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1149 Cards in this Set

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The nurse is administering sublingual nitroglycerin to a client. Immediately afterward, the client may experience:
throbbing headache or dizziness.
A client with iron deficiency anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of this type of anemia?
Dyspnea, tachycardia, and pallor
The nurse is caring for a client taking an anticoagulant. Which instruction regarding anticoagulant therapy should the nurse give the client?
Limit foods high in vitamin K.
The nurse delivers a client's 10 a.m. medications. The client is away from his room for a diagnostic study. Which action is most appropriate for the nurse to take?
Lock the medications in the medicine preparation area until the client returns.
The nurse is caring for a client receiving patient-controlled analgesia (PCA) for pain management. Which statement about PCA is true?
Pain relief is initiated by the client as needed.
The nurse is caring for a client with type 1 diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:
15 to 20 g of a fast-acting carbohydrate such as orange juice.
The nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication?
Bone fracture
The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women:
have a mammogram annually.
The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:
immediately after her menses.
The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:
changes from previous self-examinations.
The American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should the nurse recommend?
Flexible sigmoidoscopy beginning at age 50
Which nursing diagnosis should the nurse expect to see in a care plan for a client in sickle cell crisis?
Acute pain related to sickle cell crisis
What can the nurse do to prevent lipodystrophy when administering insulin to a diabetic client?
Rotate the injection sites.
For a diabetic client with a foot ulcer, the physician orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are the wet-to-dry dressings used for this client?
Because they debride the wound and promote healing by secondary intention.
An obese client is admitted to the hospital for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client?
Identify alternative ways for the client to lose weight.
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suggest referral to a sex counselor or other appropriate professional.
Policy and procedure dictate that hand washing is a requirement when caring for clients. Which statement about hand washing is true?
Frequent hand washing reduces transmission of pathogens from one client to another.
The nurse is evaluating a postoperative client for infection. Which sign or symptom would be most indicative of infection?
Red, warm, tender incision
The nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to get out of bed. The nurse should:
obtain a physician's order to restrain the client when less restrictive interventions fail.
The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?
Post a turning schedule at the client's bedside.
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Disturbed body image
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Refer the client to the American Cancer Society's Reach for Recovery program or another support program.
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Situational low self-esteem
A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which intervention is appropriate for this client?
Encouraging the client to discuss concerns with the clergy
The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point about preventing transmission of the human immunodeficiency virus (HIV) is most important for the nurse to stress?
Following safer-sex practices
The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first:
establish unresponsiveness.
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notify the physician about cloudy or foul-smelling urine.
The nurse is providing home care instructions to a client who has recently had a skin graft. It's most important that the client remember to:
protect the graft from direct sunlight.
The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should:
irrigate the NG tube gently with normal saline solution as prescribed.
A client is to be discharged from an acute care facility following treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?
Evaluation
The nurse is caring for a client who recently underwent a total hip replacement. The nurse should:
limit client hip flexion while sitting.
When caring for a client who's being treated for hyperthyroidism, it's important to:
balance the client's periods of activity and rest.
Which intervention should the nurse try first with a client who exhibits signs of sleep disturbance?
Provide the client with sleep aids, such as pillows, back rubs, and snacks.
When preparing a client for an enema, the nurse should help him into the:
left-lateral Sims' position.
The nurse is caring for a client with a right ankle sprain. When applying cold to the client's injury, the nurse should:
apply it immediately after the injury occurs.
The nurse is teaching a client with a family history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:
increase his activity level.
The nurse is teaching a client diagnosed with basal cell epithelioma. The most common cause of basal cell epithelioma is:
exposure to the sun.
The nurse is giving instructions to a client who's going home with a cast on his leg. Which point is most critical?
Reporting signs of impaired circulation
A client undergoes a surgical procedure that requires the use of general anesthesia. Following general anesthesia, the client is most at risk for:
atelectasis.
The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:
keeping his airway patent.
The nurse is working on a surgical floor. The nurse must logroll a client following a:
laminectomy.
A client underwent cataract removal with an intraocular lens implant. The nurse is giving the client discharge instructions. These instructions should include which of the following?
Avoid straining during bowel movements.
When caring for a client with a nursing diagnosis of <i>Impaired swallowing</i> related to neuromuscular impairment, the nurse should:
elevate the head of the bed 90 degrees during meals.
When performing an assessment, the nurse collects the following data: impaired coordination, decreased muscle strength, limited range of motion, and the client's reluctance to move. This data indicates which nursing diagnosis?
Impaired mobility
The nurse is teaching a client with genital herpes. Education for this client should include an explanation of:
the importance of informing his partner of the disease.
A 25-year-old client asks the nurse how often and when she should perform breast self-examinations. The nurse should tell her:
every month, 7 to 10 days after menses starts.
A male client should be taught about testicular examinations:
before age 20.
When performing an abdominal assessment, the nurse should follow which examination sequence?
Inspection, auscultation, percussion, and palpation
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"I'll only need chemotherapy therapy before receiving my bone marrow transplant."
The nurse is providing teaching to a client who's at risk for coronary artery disease (CAD). The nurse tells the client that CAD has many risk factors. Risk factors that can be controlled or modified include:
obesity, inactivity, diet, and smoking.
The nurse is collecting data on a client admitted with a diagnosis of small bowel obstruction. When assessing the client's pulse rate, the nurse should:
count the apical or radial pulse for 60 seconds.
When inserting a urinary catheter, the nurse can facilitate the insertion by asking the client to:
breathe deeply.
The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
destroys the odor-proof seal.
A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. The rationale for using TENS is to:
block painful stimuli traveling over small nerve fibers.
The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that:
inelastic skin turgor is a normal part of aging.
The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
thirst or confusion.
A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to:
distribute weight away from the involved side.
The nurse is developing a teaching plan for a client who must undergo an above-the-knee amputation of the left leg. After a leg amputation, exercise of the remaining limb:
should begin the day after surgery.
The nurse is preparing to remove a previously applied topical medication from a client. The rationale for removing previously applied topical medications before applying new medications is to:
avoid administering more than the prescribed dose.
The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the:
conjunctival sac.
The nurse is administering eardrops to an adult client. To straighten the ear canal in an adult client before instilling the drops, the nurse should gently pull the:
auricle up and back.
The nurse is teaching a client about using vaginal medications. The nurse should instruct the client to:
use only a water-soluble lubricant when inserting a suppository.
The nurse is administering sublingual nitroglycerin to a client with chest pain. The nurse should place the medication:
under the tongue.
A client has an order for 5,000 units of subcutaneous heparin every 12 hours. When injecting heparin subcutaneously, the nurse should:
use a 45- to 90-degree angle to insert.
The nurse is collecting data on a client who has developed a paralytic ileus. The client's bowel sounds will be:
hypoactive.
The nurse is instructing a client about the use of antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:
forcing blood into the deep venous system.
The nurse is caring for a client who's showing signs of hypoglycemia. This client will most likely have a blood glucose level:
below 70 mg/dl.
A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide regarding cast care?
Keep your right leg elevated above heart level.
The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:
wash and inspect feet daily.
The nurse is with a group of patient-care attendants reviewing infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:
washing hands.
A client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a 24-hour urine specimen, the collection time should:
start after a known voiding.
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
When developing a care plan for an older adult (age 65 and older), the nurse should consider which challenges faced by clients in this age-group?
Adjusting to retirement, deaths of family members, and decreased physical strength
The nurse is administering I.M. injections to an older client. The nurse should remember that an older client has:
less subcutaneous tissue and muscle mass than a younger client.
The nurse is collecting data on an elderly client. When collecting data, the nurse should consider that one normal aging change is:
diminished reflexes.
A person's psychosocial needs during the dying process of a relative may include:
flexible visitation, participation in client care, and rest breaks.
When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
Strawberries
While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?
Diphenhydramine hydrochloride (Benadryl)
Which behavior suggests that a client has obtained relief from urticaria?
The client no longer scratches his arms.
Which nursing intervention is most appropriate for a client with multiple myeloma?
Preventing bone injury
When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be:
administering pain medication.
When developing a therapeutic relationship with a client, the nurse should begin preparing the client for termination of the relationship:
during the first meeting.
In the stages of death and dying as defined by Elizabeth Kubler-Ross, feelings of loss, grief, and intense sadness are symptoms of:
depression.
To maintain a therapeutic environment with a client and his family, the nurse can use communication techniques such as the clarification technique. An example of the clarification technique is:
"What do you mean when you say...?"
The nurse is caring for a client admitted to the hospital with a bowel obstruction. The nurse should wear sterile gloves when:
inserting an indwelling urinary catheter.
The nurse is placing a client on airborne precautions. The client asks the nurse to leave his door open. The best reply to this is:
"I must keep your door closed to prevent the spread of infection. I'll open the curtains so that you don't feel so closed in."
A client is confused and continuously attempts to get out of bed. The physician prescribes a vest restraint. When applying a vest restraint, the nurse should:
allow room for the client to turn.
The nurse is about to administer a medication to a client. To verify the client's identity, the nurse should:
check the client's identification bracelet.
The nurse is caring for a client with end-stage heart failure. Which statement by the client best demonstrates understanding of an advanced directive?
