A nurse is providing teaching about hepatitis A for a group of adolescents. Which of the following should the nurse include in the teaching as increasing the risk of contracting hepatitis A? A nurse is caring for a client receiving total parenteral nutrition (TPN). The nurse observes that the bag of TPN solution has 50 mL remaining and no replacement bag is available. Which of the following actions should the nurse take? Initiate 500 mL of 10% dextrose solution A nurse is caring for a client who has COPD and who reports shortness of breath, cough, and fatigue. The client has thick mucus secretions. Which of the following nursing interventions is appropriate for the client? Administer guaifenesin as prescribed A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? Low back pain and apprehension A nurse is caring for a client newly diagnosed with diabetes mellitus. Which of the following findings indicates hypoglycemia? A nurse is providing discharge teaching to a client with an implantable cardioverter/defibrillator (ICD). Which of the following client statements indicates understanding of the instructions?
"I will tell my dentist that I have an ICD." A nurse is performing preoperative teaching for a client scheduled to have a right modified radical mastectomy. Which of the following should the nurse include in the client's plan of care? Presence of one or more surgical drains A nurse is caring for a client who has an arteriovenous fistula for dialysis. Which of the following requires intervention by the nurse? Numb fingers distal to the fistula "If I miss my morning dose, I should wait until the next day to take a pill."
A client who forgets a dose of digoxin may take it a few hours later. There is no need to wait until the next day A nurse is caring for a client who has hypothyroidism. The nurse should monitor for which of the following findings? A nurse is providing care to a client in the PACU immediately following a coronary artery bypass graft (CABG). Which of the following interventions should the nurse implement during the immediate postoperative period? Assess for a decrease in the client's temperature A client with a tracheostomy requires suctioning. Which of the following actions by the nurse is appropriate for this procedure? Preoxygenate the client for at least 30 seconds A nurse is obtaining a medication history from a client who tells the nurse he is taking sildenafil, which he bought on the Internet. The nurse should instruct the client to discontinue the use of sildenafil if he also is taking which of the following medications? A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.) Sleepiness exhibited by the client A nurse is caring for a client who is receiving chemotherapy. Which of the following assessment findings should the nurse report to the provider? Temperature of 38.3° C (100.9° F) A nurse is reviewing the laboratory findings of a client who has rheumatoid arthritis. After visiting the provider 1 month ago, the client reports increased joint pain. Which of the following laboratory findings should the nurse anticipate? Increased erythrocyte sedimentation rate A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload? A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to the audio clip. (Click on the audio file.) A nurse is caring for a client with HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects understanding of the teaching? "My joints ache because I have Lyme disease." A nurse is assessing a client who is diagnosed with rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? Alternate application of heat and cold to affected joints A nurse is providing teaching to a client who has altered venous circulation of the lower extremities and has a new prescription for elasticized bandages to wear when awake. Which of the following statements by the client indicates a need for further teaching? "I will cover my toes with the bandage." A nurse is caring for a client who recently had a stroke of the right hemisphere. Which of the following manifestations is consistent with this diagnosis? A nurse is assessing a client who had a transurethral resection of the prostate (TURP) 12 hr ago. Which of the following should the nurse identify as the priority finding? The client has concentrated red urine with intermittent clots A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin once daily. Which of the following statements by the client indicates an understanding of the teaching? "I should take this medication with a meal." A nurse is caring for a client who is experiencing an anaphylactic reaction to latex. After ensuring a patent airway, which of the following actions should the nurse take next? Administer oxygen via a non-rebreather mask A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? Use crutches with rubber tips A nurse is assisting a provider with a cholinesterase inhibitor test for a client who was previously diagnosed with myasthenia gravis. After administration of the cholinesterase inhibitor, the client demonstrates increased muscle weakness and twitching. The nurse concludes that the client is exhibiting which of the following conditions? A nurse in the emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? "It's like a curtain closed over my eye." A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor? A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following is the priority assessment finding? Increased respiratory secretions A nurse is caring for a client who is malnourished. Upon review of the client's medical record, which of the following findings places the client at risk for skin breakdown? A nurse is planning to administer platelets to a client who has thrombocytopenia. Which of the following images indicates appropriate tubing for the nurse to use when administering platelets? This image is a platelet administration set with a smaller filter to prevent trapping of platelets, a second filter to remove WBCs, and shorter tubing to decrease platelet adherence to the lumen. A nurse is providing teaching to a client who has just received a new hearing aid. Which of the following responses by the client indicates understanding? "I may have the most difficulty with background noises." A nurse is providing education to the family of a client who has tuberculosis (TB). Which of the following is important to include? Family members in the household should undergo TB testing A nurse is caring for a client who has a pacemaker in synchronous mode. Which of the following findings indicates the pacemaker is functioning appropriately? The pacemaker discharges to maintain the programmed heart rate A nurse is caring for a client who had an open thoracotomy with chest tube insertion. Which of the following actions should the nurse take? The nurse should keep the collection chamber below chest level to allow drainage by gravity A nurse is caring for a client who has portal hypertension. The client had vomiting of blood mixed with food after a meal. Which of the following actions should the nurse take first? When caring for an older adult client with pain, which of the following should the nurse consider regarding pain management? Ibuprofen may cause gastrointestinal bleeding in older adults A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following could interfere with the absorption of the medication? A nurse is caring for a client who had a