable drainage evacuator. Which of the following actions should the nurse take?A. Dangle the operative limb for 5 min every hourB. Place the HOB at a 15 degree angleC. Keep the wound drain evacuator fully expanded at all timesD. Take BPs on the client's non-affected arm
D. Take Bps on the client's non-affected arm
A nurse is teaching a client about the side effects of chemo medication. Which of the following nursing statements should the nurse include in the teaching?A. Most clients do not experience nauseaB. Hair loss is common and includes eyebrows and eyelashesC. Most clients start to gain weight during their txD. Clients lose their hair, but it usually grows back nice and thick
B. Hair loss is common and includes eyebrows and eyelashes
A nurse is caring for a client who has new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?A. HypocalcemiaB. BMI less than 25C. Family hxD. Diuretic use
C. Family history
A nurse is teaching for a client who is to begin taking tamoxifen to tx breast cancer. The nurse should instruct the client to expect which of the following findings as an adverse effect of the medication?A. TinnitisB. ConstipationC. Urinary retentionD. Hot flashes
D. Hot flashes
A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?A. Perhaps you should discuss this w/ your physicianB. Of course you aren't going to die, at least not in the immediate futureC. I recommend you exercise daily and avoid smoking to decrease your riskD. Tell me more about your fears of dying from a heart attack
D. Tell me more about your fears of dying from a heart attack
A nurse is teaching a client who has BPH and has a new prescription for finasteride. Which of the following instructions should the nurse include in the teaching?A. Avoid drinking grapefruit juice when taking this medicationB. Expect to see a response from the medication within one weekC. Decreased libido is an adverse effect of the medicationD. PSA levels will increase while taking this medication
C. Decreased libido is an adverse effect of the medication
A nurse is reviewing discharge instructions with a client who has Raynaud's disease. Which of the following client statements indicates an understanding of the teaching?A. I plan to use nicotine gum to help me quit smokingB. I am going to take a stress management classC. I will limit myself to only two cups of coffee in the morningD. I should not drive in the winter months
B. I am going to take a stress management class
A nurse is caring for a client who is 1 day postop following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?A. Document the amount of drainageB. Obtain a culture of the drainageC. Check the drainage for glucoseD. Notify the client's provider
C. Check the drainage for glucose
A nurse is providing dietary teaching to a client who has frequent kidney stones. Which of the following instructions should the nurse include in the teaching?A. Limit your intake of dairy productsB. Increase the amount of protein in your dietC. Avoid eating tree nuts, such as almondsD. Take a vitamin C supplement twice daily
C. Avoid eating tree nuts, such as almonds
A nurse is reviewing the health hx for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the hx should the nurse report to the provider?A. A client has a hx of hypothyroidism B. Client has a hx of bronchial asthmaC. Client has a hx of HTND. Client has a hx of migraine headaches
B. Client has a hx of bronchial asthma
A nurse is caring for a client who is receiving a unit of packed RBCs. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?A. FebrileB. AllergicC. Acute painD. Hemolytic
D. Hemolytic
A nurse is assessing a client who has hypokalemia as a result of N/V/D. Which of the following findings should the nurse expect?A. Hyperactive reflexesB. Extreme thirstC. Weak, irregular pulseD. Hyperactive bowel sounds
C. Weak, irregular pulse
A nurse is caring for a client who has nausea and a prescription for metoclopramide intermittent IV bolus every 4 hrs as needed. The client asks the nurse how much metoclopramide will relieve her nausea. Which of the following explanations should the nurse provide?A. The medication relieves nausea by promoting gastric emptyingB. The medication works by decreasing gastric acid secretionsC. The medication relieves nausea by slowing peristalsisD. The medication works by relaxing gastric muscles
A. The medication relieves nausea by promoting gastric emptying
A nurse is assisting a client who has hypothyroidism w/meal planning. Which of the following foods should the nurse recommend that the client add to her diet?A. Ripe bananasB. Poached eggsC. Whole grainsD. Baked chicken
C. Whole grains
A nurse is providing discharge teaching to a client who has gastroesophogeal reflux disease. Which of the following statements by the client indicates an understanding of the teaching?A. The type of foods I eat does not affect this conditionB. I will sleep on my left sideC. I will eat a snack just before going to bedD. I will sleep w/my head of my bed elevated
D. I will sleep w/my head of bed elevated
A nurse is caring for a client who has chemo-induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms?A. Extremities that turn blue when exposed to coldB. Tingling feeling in extremitiesC. Jerking movements of the extremitiesD. Spasms of the extremities
B. Tinging feeling in extremities
A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the clients apical pulse.