"A living will allows my decisions for health care to be known if I'm not able to speak for myself."
A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:
place saline-soaked sterile dressings on the wound.
The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:
progressively deeper breaths followed by shallower breaths with apneic periods.
A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the functions of the three lumens include:
continuous inflow and outflow of irrigation solution.
A client with seizure disorder is having a grand mal seizure. During the active seizure phase, the nurse should:
place the client on his side, remove dangerous objects, and protect his head.
A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?
Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin.
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afebrile, tachycardia, normal respiratory rate, and hypotension.
The nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-dry dressing. Which guideline is appropriate for a wet-to-dry dressing?
The wound should remain moist from the dressing.
As a nurse is talking to a client, the client begins choking on his lunch. He's coughing forcefully. The nurse should:
stay with him but not intervene at this time.
In community-based nursing, primary responsibility for decisions related to health care belongs to the:
client.
A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan?
Teach the client how to prevent problems caused by immobility.
A client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
Take piroxicam with food or an antacid.
The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:
walk from his room to the end of the hall and back before discharge.
The nurse is caring for a client who was given pain medication before leaving the postanesthesia care unit. Upon returning to her room, the client complains of pain and requests more pain medication. Which is the best action for the nurse to take?
Notify the physician that the client is continuing to complain of pain.
The nurse is caring for a client infected with methicillin-resistant <i>Staphylococcus aureus</i> (MRSA). What's the major infection control measure to reduce MRSA and other nosocomial pathogens in a health care setting?
Ensuring that personnel wash their hands before and after contact with every client
A nurse received an accidental needle stick while giving an I.M. injection. The greatest threat for the nurse is:
hepatitis B (HBV).
The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:
keeping the bed in the lowest possible position.
A client has three children and his mother lives with them. This is called:
an extended family.
The nurse is collecting data on a 47-year-old client who has come to the physician's office for his annual physical. One of the first physical signs of aging is:
failing eyesight, especially close vision.
The nurse is collecting data on an 80-year-old widow. Which statement best describes the developmental stage of the client at this age?
The client realizes that she can provide others with an example of wisdom and courage.
The nurse is taking the health history of an 85-year-old client. Which information will be most useful to the nurse for when planning care?
Current health promotion activities
The nurse is teaching a client about the importance of disease prevention. Why is disease prevention necessary in health promotion?
Prevention is emphasized in the link between personal behavior and health.
The nurse is collecting data on a 71-year-old female client with ulcerative colitis. Which factor related to the family will have the greatest impact on the client's rehabilitation after discharge?
Emotional support from the family
The nurse is caring for an 85-year-old client. What's the most important factor directly influencing this client's mental health?
The client's attitude toward life circumstances
The nurse is instructing a client with a left fractured tibia how to walk with crutches. Which instruction would be appropriate?
All weight should be on the hands.
Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience:
heat intolerance.
The nurse is caring for a client dying of lung cancer. According to Maslow's hierarchy of needs, which dimension of care is considered primary in importance when caring for a dying client?
Physiological
The nurse is giving a bath to a client with a decreased level of consciousness who has a normal body temperature. When giving a bed bath, what temperature should the water be?
110<font face="LWWSYM">%</font> to 115<font face="LWWSYM">%</font> F (43.3<font face="LWWSYM">%</font> to 46.1<font face="LWWSYM">%</font> C)
The nurse is admitting a client with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:
daily weight.
When performing oral care on a comatose client; the nurse should:
place the client in a side-lying position, with the head of the bed lowered.
The nurse is providing care for an immobilized client. For this client, the most appropriate and most effective nursing intervention would be:
repositioning the client on alternate sides at least every 2 hours.
Clients commonly confuse adverse effects of a drug with allergic reactions to the drug. Which of the following would most likely be an adverse effect, not an allergic reaction?
Nausea and occasional vomiting after taking the drug
The nurse is administering neomycin to a client. Which adverse effect should the nurse ask the client to report?
Hearing loss
A client with cholecystitis is receiving propantheline bromide (Pro-Banthine). The client is given this medication because it:
inhibits contraction of the bile duct and gallbladder.
The nurse is preparing to administer morphine to a postoperative client. Before administering morphine, the nurse should assess the client's:
respiratory rate.
A 78-year-old client with sensorineural hearing loss is admitted to a rehabilitation center after hip replacement surgery. A risk factor for this client would be:
altered perceptions.
The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
drink liquids only between meals.
The nurse is administering preoperative sedation to a client going to the operating room for a aortobifemoral bypass. After administering preoperative sedation to the client, the nurse should:
place the bed in low position with the side rails up.
The nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is nonmodifiable?
Advanced age
The client most at risk for sensory overload is:
an 80-year-old client in the intensive care unit (ICU).
A client has just finished his glucose tolerance test. How many hours should it take for his blood glucose level to return to normal?
3 hours
The nurse is teaching a client recently diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:
a lower motor neuron lesion.
A client underwent a modified mastectomy and has a pressure dressing encircling her chest. Which postoperative nursing care function should the nurse anticipate to be difficult?
Promoting turning, coughing, and deep breathing
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
auscultate bowel sounds.
The nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to prevent an increase in intracranial pressure (ICP)?
Elevate the head of the bed 30 to 45 degrees.
The nurse is caring for a client with active upper GI bleeding. What's the appropriate diet for this client during the first 24 hours after admission?
Nothing by mouth
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
fine needle aspiration.
A client who has discovered a breast lump is tearful and expresses concern over her situation. The best way for the nurse to respond to her is by:
encouraging a discussion of her problems and fears.
The nurse is developing a teaching plan for a client with genital herpes. She should include information about:
acyclovir (Zovirax).
A female client is being treated for genital herpes. The client should receive teaching on the:
need to abstain from sexual contact.
A 68-year-old male is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him:
onto the bedpan.
The nurse is collecting data on a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
Polyps
For a client with an exacerbation of rheumatoid arthritis, the physician prescribes prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
Weight gain, hypertension, and insomnia
A client is suspected of having herpes zoster. The nurse knows that the lesions of herpes zoster are typically:
grouped vesicles in linear patches along a dermatome.
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a panic attack.
What should the nurse do for a client who's having a seizure?
Loosen the clothing around the client's neck.
To encourage adequate nutritional intake for a client with Alzheimer's disease, the nurse should:
stay with the client and encourage him to eat.
An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for:
aspiration.
Which of the following nursing interventions should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?
Change the tube feeding solutions and tubing at least every 24 hours.
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Bibasilar fine crackles
The nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse can anticipate using:
diuretics.
A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:
acute pulmonary edema.
The nurse is caring for a client with suspected acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:
place the client in high Fowler's position.
The physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse can prevent chest tube air leaks by:
checking and taping all connections.
A client is unable to take a deep breath and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client compliance with activity and deep breathing, the nurse should:
administer pain medication before having the client deep breathe, cough, or get out of bed.
To assess effectiveness of incentive spirometry, the nurse can use a pulse oximeter to monitor the client's:
oxygen saturation.
The nurse is caring for a client who required chest tube insertion for a pneumothorax. To confirm pneumothorax resolution, the nurse can anticipate that the client will require:
a chest X-ray.
A 50-year-old male is diagnosed with multiple myeloma and the prognosis is poor. He's tearful and trying to express his feelings, but he's having difficulty. The nurse should first:
ask if he would like her to sit with him while he collects his thoughts.
A client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include:
Bence Jones protein in the urine.
The nurse is providing care for a client with multiple myeloma, a disorder characterized by episodes of remissions and exacerbations. Which resource may best help the client adapt to the disease?
Support group
The nurse is caring for a client with multiple myeloma. A sign that a client with multiple myeloma isn't coping well with his prognosis is that he:
avoids any conversation concerning his health.
The nurse is collecting data on a client with possible osteoarthritis. The most significant risk factor for osteoarthritis is:
age.
A client with possible osteoarthritis is having X-rays performed on both knees. X-rays of an osteoarthritic joint reveal:
osteophyte formation.
The nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to:
install safety devices in his home.
The nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include:
administration of nonsteroidal anti-inflammatory drugs (NSAIDs).
The nurse is collecting data on a postcraniotomy client and finds the urine output from a catheter is 1,500 ml for the first hour and the same for the second hour. The nurse should suspect:
diabetes insipidus.
The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about the deficiency of which hormone?
antidiuretic hormone (ADH).
The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
vasopressin (Pitressin).
A client who sustained a closed head injury is deteriorating and the prognosis is poor. The client meets brain-death criteria. Which nursing intervention is most appropriate at this time?
Approach the client's family about organ donation.
An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking. When assessing him for dehydration, the nurse would expect to find:
tachycardia.
The nurse is helping a client with her meal choices. Which breakfast selection indicates that the client understands her low-potassium diet?
Scrambled eggs and toast with tea
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?
27%
A 52-year-old married man with two adolescent children is beginning rehabilitation following a stroke. When planning the client's care, the nurse should recognize that his condition will affect:
him and his entire family.
A client who has suffered a stroke is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:
turn him frequently.
The nurse is assisting with a screening for testicular cancer. Which client has the highest risk of developing testicular cancer?
A 28-year-old man
The nurse is teaching breast self-examination to a college student. The nurse knows that the client understands the best time to examine her breasts when the client says:
"I'll examine my breasts a week after my period starts."
A client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by:
wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle.
A 78-year-old client has a history of osteoarthritis. Which signs and symptoms would the nurse expect to find on physical assessment?
Joint pain, crepitus, Heberden's nodes
A client undergoes a total hip replacement. Which statement made by the client would indicate to the nurse that the client requires further teaching?
"I don't know if I'll be able to get off that low toilet seat at home by myself."
The nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?
Provide rest periods in between nursing interventions.
The nurse is administering neostigmine (Prostigmin) to a client with myasthenia gravis. Which nursing intervention should the nurse implement?
Schedule the medication before meals.
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
Alternately patch one eye every 2 hours.
The nurse is assisting with a screening for colorectal cancer. The client with the highest risk of colorectal cancer is a:
52-year-old man with a family history of polyposis.
The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching?
Hanging the irrigation bag 24<font face="LWWSYM">"</font> to 36<font face="LWWSYM">"</font> (60 to 90 cm) above the stoma
The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
Ineffective peripheral tissue perfusion
A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The most appropriate response to her would be:
"You seem angry. Would you like to talk about it?"
The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?
Monitor body temperature.
The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?
Use diaphragmatic breathing.
The nurse administered NPH insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?
4 p.m.
A client tells the nurse that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check:
glycosylated hemoglobin level.
The nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find:
deposits of adipose tissue in the trunk and dorsocervical area.
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
Monitoring the patency of an indwelling urinary catheter
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?
Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician.
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Tie the restraint to the bed frame.
The nurse is performing wound care on a foot ulcer in a client with type 1 diabetes mellitus. Which technique demonstrates surgical asepsis?
Changing the sterile field after sterile water is spilled on it
A client has a conductive hearing loss caused by otosclerosis and has repeatedly refused surgery. To facilitate communication with the client, the nurse should:
sit or stand in front of the client when speaking.
The nurse is assisting with developing a care plan for a client who's at risk for impaired coping due to the effects of chronic illness. Which factor provides the best evidence that the client is at risk for difficulty in coping with his illness?
Lack of social support
The nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?
Assessing the extremity for neurovascular integrity
The nurse administers basic cardiac life support to a client in cardiac arrest. Which action does the nurse perform?
Assessing the patency of the airway
The nurse is caring for an unconscious client. Which nursing intervention takes highest priority?
Maintaining a patent airway
The nurse is providing care for a postoperative client who has undergone a small bowel resection. The client has an epidural catheter. Which of the following can be administered through this catheter?
Analgesics
The nurse is collecting baseline data on a client's skin integrity. Which of the following is a key assessment parameter?
Overall risk of developing pressure ulcers
A client complaining of right, lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately?
White blood cell (WBC) count of 22.8/mm<font face="LWWSUP">3</font>
The nurse is preparing to care for a client who was just transferred from the emergency care unit to the medical surgical floor. What's the most effective means of preventing microbial transmission?
Meticulous hand washing
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Aspiration
Which phrase is used to describe the volume of air inspired and expired with a normal breath?
Tidal volume
The nurse is performing a painless, noninvasive procedure to measure Sa<font size="-2">O</font><font face="LWWSUB">2</font>. What procedure is it?
Pulse oximetry
The nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?
Lateral recumbent, with chin resting on flexed knees
A client with bladder cancer undergoes a total cystectomy and ileal conduit. Postoperatively, the nurse notes mucus in the client's urine. Which nursing intervention is most appropriate?
Explaining to the client that this is normal after this type of surgery
The nurse is performing a mental status examination on a client diagnosed with subdural hematoma. This test assesses which of the following?
Cerebral function
The nurse is caring for a confused, elderly client. What's the nurse's most important consideration?
Protecting the client from injury
A client with cancer is receiving chemotherapeutic drugs. What adverse effects are most common?
Nausea and vomiting
To combat the most common adverse effects of chemotherapy, the nurse would administer an:
antiemetic.
The nurse administers furosemide (Lasix) to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?
Low serum potassium level
A client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are effective only if the client:
has type 2 diabetes.
The nurse is teaching a client who receives nitrates for the relief of chest pain. Which of the following instructions should the nurse emphasize?
Lie down or sit in a chair for 5 to 10 minutes after taking the drug.
The nurse is teaching a client who has been prescribed allopurinol for the treatment of gout. Which instruction would the nurse give to the client?
Avoid foods that are rich in purine.
The nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?
Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.
The nurse provides care for a client receiving oxygen from a nonrebreathing mask. Which nursing intervention has the highest priority?
Assessing the client's respiratory status, orientation, and skin color
The nurse assesses a client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing?
Use of accessory muscles
The nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
Auscultation
Which of the following clinical findings would the nurse look for in a client with chronic renal failure?
Uremia
The nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak.
The nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
Call the physician immediately.
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Excess fluid volume related to congestion of the cardiovascular system
A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?
Compatible blood and tissue types
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Talk to the client about his attitudes toward the medications.
A client with pulmonary edema is receiving furosemide (Lasix). To help evaluate the effectiveness of this diuretic, what should the nurse assess?
Breath sounds
A train accident sends a large number of injured passengers to the hospital. The hospital's disaster plan is put into effect. Which one of the following nursing actions will best serve the hospital in a disaster situation?
The nurse should know the hospital's disaster plan and what is expected of her during a disaster.
Which intervention will best help to prevent a client from falling?
Monitor the client regularly or continually if his condition warrants it.
The nurse is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true?
A positive reaction indicates that the client has been exposed to the disease.
A nurse working in a senior center encounters a client who recently lost his spouse as well as several friends and family members. What is the best way for the nurse to assist the client?
Encourage the client to participate in grief counseling.
The nurse is developing a teaching plan for a client with asthma. Which of the following teaching points has the highest priority?
Take prescribed medications as scheduled.
The nurse is assisting with a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point would the nurse expect to be included?
Notify the physician if urinary urgency, burning, frequency, or difficulty occurs.
The nurse is teaching a client about breast self-examinations. The client asks if she should have an annual mammogram. According to the American Cancer Society, how should the nurse respond?
All women over 40 years of age should have an annual mammogram.
The nurse is teaching a male client to perform monthly testicular self-examinations. Which of the following points would be appropriate to make?
Testicular cancer is a highly curable type of cancer.
The nurse is teaching a client about maintaining a healthy heart. The nurse should include which recommendations?
Use alcohol in moderation.
The nurse is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?
The recommended daily allowance of calcium may be found in a wide variety of foods.
The nurse is preparing a client with a malignant tumor for colorectal surgery and subsequent colostomy. The client tells the nurse that he's anxious. What would the nurse's initial step be in working with this client?
Determining what the client already knows about colostomies
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Investigating community resources for adult day care and other services
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Help the client use effective coping strategies to ease spiritual discomfort.
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Allowing the client to express her feelings without judging her
A client on long-term mechanical ventilation becomes frustrated when he tries to communicate. Which of the following interventions should the nurse perform to assist the client?
Ask the client to write, use a picture board, or spell words with an alphabet board.
Based on an assessment of a client's health and home environment, the nurse determines the need for assistive devices, such as a cane, walker, wheelchair, shower chair, or hearing aid. What is the purpose of providing assistive devices?
To help the client to remain independent and thereby improve self-confidence
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Encouraging the client to express emotions associated with relocation
Which of the following statements describing urinary incontinence in the elderly is true?
Urinary incontinence isn't a disease.
The nurse is teaching an elderly client about good bowel habits. Which statement by the client would indicate to the nurse that additional teaching was required?
"I need to use laxatives regularly to prevent constipation."
A client is having trouble sleeping. Which of the following should the nurse suggest to the client?
Maintain the same schedule for waking and sleeping.
The nurse is changing a dressing and providing wound care. Which activity should she perform first?
Wash hands thoroughly.
A newly hired licensed practical nurse (LPN) and her preceptor are establishing priorities for their morning assessments. Which client should they assess first?
A newly admitted client with acute abdominal pain
The nurse is giving instructions to family members of a client with a self-care deficit. Family members must feed the client. Which of the following should the nurse recommend?
Determine foods best handled by the client, and feed these foods to him.
An elderly client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of a thromboembolism?
Homans'
A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work site health screening. What should the nurse do?
Recommend he have his blood pressure rechecked within 2 months.
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Osteoporosis
A recent immigrant from Vietnam is diagnosed with pulmonary tuberculosis (TB). Which intervention is most important for the nurse to implement with this client?
Developing a list of people with whom the client has had contact
A quadriplegic client is in spinal shock. What should the nurse expect?
Absence of reflexes along with flaccid extremities
A client develops a pulmonary embolism after total knee surgery and must be converted from heparin to warfarin (Coumadin) anticoagulant therapy. What should the nurse tell the client?
Prothrombin time (PT) and international normalized ratio (INR) will be periodically checked for dose adjustment.
The nurse is planning care for a client who suffered a stroke in the right hemisphere of his brain. What should the nurse do?
Provide close supervision due to the client's impulsiveness and poor judgment.
The nurse is caring for an L1-L2 paraplegic undergoing rehabilitation. Which of the following goals is appropriate?