Bottom (right on for me) Left on them
A nurse in a providers office is reviewing the lab findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?A. BUN 15B. Platelet count 60,000C. WBC 6,000D. Hemoglobin 14
Platelet count 60,000
A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching?A. Pyelonephritis increases a pregnant womens risk for preterm laborB. Pyelonephritis is most of caused by staph saprophyticusC. Pyelonephritis is an infection of the lower urinary tractD. Pyelonephritis often causes no symptoms in affected clients
A. Pyelonephritis increases a pregnant womens risk for preterm labor
A nurse is assessing a client for early manifestations of RA. Which of the following changes is an early manifestation of RA?A. Morning stiffnessB. FatigueC. Temporomandibular joint painD. Bakers cysts
B. Fatigue
A nurse is caring for a client who is on warfarin therapy for a fib. The clients INR is 5.2. Which of the following medications should the nurse prepare to administer?A. EpinephrineB. AtropineC. ProtamineD. Vitamin K
D. Vitamin K
A nurse is reinforcing teaching w/a client regarding reduction of risk factors for CAD. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply)A. i must stop smokingB. I should limit my smokingC. I will stop consuming alcoholD. I need to monitor my weightE. I am limiting my intake of fast foods
A, D, E (I must stop smoking, I need to monitor my weight, I am limiting my intake of fast foods)
A nurse is instructing a client how to decrease the nausea associated w/chemo and radiation. Which of the following statements indicates an understanding of the teaching?A. I will eat smaller meals if I feel nauseatedB. I will eat foods that are served at room temperatureC. I will drink more liquids w/my mealsD. I will increase the amount of unsaturated fats in my diet
B. I will eat foods that are served at room temp
A community health nurse is developing a pamphlet about breast self-exam for a local health fair. Which of the following instructions should the nurse include?A. Expect some breast dimpling or discharge w/ageB. For those who have a menstrual cycle, perform a BSE every month 2-3 days before menstruationC. Use the palm of the hand, feel for lumps using circular motionD. Breasts can be examined in the shower w/soapy hands
D. breasts can be examined in the shower w/soapy hands
A nurse is assessing a clients cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?A. The left 2nd intercostal spaceB. The right 2nd intercostal spaceC. The left 5th intercostal spaceD. The left 5th intercostal space at the midclavicular line
A. the left 2nd intercostal space
A nurse is providing dietary teaching for a client who has Cushings disease. Which of the following recommendations should the nurse include in the teaching?A. Limit intake of potassium-rich foodsB. Restrict sodium intakeC. Increase Carbohydrate intakeD. Decrease protein intake
B. restrict sodium intake
A nurse is taking a health hx of a client who reports occasionally taking several otc medications, including an H2 receptor antagonist. Which of the following outcome indicates the H2RA is therapeutic?A. Relief of heartburnB. Cessation of diarrheaC. Passage of flatusD. Absence of constipation
A. relief of heartburn
A nurse is caring for a client who has DVT and is receiving IV fluid that contains 10,000 units of heparin in 500 mL infusing at 1,000 units/hr. When calculating I&O, how much should the nurse document as intake from this infusion in 8-hr shift? (nearest whole #)
400 mL
A nurse is planning care for a client being tx w/chemo and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the clients plan of care?A. All visitors from entering clients roomB. Fresh flowers and potted plants in roomC. Oral fluid intake to between meals onlyD. Activities that could result in bleeding
B. fresh flowers and potted plants in room
A female middle adult client tells the nurse that she tested positive for a mutant BRCA1 gene. The nurse should recognize that the client is at an increased risk for which of the following situations?A. Delivering a child who has downs syndromeB. Developing alzheimers diseaseC. Developing breast cancerD. Developing thyroid cancer
C. Developing breast cancer
A nurse is teaching a client who has a new prescription for ranitidine to tx PUD. Which of the following statements by the client indicate an understanding of the teaching? (select all that apply)A. I can take this w/ or w/o foodB. I will take this medication in the morningC. I should expect my stools to turn blackD. I will take this medication w/an antacidE. I will take this med when needed for painF. I will eat 5 small meals a day
A, F (I can take this with or without food, I will eat 5 small meals/day)
A nurse is reviewing the EKG strip for a client who has prolonged vomiting. Which of the following abnormalities on the clients EKG strip should the nurse interpret as a sign of hypokalemia?A. Abnormally prominent U waveB. Elevated ST segmentC. Wide QRSD. Inverted P wave
A. Abnormally prominent u wave