Establishing an intermittent catheterization routine every 4 hours
The nurse is giving home care instructions to a client who just had a cataract removed and an intraocular lens implanted. What should the nurse tell the client?
Don't sleep on the operated side.
The nurse is providing home care to a client with failing vision due to macular degeneration. The nurse is concerned about the client's safety. Which of the following activities would help to lessen the client's risk of a fall?
Installing handrails on steps and in hallways and bathrooms
A client underwent a retinal detachment repair. The nurse receives the following order from the client's physician: Keep client in upright sitting position, with head over the bed table, until first dressing change. What should the nurse do?
Follow the order because this position will help keep the retinal repair intact.
Which of the following statements about external otitis is true?
External otitis is characterized by pain when the pinna of the ear is pulled.
During a senior citizen health screening, the nurse observes a 75-year-old female with a severely increased thoracic curve or humpback. What is this condition called?
Kyphosis
A 69-year-old client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?
"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."
The nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?
Prevent internal rotation of the affected leg.
The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal?
Urine retention or incontinence
Which symptoms indicate that a client probably has a sinus infection?
Pain in the upper molars and tan or green drainage in the oropharynx
A 72-year-old client seeks help for chronic constipation. This is a common problem for elderly clients due to several factors related to aging. Which of the following is one such factor?
Decreased abdominal strength
The nurse is assisting with coordinating an immunization program for health care workers and clients. What information should be included as part of the program?
Hepatitis B immunization should be given to neonates before they leave the hospital.
A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?
Exercise and a weight reduction diet
Laboratory studies indicate a client's blood sugar level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose utilization?
A test of serum glycosylated hemoglobin (HbA<font face="LWWSUB">1c</font>)
Every morning, a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?
70% NPH insulin and 30% regular insulin
The nurse is caring for a postthyroidectomy client at risk for hypocalcemia. What should the nurse do?
Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.
To verify the placement of a gastric feeding tube, the nurse should perform at least two tests. One test requires instilling air into the tube with a syringe and listening with a stethoscope for air passing into the stomach. What is another test method?
Aspiration of gastric contents and testing for a pH less than 6.0
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Phenazopyridine (Pyridium)
A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?
This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually.
A 35-year-old female client is requesting information about mammograms and breast cancer. She isn't considered at high risk for breast cancer. What should the nurse tell this client?
She should eat a low-fat diet to further decrease her risk of breast cancer.
What should a male client over the age of 50 do to help ensure early identification of prostate cancer?
Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.
Clients diagnosed with a chronic illness exhibit a general pattern of adaptation, which consists of three stages. What is the sequence of these stages?
Disbelief, developing awareness, integration
A client is admitted to the hospital with a possible electrolyte imbalance. The client is disoriented, weak, has an irregular pulse, and takes hydrochlorothiazide. The client most likely suffers from:
hypokalemia.
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?
Take a stool softener, such as docusate sodium (Colace), daily
The nurse is providing postoperative care for a client recovering from abdominal surgery. The client is receiving morphine through a client-controlled analgesia pump. Which finding would indicate that the client is obtaining adequate pain relief?
Pain rating of 2 or 3 on a scale of 0 to 10
A peripherally placed needle for intermittent infusion of antibiotics is a potential site for infection. When assessing the infusion site, the nurse should look for what signs of infection?
Redness and drainage around the insertion site of the needle
A client who experienced a stroke and developed left-sided paralysis is learning how to dress independently. What is the proper technique for upper extremity dressing?
Placing the affected arm in the shirt before the unaffected arm
A client taking aspirin for arthritis reports experiencing adverse effects. What adverse effect indicates that a decrease in dose may be necessary?
Tinnitus
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"Would you like to meet with your family and your physician about this matter?"
When does a nurse use sterile technique?
When inserting an indwelling urinary catheter
While packing a client's abdominal wound with sterile, half-inch Iodoform gauze, the nurse drops some of the gauze onto the client's abdomen 2 inches away from the wound. What should the nurse do?
Discard the gauze packing and repack the wound with new Iodoform gauze.
The nurse is assisting with an exercise group for older adults who live in a retirement community. Which statement is appropriate for the nurse to make to this group of clients?
If you have arthritis, exercise your affected joints to the point of discomfort.
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
Abnormally low hematocrit and hemoglobin levels
The nurse is caring for a client who just had surgery. What's the nurse's highest priority?
Maintaining a patent airway
A client receives fentanyl through an epidural catheter for control of postoperative pain. The nurse should observe for which common adverse effect?
Pruritus
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Increase the I.V. rate, and continue to reassess vital signs and urine output hourly.
Which one of the following clients has the greatest risk for aspiration?
A stroke client with dysarthria
Several conditions may cause sexual dysfunction in men. Which condition represents one of the most common causes?
Diabetes mellitus
Hospice care is primarily geared toward which population?
Clients in the terminal stage of an illness
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Acceptance
Clients taking certain drugs should be cautioned against using them with alcohol. What are some of these drugs?
Aspirin, antihistamines, and sedatives
The nurse is caring for a client undergoing I.V. antibiotic therapy with gentamicin sulfate. Which of the following interventions is most important?
Monitor blood urea nitrogen (BUN) and creatinine levels, throughout the course of therapy
During the assessment of a geriatric client, a nurse would expect which findings?
Eye structure and visual acuity changes
A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should the nurse include in a bladder retraining program?
Assessing present elimination patterns
Which intervention has the highest priority when providing skin care to a bedridden client?
Keeping the skin clean and dry without using harsh soaps
The nurse is caring for a client with <i>Impaired gas exchange.</i> Which of the following outcomes is desired based on this nursing diagnosis?
The client has normal breath sounds in all lung fields.
The nurse is planning care for a client after a tracheotomy. One of the client's goals is to overcome verbal communication impairment. Which of the following interventions should the nurse include in the care plan?
Encourage the client to communicate by allowing him time to select or write words.
Which of the following nutritional deficiencies may delay wound healing?
Lack of vitamin C
The nurse must assess a client's splinted extremity for neurovascular damage. What should she do?
Compare capillary refill of both extremities, making sure it's the same bilaterally.
A client is admitted with a diagnosis of acute renal failure. The nurse should monitor closely for:
drug toxicity.
In a client who is having a myocardial infarction, which of the following assessment findings are typical?
Hypotension, rapid pulse, and chest pain
The nurse and assistant must put a rigid, comatose client back into bed. The client is currently propped up in a reclining chair that doesn't have removable arms. What is the best way to return the client to bed?
Use a mechanical lift.
The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit level in this client?
Volume overload
The nurse provides care for a client who experienced an extensive myocardial infarction. The client exhibits behavior characteristic of the denial stage of the grieving process. What should the nurse do?
Let the client know that the nurse is available to talk.
The client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. The nurse suspects the catheter is blocked. Which of the following nursing interventions is appropriate?
Use sterile technique when irrigating the catheter.
A client with coronary artery disease reports intermittent chest pain that occurs with exertion. The physician prescribes sublingual nitroglycerin. When teaching the client about nitroglycerin administration, the nurse should include which instruction?
Be careful after taking nitroglycerin because it may cause dizziness.
When should the client with type 2 diabetes take the oral antidiabetic agent glipizide?
30 minutes before breakfast
During a routine follow-up examination, the nurse updates the client's medication history. The client currently receives prednisone therapy. Which drug class increases the risk of peptic ulcer disease when taken with prednisone?
Nonsteroidal anti-inflammatory drugs (NSAIDs)
The nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?
Encourage the client to ambulate at least three times per day.
On a routine visit, the client asks the nurse if he can cut his large enteric-coated tablets in half. The nurse tells the client no because dividing the medication will:
alter the medication's absorption.
The nurse brings a client his prescribed antibiotic. The client tells the nurse that he usually takes a white tablet, not the yellow tablet in the medication cup. What should the nurse do?
Recheck the medication name and strength.
A client comes to the emergency department with chest pain. After an electrocardiogram shows a heart rate of 116 beats/minute with irregular beats, the client is admitted to the intensive care unit. Which nursing diagnosis is the priority?
Anxiety related to the threat of death
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Practice meticulous foot care.
The nurse is caring for a client with adult respiratory distress syndrome (ARDS). What is the most likely laboratory finding in the early stages of this disease?
Decreased partial pressure of arterial oxygen (Pa<font size="-2">O</font><font face="LWWSUB">2</font>)
The nurse provides care for a client with chronic obstructive pulmonary disease (COPD). The nurse understands that administering high doses of oxygen may produce what result?
Diminished respiratory drive
Conjunctivitis may be caused by bacteria, viruses, allergens, or irritants. What signs and symptoms differentiate bacterial conjunctivitis from other types?
Acute onset, moderate pain, and purulent discharge
What finding would lead the nurse to conclude that treatment for conjunctivitis was effective?
Purulent discharge is resolved.
A client arrives in the emergency department complaining of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?
Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin
What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
Deficient fluid volume
Peritoneal lavage is a diagnostic tool used to detect abdominal injuries. Which of the following is a contraindication for peritoneal lavage?
A distended bladder
The nurse instructs a client on diuretic therapy to eat foods high in potassium. The selection of which food indicates teaching is effective?
Potatoes
What does a positive Chvostek's sign indicate?
Hypocalcemia
The nurse is about to begin teaching a client how to perform tracheostomy care. What is the most important principle in client teaching that the nurse needs to utilize?
Determining the client's readiness to learn new information
The nurse is devising a teaching plan for a client diagnosed with type 1 diabetes. Which teaching method is most effective for teaching the client about self-administration of insulin?
A discussion and demonstration between the nurse and the client
The nurse is planning care for a client with M<font face="LWWSYM">e</font>ni<font face="LWWSYM">c</font>re's disease. Which nursing diagnosis takes highest priority?
Risk for injury related to vertigo
After stepping on a rusty nail in her backyard, a client comes to the emergency department for a tetanus immunization. Which bacterium is responsible for tetany?
Clostridium
The nurse is repositioning a client in bed. What should the nurse do to maintain proper body mechanics?
Stand with her feet apart.
The nurse must practice surgical asepsis when performing which procedure?
Indwelling urinary catheter insertion
The nurse is transferring a client from the bed to a chair. What action should the nurse take during client transfer?
Help the client dangle his legs.
A client is placed on a low-sodium diet. Which statement by the client indicates that the nurse's nutrition-teaching plan has been effective?
"I chose a baked potato with broiled chicken for dinner."
When following standard precautions, the nurse should perform which of the following measures?
Change gloves after each client contact.
The nurse is performing wound care. Which of the following practices violates surgical asepsis?
Pouring solution onto a sterile field barrier
The nurse places a client in isolation. Isolation techniques attempt to break the chain of infection by interfering with:
the transmission mode.
For a client who must undergo colon surgery, the physician orders preoperative cleansing enemas and neomycin (Mycifradin). What's the rationale for neomycin use in this client?
To decrease the intestinal bacteria count
The nurse is demonstrating how to clean dentures to a nursing assistant. What should the nurse teach the nursing assistant to do?
Place a washcloth in the sink to prevent damage if the dentures are dropped.
The nurse is about to give a back rub to a client after a complete bed bath. How should the nurse proceed?
Massage gently in areas directly over pressure points.
The nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates that teaching has been effective?
"I'll eat plenty of fruits and vegetables."
The nurse wants to help a client maintain healthy skin. Which nursing intervention will help achieve this goal?
Keeping the client well-hydrated
The nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?
Applying knee splints
An obese client is admitted to the hospital for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client?
Teaching the client alternative ways to lose weight
The nurse is teaching a client with allergies how to prevent anaphylaxis. Which recommendation is most appropriate?
Wear medical identification.
The nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?
Encouraging intake of at least 2 qt (2 L) of fluid daily
The nurse is caring for a client who just underwent a colectomy. What should the nurse do to prevent postoperative thrombus formation in the legs?
Encourage the client to dorsiflex and plantar flex the feet.
A client is scheduled for an appendectomy. The nurse must teach the client about incision splinting and leg exercises. When is the best time for the nurse to provide teaching?
Before the surgical procedure
The nurse is providing postoperative care for a client who has had spinal anesthesia. The nurse should place the client in which position?
On the left side in Sims' position
The nurse is caring for a client who is unconscious. How should the nurse position the client?
On his side, with the head of the bed elevated
The nurse is caring for a client admitted with an acute head injury. The client has stabilized and is ready to begin rehabilitation. When transferring the client from his bed to a chair, what should the nurse do to ensure client safety?
Lock the brakes on the bed
The nurse is caring for a 45-year-old male client admitted with a retinal detachment in his left eye. What symptoms would the nurse expect to find during assessment?
Flashing lights in the visual field
The nurse is planning care for a client with retinal detachment. The client has both eyes patched but is alert and oriented. What measure should the nurse include in the care plan to promote safety?
Placing the call bell within the client's reach and making sure he knows how to use it
The nurse provides care for a client with a detached retina who has both eyes patched. When communicating with the client, the nurse should:
identify herself every time she enters the room.
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I'll lie face down with my head turned to the left.
The nurse is collecting data on a 32-year-old client with otosclerosis. The nurse should be aware that the client's hearing loss:
affects both ears.
The nurse is caring for a client with otosclerosis scheduled to undergo a stapedectomy. The client asks the nurse when her hearing will improve. Which response by the nurse is most appropriate?
"It may take as long as 6 weeks for your hearing to improve."
The nurse is caring for a client who underwent stapedectomy. To prevent postoperative complications, the nurse should instruct the client to:
sneeze with her mouth open.
The nurse is collecting data on a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?
Foul-smelling discharge from the penis
The nurse is caring for a male client with gonorrhea. The client asks how he can reduce his risk of contracting another sexually transmitted disease (STD). The nurse should instruct the client to:
wear a condom every time he has intercourse.
The nurse is caring for a client experiencing acute addisonian crisis. Which laboratory data would the nurse expect to find?
Hyperkalemia
The nursing care for the client in addisonian crisis should include which of the following interventions?
Placing the client in a private room
The nurse is administering captopril (Capoten) to a client with heart failure. Which assessment finding would prompt the nurse to withhold the next dose and notify the physician?
Hyperkalemia
The nurse is caring for a client who complains of lower back pain. Which instructions should the nurse give to this client to prevent back injury?
Stand close to the object you're lifting.
The nurse is caring for a client with lower back pain scheduled for myelography using a water-soluble contrast dye. After the test, the nurse should place the client in which position?
Head of the bed elevated 45 degrees
The nurse is planning care for a female client diagnosed with acute hepatitis A. What is the primary mode of transmission for hepatitis A?
Fecal contamination and oral ingestion
The nurse is teaching family members of a client with hepatitis A (HAV). Family members were exposed to the client and, therefore, should receive immunoglobulin (Ig). The nurse should tell the family members that Ig:
must be administered within 2 weeks of exposure.
The nurse is teaching a client with acute hepatitis about to be discharged to her home. Which activity guideline is most appropriate?
Maintain bed rest except for trips to the bathroom.
The nurse is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
Pallor, tachycardia, sore tongue
The nurse is teaching a client with pernicious anemia who requires vitamin B<font face="LWWSUB">12</font> replacement therapy. Which statement indicates that the client understands the treatment program?
"I'll need an injection of vitamin B<font face="LWWSUB">12</font> every month, for life."
The nurse is collecting data on a 38-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?
Vision changes
The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in an air-conditioned room.
The nurse is caring for a client with a fractured left femur. What signs indicate potential fat emboli?
Cyanosis, decreased Pa<font size="-2">O</font><font face="LWWSUB">2</font>
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Preparing the client for cast removal or bivalving of the cast
The nurse is caring for a postoperative client. What intervention should the nurse perform to prevent thrombophlebitis?
Applying a sequential compression device
The nurse is instructing a client about taking oral corticosteroids to control severe chronic asthma. Which statement indicates that the client understands his treatment plan?
"I'll tell my other health care providers that I'm taking a corticosteroid."
The nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?
Encourage plenty of fluids.
The nurse is teaching a women's group about ovarian cancer. Which woman is at the highest risk for this disease?
45-year-old woman who has never been pregnant
The nurse is caring for a client who just underwent cardiac catheterization through a femoral access site. Which nursing intervention should be included in the care plan for the next 8 hours?
Maintaining pressure over the femoral access site
The nurse is teaching a client about the use of sublingual nitroglycerin. Which statement indicates the client understands the teaching plan?
"I'll keep the nitroglycerin in its original dark, airtight container."
The nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to:
advance both crutches first.
The nurse is caring for a 74-year-old client with chronic open-angle glaucoma. After the nurse administers pilocarpine (Pilocar), the client reports blurred vision. Which nursing action is most appropriate?
Explaining that this is an expected adverse effect
The nurse is caring for a client with glaucoma who has gradually lost his eyesight. When assisting the client with ambulation, the nurse should walk:
slightly in front of the client offering an elbow for the client to hold.
The nurse is assessing a client diagnosed with appendicitis. Which of the following signs or symptoms should the nurse expect to find?
Rebound tenderness, McBurney's sign, low-grade fever
The nurse is assessing pain in a client with appendicitis. Which initial statement or question by the nurse will be most effective in eliciting information?
"Tell me how you feel."
The nurse is providing preoperative care to a client scheduled for an appendectomy. Which statement regarding pain control is most appropriate?
"Take your pain medication before your pain becomes intense."
The nurse is admitting a client with tuberculosis who is coughing. To minimize the transmission of tuberculosis, which nursing measure is most appropriate?
Wearing an N95 disposable respirator mask when entering the client's room
The nurse is caring for a client with tuberculosis. The client's wife has a positive reaction to purified protein derivative (PPD) skin testing but doesn't have active tuberculosis. What treatment would the nurse expect to administer?
Isoniazid (INH) for six months
The nurse is caring for a client on a regimen of four medications to treat tuberculosis. The nurse discovers that the client isn't taking all of his medications. Which is appropriate for the nurse to say to the client?
"Taking many medications can be difficult. Tell me about the difficulties you're having."
The nurse is performing a dressing change for a client with a red, granulating foot ulcer. Which of the following actions is part of this procedure?
Cleaning the wound with normal saline solution
The nurse is caring for a client with diabetes mellitus. When teaching the client about foot care, which instruction should the nurse provide?
Avoid hot water bottles and heating pads.
The nurse is assessing a client with hyperthyroidism (Grave's disease). What findings should the nurse expect?
Weight loss, nervousness, tachycardia
The nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect what complication?
Tetany
The nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?
Clay-colored stools
The nurse is caring for a client receiving spironolactone (Aldactone) to treat hypertension. Which instruction should the nurse give the client?
Avoid salt substitutes.
The nurse is caring for a client undergoing a cystoscopy to diagnose bladder cancer. Following the test, the client returns to his room. Which signs should alert the nurse to a potential complication?
Chills and tachycardia
The nurse is collecting data on an adult client's stage of psychosocial development. The nurse should consider:
the client's previous problem-solving strategies.
Which nursing action takes priority when admitting a client with right lower lobe pneumonia?
Elevate the head of the bed 45 to 90 degrees.
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The fluid level in the water-seal chamber fluctuates.
The nurse is assessing a client for signs of hypoxemia. Which of the following should the nurse interpret as a late sign of hypoxemia?
Diaphoresis
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"Increase fiber and fluids in your diet."
A male client who has had spinal anesthesia is under the physician's orders to lie flat postoperatively. When the client asks to go to the bathroom, the nurse encourages him to comply with the order. By complying, the client can avoid which complication?
Headache
The nurse is participating in a cancer-screening program for colorectal cancer. Which of the following clients presents the fewest risk factors for colon cancer?
A 60-year-old man who follows a diet low in fat and high in fiber
A client has severe pruritus from hepatitis B. Which of the following nursing measures would best enhance the client's comfort?
Providing sponge baths using tepid water.
A 46-year-old male client is admitted to the hospital with a suspected diagnosis of hepatitis B. He's jaundiced and complaining of weakness. Which of the following should the nurse include in the client's care plan?
Rest periods after small, frequent meals
A client receiving hemodialysis treatments has had surgery to form an arteriovenous fistula. Which of the following is most important for the nurse to be aware of when providing care for the client?
Taking a blood pressure reading on the affected arm can cause clotting of the fistula.
A 30-year-old teacher performs self-breast examinations monthly. Which of the following findings should she report promptly?
A hard, nontender mass in the upper outer quadrant of the left breast
A 42-year-old male complains of extreme fatigue and weakness after his first week of radiation therapy. Which of the following responses by the nurse would best reassure him?
"These symptoms usually diminish after therapy ends."
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The client requests that her family bring her makeup and a wig.
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Encouraging her to express her feelings and fears about her son's injury
A client is in the first postoperative day after a total laryngectomy and radical neck dissection. Which of the following is a priority goal?
Maintaining a patent airway
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Check the pharynx with a penlight for bleeding, and notify the physician.
The nurse is teaching a female client with osteoporosis about her prescribed diet. Which of the following foods is the best source of calcium?
1 cup of low-fat yogurt
An 83-year-old female client arrives at the emergency department after falling on the ice outside her senior citizens' housing facility. The admitting diagnosis is right hip fracture. Which of the following would be most important for the nurse to assess?
Neurovascular compromise
During afternoon rounds, the nurse finds a male client using a pencil to scratch inside his knee-to-toe cast. The client is complaining of severe itching in the ankle area. Which action should the nurse take?
Encourage him to avoid scratching, and notify the physician if severe itching persists.
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A head injury is suspected and she's being evaluated further.
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Establish unresponsiveness.
A client with heart failure develops pink frothy sputum, coarse crackles, and restlessness. Which of the following actions should the nurse take first?
Place the client in high Fowler's position.
A 74-year-old man with a history of heart failure is admitted to the telemetry unit. Which of the following parameters should the nurse closely monitor in assessing the client's response to a bolus dose of I.V. furosemide (Lasix)?
Hourly urine output
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Begin electrocardiogram (ECG) monitoring.
A 56-year-old male has a blood pressure of 146/96 mm Hg. Upon hearing the reading, he exclaims, "My pressure has never been this high. Will I need to take medication to reduce it?" Which of the following is the best response by the nurse?
"You'll need to have your blood pressure rechecked several times before making a diagnosis."
The nurse must plan care for a 28-year-old female admitted with a diagnosis of myasthenia gravis. Which of the following times would be most appropriate for procedures and care to be completed?
In the morning, with frequent rest periods
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Blurred vision, intention tremor, and urinary hesitancy
A client is being discharged after successful same-day cataract surgery. The nurse instructs the client about permitted activities and those to avoid. Which of the following activities is permitted?
Cooking
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Call the physician to report the vital signs.
A client with a neurogenic bladder is beginning bladder training. Which of the following nursing actions is most important?
Set up specific times for the client to empty his bladder.
A 58-year-old male is admitted for a wedge resection of the left lower lung lobe after a chest X-ray revealed a lesion. The client is anxious and asks if he can smoke. Which of the following statements by the nurse would be most therapeutic?
"You're anxious about the surgery. Do you see smoking as helping?"
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Notify the physician of the symptoms and request to draw a serum potassium level.
A male client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of severe pain in the surgical wound. Which action should the nurse take?
Assess the surgical site and affected extremity.
A client sustains a C5 spinal cord injury that results in quadriplegia. Several days after being moved out of the intensive care unit, he complains of a severe throbbing headache. What should the nurse do next?
Check the client's indwelling urinary catheter for kinks to ensure patency.
The nurse knows that a client has mastered the technique needed to correctly use an incentive spirometer when the client:
inhales slowly and deeply through the mouthpiece.
A client is receiving oxygen by way of a nasal cannula at a rate of 2 L/minute. How should the oxygen flow meter be set?
The line marked "2" should cut the ball in half.
An elderly client with pneumonia has a nursing diagnosis of <i>Ineffective airway clearance.</i> Which intervention would be most appropriate?
Monitor the need for suctioning every hour.
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The student has made little or no change in behaviors.
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition?
Monitoring the client's weight every day
Which behavior during dinner suggests a therapeutic response to pyridostigmine (Regonol) in a client with myasthenia gravis?
The client swallows food without difficulty.
A client who underwent abdominal surgery complains of abdominal pain that makes him feel "full and uncomfortable." Which assessment should the nurse perform first?
Assess patency of the nasogastric (NG) tube.
The nursing instructor evaluates a nursing student who's assisting a client on crutches. Which nursing behavior demonstrates safe practice for a client who's learning to walk with crutches?
Placing a walking belt around the client's waist
When caring for a geriatric client, the nurse should expect to find which normal age-related change?
Slowed reaction time
A client with Alzheimer's disease has a nursing diagnosis of <i>Risk for injury related to memory loss, wandering, and disorientation.</i> Which nursing intervention should appear in this client's care plan to prevent injury?
Remove hazards from the environment.
For a client who has had a stroke, which nursing intervention can help prevent contractures in his lower legs?
Attaching braces or splints to each foot and leg
A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety with the nurse. Which behavior indicates that the client accurately understands safety measures related to paralysis?
The client uses a mirror to inspect his skin.
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"It isn't a problem to rescind your DNR order. I'll let your physician know your wishes right away."
To treat cervical cancer, a client has had an applicator of radioactive material placed in her vagina. Which observation by the nurse indicates a radiation hazard?
The client receives a complete bed bath each morning.
A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF?
Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl
A client with nephritis is taking the diuretic furosemide (Lasix), as prescribed. Which client statement indicates an accurate understanding of client teaching about furosemide?
"I'll eat such foods as apricots, dates, and citrus fruits."
When a client's ventilation is impaired, the body retains which substance?
Carbon dioxide
The nurse is caring for a client with a chest tube. If the chest drainage system accidentally is disconnected, what should the nurse plan to do?
Place the end of the chest tube in a container of sterile saline.
A client with emphysema will be discharged in a few days. During a discharge teaching session, the nurse should instruct the client to avoid which possible exacerbation of the disorder?
Fumes
The nurse is caring for a 25-year-old client with end-stage testicular cancer who has been referred to hospice care. Which criterion excludes the client from hospice care?
The client entered a clinical trial through the National Cancer Institute.
Which medication should the nurse use to prevent infection in a client who has been burned?
Mafenide acetate (Sulfamylon)
Which nursing intervention helps prevent contractures in a client with burns on his legs?
Applying knee splints
The nurse is assisting with developing a care plan for a client with type A hepatitis. What is the main route of transmission of this hepatitis virus?
Feces
What data should the nurse collect to minimize the complications of myasthenia gravis?
Respiratory status
What should the nurse advise a young client to do to help prevent osteoporosis?
Consume at least 800 mg of calcium daily.
A client with a seizure disorder should be instructed to avoid which activity until the seizures are controlled by medication?
Swimming
The nurse is caring for a client with thrombocytopenia. What's the best way to protect this client?
Use the smallest needle possible for injections.
The nurse is using the Glasgow Coma Scale to help assess a client's level of consciousness (LOC). Which score on the Glasgow Coma Scale indicates a deep coma?
3
A 26-year-old client is diagnosed with a brain tumor. As the nurse assists him from the bed to the chair, the client begins having a generalized seizure. Which action should the nurse take first?
Assist the client to floor, place him in a side-lying position, and protect him with linens.
The nurse and a client have just discussed the client's recent diagnosis of hypothyroidism and its causes and effects. Which statement indicates that teaching was effective?
"Now I see. My clumsiness is caused by a hormone problem."
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Antacids
The nurse is collecting data on a client who comes to the clinic complaining of having a fever and chills for the past 2 days. Which findings suggest bacterial pneumonia?
Dyspnea and wheezing
The nurse is caring for a client who has just undergone a right nephrectomy. While evaluating the client for response to the surgery, the nurse should stay alert for which signs and symptoms of hemorrhage?
Weak, irregular pulse; cool, moist skin; and hypotension
A client with a spontaneous pneumothorax has a chest tube connected to a Pleur-evac drainage system and suction. Which of the following could cause a problem in the chest tube drainage system?
Blood clots in the drainage tubing
A client is recovering from a stroke and will be discharged in a few days. When helping to develop this client's discharge plan, the nurse should include which intervention?
Discuss home care needs with the client before the day of discharge.
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Data collection
A client with bladder cancer has had his bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude?
The pouch faceplate doesn't fit the stoma.
The nurse is collecting data on a client who sustained a head injury. Which findings suggest increased intracranial pressure (ICP)?
Restlessness, disorientation, pupil dilation, and projectile vomiting
Which laboratory test value is elevated in clients who smoke and therefore can't be used as a general indicator of cancer?
Carcinoembryonic antigen level
After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded?
The client reports bladder spasms and the urge to void.
An alcoholic client is hospitalized with cirrhosis of the liver. In this client, which data collection findings may be early signs of alcohol withdrawal?
Hand tremor, irritability, and anxiety
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Report these findings to the physician.
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The client keeps the drainage bag below the bladder at all times.
The nurse is planning postoperative care for a client who has received general anesthesia. During the immediate postoperative period, which nursing activity takes the highest priority?
Maintaining a patent airway
During rounds, a client admitted with gross hematuria asks the nurse about his diagnosis. To facilitate effective communication, what should the nurse do?
Provide privacy for the conversation.
The physician has ordered a condom catheter for a male client. While cleaning the client's perineal area, the nurse observes irritation, excoriation, and swelling of the penis. What should the nurse do next?
Inform the charge nurse of these findings.
A client comes into the clinic with pain and warmth in his big toe and reduced urine output. The physician suspects gouty arthritis. The nurse can expect the physician to confirm this diagnosis by ordering which diagnostic tests?
Synovial fluid analysis and serum uric acid level
Before administering morphine to reduce a client's pain, the nurse collects data on several parameters, including heart rate, blood pressure, and respiratory rate. Which assessment should the nurse perform 15 to 30 minutes after she administers the drug?
Pain level
The nurse is teaching a client how to use transcutaneous electrical nerve stimulation (TENS) to manage pain. Which client statement indicates an accurate understanding of its use?
"If I have a headache, nausea, or unpleasant sensations, I'll use my troubleshooting techniques."
A few days ago, a client underwent a urinary diversion procedure and now has a continent ileal reservoir (Kock pouch). Which action indicates that the client is coping with his altered body image?
The client combs his hair and puts on street clothes.
When collecting data on a client with primary stage syphilis, the nurse should expect to discover which finding?
Painless chancre
While a client is being prepared for discharge, his nasogastric (NG) tube becomes clogged. To remedy this problem and teach the client's family how to deal with it at home, what should the nurse do?
Irrigate the tube with cola.
The nurse is planning care for a client with burns on his upper torso. Which nursing diagnosis should take the highest priority?
Ineffective airway clearance related to edema of the respiratory passages
The nurse needs to administer medication as prescribed to a client with heart failure. What's the best way to verify the client's identity?
Check the client's medical record number and name on his identification bracelet.
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?
Less sneezing
During the acute phase of a burn, the nurse should collect data on which topic?
Circulatory status
A client with advanced cancer is about to begin hospice care at home. Which statement shows that the client understands the primary focus of hospice care?
"It will enhance the quality of my life."
The nurse is assigned to a client with infectious tuberculosis (TB). When assisting with creating a care plan for this client, how should the nurse plan to prevent disease transmission to other staff members?
Teach about safe disposal of tissues after coughing or sneezing.
A home health nurse is visiting a home care client with advanced lung cancer. While collecting data on the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?
Hypoxia
The anesthesiologist orders atropine for a client who will undergo cholecystectomy. Why is this drug administered preoperatively?
To reduce respiratory secretions
The nurse is caring for a client with deep vein thrombosis. She is monitoring for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?
Chest pain and dyspnea
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Poultry, red meat, and turnips
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Close the bed curtains and give the other nurse a sheet or bath blanket to cover the client.
What should the nurse do to prevent infection transmission when caring for a client with hepatitis A?
Put on gloves to empty the emesis basin.
For a client with diverticulosis, the nurse asks the dietitian for a list of foods that should be avoided to prevent complications. Which foods are likely to be on the list?
Cucumbers and fresh tomatoes
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Respiratory depression
At 8 a.m., the nurse collects data on a client who's scheduled for surgery at 10 a.m. During the data collection, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?
Notify the physician immediately of these findings.
The physician has ordered an enema of soap solution for an adult client. Which technique should the nurse use?
Hold the solution container no higher than 12<font face="LWWSYM">"</font> (30 cm) above the rectum.
When helping to plan nursing care to maintain skin integrity for an adult client, the nurse should remember which general guideline?
Keep skin clean and dry to prevent breakdown.
The nurse is administering morphine, as prescribed, to a client before surgery. Why is this medication given preoperatively?
To relieve anxiety
The nurse is conducting a preoperative teaching session with a client who's expressing concerns about a breast mass. In this session, the nurse should use which nonverbal technique?
Facing the client squarely
The nurse is teaching a client with diabetes mellitus about dietary restrictions. This client should be instructed to avoid which foods?
Pecan pie and vanilla ice cream
Before preparing a client for surgery, the nurse assists in developing a teaching plan. What's the primary purpose of preoperative teaching?
To reduce the risk of postoperative complications
The physician has told a client to check his pulse each morning before taking digoxin (Lanoxin). After the nurse teaches the client how to take a radial pulse, what client behavior indicates an accurate understanding of the technique?
The client uses his middle three fingertips to palpate the radial artery.
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Repeat the radial pulse assessment and obtain an apical pulse.
A client who has had a pacemaker inserted is ready for discharge. What information should the nurse include in her discharge instructions to the client?
Avoid exposure to magnetic resonance imaging (MRI) equipment.
The nurse is assigned to care for an elderly client diagnosed with labyrinthitis (inflammation of the inner ear). Which of the following should the nurse expect to occur in the client?
Sudden onset of incapacitating vertigo, usually accompanied by nausea and vomiting
The nurse is assigned to care for a client experiencing acute pain. Which change in vital signs should the nurse expect to find?
Tachycardia
The nurse is caring for an elderly client about to undergo paracentesis. What intervention should the nurse perform to prepare the client for the procedure?
Have the client void before the procedure.
The nurse is assigned to care for a client in the immediate postoperative recovery phase. Although all are important, which criteria take priority during monitoring?
Airway, respiratory rate and depth, other vital signs, and skin color
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Raise the bed to semi-Fowler's position.
A client with a history of duodenal ulcers tells the admitting nurse that he takes antacids once in a while to relieve the pain. Which statement by the client should be reported immediately?
"My bowel movements have been sticky and black."
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Constipation
The nurse is caring for a client who has just had a liver biopsy. Which nursing intervention is most applicable after the biopsy?
Keep the client on bed rest, lying on his right side.
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"It helps reduce swelling in the rectal area, which helps relieve the discomfort."
The nurse is assisting with the placement of a Levin's nasogastric (NG) tube in a 56-year-old client with alcoholic cirrhosis. What is the best way to determine whether the NG tube is in his stomach?
Apply suction to the tube with a bulb syringe and observe for the return of gastric contents.
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maintain drainage of bile from the common bile duct.
A client with advanced cancer of the mouth has a tongue that's swollen, necrotic, and seeping. Which nursing diagnosis should be a priority in planning care?
Ineffective airway clearance
A client has a colostomy in the descending colon after surgical removal of a tumor. Which of the following should the nurse anticipate when the client resumes a regular diet?
Formed, soft stools
The physician inserts a Miller-Abbott tube in a client with a suspected small-bowel obstruction who has been vomiting fecal-like material. Which intervention would the nurse expect to perform after insertion of the tube?
Ambulate the client and turn him from side to side every 2 hours.
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Assist the client in standing and using the urinal or toilet.
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Withhold the client's insulin, bring her a glass of orange juice, and report her findings to the head nurse.
A 21-year-old client recently has been diagnosed with type 1 diabetes. The client's receiving 5 units of regular insulin and 15 units of NPH insulin every morning before breakfast at 7 a.m. Which statement is correct?
The NPH insulin will begin to act in 1 to 1<font face="LWWSYM">r</font> hours and will peak in 4 to 12 hours (by mid-afternoon)
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Flushed cheeks, dry mouth, and acetone breath odor
A client with diabetes who had a stroke has right-sided paralysis and incontinence and is in the rehabilitation center. Which action should be the nurse's priority in caring for this client?
Wash the client's skin with soap and water, gently patting it dry.
A 55-year-old client with type 2 diabetes is obese and hasn't been successful at controlling his condition by diet alone. The physician has prescribed glipizide (Glucotrol). The nurse knows that glipizide is commonly used for type 2 diabetes because it:
stimulates the pancreas to secrete more insulin.
The nurse knows that dietary management is part of the treatment regimen for clients with diabetes. Which information should the nurse include in client-teaching sessions with clients who have diabetes?
Meals should be eaten at consistent times each day.
A female client has been diagnosed with hyperthyroidism. In planning her care, the nurse should give priority to which goal?
Providing adequate rest and sleep
A 35-year-old client is returned to his room after a thyroidectomy. Which nursing measure is most important on the evening of surgery?
Asking the client to say a few words to check his voice for tone and hoarseness
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Thin, easily damaged skin
During a shift report, the nurse is told that a postoperative client with diabetes is on a "sliding scale." What does the "sliding scale" indicate?
Administration of regular insulin is based on periodic blood glucose readings.
A 70-year-old client is admitted to the hospital after an episode of right-sided weakness, difficulty speaking, and blurred vision. The physician diagnoses a stroke in evolution. Why does the nurse ask the client to squeeze her hand?
To assess the client's ability to follow simple commands
A client has lost his ability to express words. The nurse should plan to:
provide opportunities for the client to repeat words and point to objects.
A 22-year-old client has a history of seizures. While the client's transported to the medical imaging laboratory for a brain scan, he cries out, his muscles become rigid, and he falls to the floor. What should the nurse do first?
Move furniture away from the client.
After a client experiences a generalized tonic-clonic seizure, what's the priority nursing action?
Check the client's vital signs and remove restrictive clothing.
The physician prescribes levodopa-carbidopa (Sinemet) for a client with Parkinson's disease to control symptoms. Which information should the nurse include while teaching the client about this drug?
Antiembolism stockings are useful to prevent orthostatic hypotension, which is an adverse effect of this medication.
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Turn the client on her right side and elevate the head of the bed 15 degrees.
The nurse is assisting the physician with a lumbar puncture. The client appears worried and anxious. After the procedure, which statement is most appropriate for the nurse to make?
"I want you to lie flat for awhile. I'll close the curtain, and perhaps you can rest. I'll be quiet when I check on you in a few minutes."
An 86-year-old female client with generalized arthritis arrives at the clinic for her regular checkup. The client takes aspirin several times per day. Because of the client's heavy use of aspirin, the nurse should gather information about:
easy bruising and reports of unusual bleeding.
A female client who fell while washing her windows has a fractured right ankle, requiring a cast. After assisting with the cast application, what instructions should the nurse give the client?
"Move the toes on your right foot for several minutes every hour."
A client with advanced cancer has been receiving chemotherapy and is experiencing stomatitis. To promote comfort and nutrition while the client's mouth is sore, the nurse should plan to speak with the client's family about:
rinsing the client's mouth with diluted hydrogen peroxide every 2 hours.
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"I can't give out information about a client without consent from the client or the client's legal guardian.
A client reports urinary frequency and burning. The physician diagnoses cystitis and prescribes co-trimoxazole (Bactrim DS). What should the nurse tell the client?
"Take the medication with 6 to 8 oz (177 to 237 ml) of water."
An 86-year-old female client has a fractured left hip. Her left leg is in Buck's traction while she's being prepared for a hip pinning. The nurse who's planning to insert an indwelling urinary catheter would:
instruct the client to deep-breathe during catheterization.
A client who is at risk for blood clots after bone surgery is to receive subcutaneous heparin. A multidose vial of heparin contains 20,000 units in 5 ml. How many milliliters should the nurse administer for an ordered dose of 5,000 units?
1.25 ml
A client has been admitted to the hospital with heart failure. On entering the room, the nurse notices that the client is having difficulty breathing. Which position would be the most appropriate to help the client's breathing?
Place the client in high Fowler's position.
A client is on the surgical unit after orthopedic surgery. The physician has ordered 8 mg of morphine I.M. for pain. The Tubex reads "MS gr 1/6 <font face="LWWSYM">=</font> 1 cc." How much should the nurse inject?
0.8 ml
The nurse knows that client teaching about hypertension has been effective when the client states:
"I shouldn't adjust my medication without my physician's advice."
A male client has arteriosclerosis with intermittent claudication. The nurse has worked with him to develop a walking program. Which client statement indicates that he understands the program?
"I should walk until pain occurs, then rest."
A client with pneumonia has a nursing diagnosis of <i>Ineffective airway clearance related to increased secretions and ineffective cough.</i> Which intervention would facilitate effective coughing?
Sipping water, hot tea, or coffee
The nurse is teaching a client how to perform deep-breathing and coughing exercises. Which technique is correct?
Take a deep breath and cough until the lungs are empty of air.
An elderly client becomes extremely agitated and attempts to remove his endotracheal tube. The physician orders physical restraints. Which action indicates that a nurse has correctly applied the restraints?
A quick-release knot is used to tie the restraint.
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Verify the dose against the physician's order in the client's medical record.
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Inform the pharmacy that the medication is unavailable, ask them to prepare it, and tell them that someone will pick it up immediately.
A client is prescribed digoxin (Lanoxin), 0.125 mg by mouth stat. The pharmacy dispenses digoxin 0.25 mg. The nurse promptly administers the medication and then realizes she administered the wrong dose. How should the nurse proceed?
Obtain vital signs and notify the physician and nursing supervisor immediately of the error.
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Inform the physician and request a social services consult.
The nurse is caring for a client who sustained a chemical burn in his right eye. She's preparing to irrigate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply:
Place absorbent pads on the client's shoulder area.
The nurse is caring for a client who sustained a chemical burn in his right eye. She's preparing to irrigate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply:
Wash hands and put on gloves.
The nurse is caring for a client who sustained a chemical burn in his right eye. She's preparing to irrigate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply:
Direct the solution onto the exposed conjunctival sac from the inner to outer canthus.
A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply:
Administration time of the last dose
A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply:
Client's pain level on a scale of 1 to 10
A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply:
Type of medication the client has been taking
A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply:
Effectiveness of previous dose of medication
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A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply:
Assist the client into Sims' position.
A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply:
Wash hands and put on gloves.
A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply:
Encourage the client to retain the solution for 5 to 15 minutes.
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Notify the client's primary physician.
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Cover the wound with saline-soaked sterile gauze.
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Assess and document the behavior that requires continued use of restraints.
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Tie the restraints in quick-release knots.
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Ask the client if he needs to go to the bathroom and provide range-of-motion (ROM) exercises every 2 hours.
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"Let's talk about your mother's illness and how it will progress."
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"You sound like you have some questions about your mother dying. Let's talk about that."
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"Tell me how you're feeling about your mother dying."
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Document the client's statement and the location, and type of injuries.
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Assist the client in developing a safety plan for times of increased violence.
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Provide the client with telephone numbers of local shelters and safe houses.
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Take a seat next to the client and sit quietly.
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Say to the client, "You're feeling upset about the news you received about the transplant."
The nurse is collecting data on a newly admitted client. When filling out the family assessment, who should the nurse consider to be a part of the client's family? Select all that apply:
All people the client views as family
The nurse is collecting data on a newly admitted client. When filling out the family assessment, who should the nurse consider to be a part of the client's family? Select all that apply:
People who provide for the physical and emotional needs of the client
A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate? Select all that apply:
Consider that nonverbal cues may have different meanings in different cultures.
A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate? Select all that apply:
Respect the client's cultural beliefs.
A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate? Select all that apply:
Ask the client if he has cultural requirements that should be considered during his care.
The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply:
Illness in one family member can affect all members.
The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply:
A family member may have more than one role in a family.
The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply:
The effects of an illness on a family depend on the stage of the family's life cycle.
The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply:
Changes in sleeping and eating patterns may be signs of stress in a family.
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Recommending community resources for adult day care and respite care
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Encouraging the spouse to talk about the difficulties of caregiving
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Asking whether friends can help with errands or provide short periods of relief
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Assess the client for allergies to penicillin.
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Administer the medication because the amount is within the dosing recommendations.
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Obtain a sputum culture before administering the medication.
The nurse is using the Z-track method of I.M. injection to administer iron dextran to a client with iron deficiency anemia. Which actions should the nurse take to give this injection? Select all that apply:
Confirm the client's identity before administering the iron dextran.
The nurse is using the Z-track method of I.M. injection to administer iron dextran to a client with iron deficiency anemia. Which actions should the nurse take to give this injection? Select all that apply:
Change the needle after drawing up the iron dextran.
The nurse is using the Z-track method of I.M. injection to administer iron dextran to a client with iron deficiency anemia. Which actions should the nurse take to give this injection? Select all that apply:
Before inserting the needle, displace the skin laterally by pulling it away from the injection site.
The nurse is using the Z-track method of I.M. injection to administer iron dextran to a client with iron deficiency anemia. Which actions should the nurse take to give this injection? Select all that apply:
Inject the iron dextran after aspirating for blood return.
The nurse is preparing to administer 4 units of regular insulin to a client with type 1 diabetes mellitus. Which supplies does the nurse need to perform the injection? Select all that apply:
Medication administration record