gastrectomy 5 days ago. Which of the following interventions will assist in the prevention of dumping syndrome? Instruct the client to lie in a supine position after meals A nurse is caring for a client who has an ileostomy and is 4 weeks postoperative. The client reports leakage and irritation around the stoma. Which of the following is an appropriate intervention? Instruct the client to use a skin barrier when refitting the pouch system A client has been receiving propranolol hydrochloride 40 mg PO daily for hypertension. Which of the following findings indicates the client is experiencing an adverse reaction to this medication? A nurse is caring for a client who is receiving morphine via a PCA pump. The nurse should monitor the client for which of the following? A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following should the nurse include when instructing the client? "Take insulin even if you are unable to eat your regular diet." A nurse is caring for a client who has full-thickness burns of the arm and is in the rehabilitation phase of recovery. Which of the following is the priority nursing intervention during rehabilitation? Encourage use of the affected extremity A nurse is providing teaching for a client who is perimenopausal and has been prescribed hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? (Select all that apply.) Calf pain A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following should the nurse recognize as an adverse effect of this medication? A nurse is performing discharge teaching for a client who has an above-the-knee amputation and a temporary prosthesis. Which of the following responses by the client indicates a need for further teaching? "I will make sure I have a soft mattress on my bed." A nurse is teaching a client who has a known allergy to bee venom and a prescription for a prefilled epinephrine injector how to respond in the event he is stung by a bee. Identify the sequence the client should follow The first thing the client should do is to inject the epinephrine to prevent anaphylaxis. Next, the client should remove the stinger and clean the area with soap and water to prevent further exposure to the venom. Next, the client should apply ice to decrease swelling. Finally, the client should receive medical treatment because the effects of the epinephrine are short-lasting and the client may have an anaphylactic reaction. A nurse is providing teaching to a client who has just been prescribed an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? "I will eat more high-fiber foods." A nurse is caring for a client who is scheduled for a total hip arthroplasty the next day. Upon review of the client's medical history, which of the following medications taken by the client should the nurse report to the provider? A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central venous catheter. Which of the following laboratory findings should the nurse report to the provider? Serum magnesium 1.1 mg/dL A nurse is caring for a client who is 1 day postoperative following a thoracotomy. Which of the following findings indicates a tension pneumothorax? A nurse is assessing a client who has peripheral vascular disease. Findings include respiratory rate of 16/min and oxygen saturation of 90%. Which of the following interventions should the nurse take first? Move the pulse oximetry probe to a different location A nurse is providing instruction about traveling for a client who has a new diagnosis of type 1 diabetes mellitus and is planning a trip by airplane. Which of the following should the nurse include in the teaching? Take additional pairs of shoes A nurse is providing teaching to a client who has AIDS. Which of the following client statements indicates that the teaching has been effective? "I should get an influenza vaccine every year." A nurse is planning to irrigate and dress a clean, granulating wound of a client who has a pressure ulcer. Which of the following actions should the nurse take? A nurse is caring for a client who is newly diagnosed with hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider? Blood pressure 170/80 mm Hg A client is receiving albuterol via a nebulizer for an acute exacerbation of asthma. The nurse recognizes that which of the following findings indicates the nebulizing treatment has been effective? A nurse is preparing to administer a blood transfusion to a client. Which of the following IV solutions should the nurse use for the transfusion? A nurse is assessing a client who has acute pancreatitis. Which of the following findings is the highest priority? A nurse is reviewing the medical record of a client who has osteomyelitis and is to receive a dose of gentamicin. Which of the following findings indicates the nurse should withhold the medication and notify the provider? A client who has an elevated serum creatinine level should not receive gentamicin because it is nephrotoxic. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following findings should indicate to the nurse the client's condition is improving? A nurse is caring for a client who is receiving continuous IV fluids through a saline lock located in the client's forearm. The client reports discomfort and coolness to the touch at the insertion site. Which of the following actions should the nurse take first? Compare the site to the opposite extremity A nurse is caring for a client during conscious sedation. For which of the following findings should the nurse intervene? The client has a pulse oximetry of 90%. A nurse is planning care for a client who has a small bowel obstruction and a nasogastric (NG) tube. Which of the following is appropriate for the nurse to include in the plan of care? Assess for the passage of flatus A nurse is caring for a client who has an arterial line. Which of the following actions is appropriate for the nurse to take? Place a pressure bag around the flush solution A nurse is caring for a client who has chronic kidney failure. The provider prescribes erythropoietin injections three times per week. Which of the following statements by the client indicates a need for further teaching about the effects of erythropoietin? "I will limit the amount of protein in my diet while taking this medication." A nurse is providing teaching on the use of a prednisone inhaler to a client who has asthma. The nurse should recognize the client needs further instruction if the client spaces the two puffs 15 seconds apart A nurse is assisting with the insertion of a nontunneled percutaneous central venous catheter (CVC) for a client who requires parenteral nutrition. Which of the following actions should the nurse take? Place the client in the Trendelenburg position A nurse observes a client in the hallway who is having a generalized tonic-clonic seizure. The client has become cyanotic. Which of the following nursing interventions is appropriate for this client? Turn the client onto her side A client is admitted to the emergency department with anxiety, loss of muscle coordination, and skin that is hot and dry. The client had been working in the yard prior to coming to the hospital. Which of the following actions should the nurse anticipate taking first? Place the client on a cooling blanket A nurse is admitting a client who has a hip fracture and will undergo hip replacement surgery in 48 hr. Which of the following prescriptions requires clarification by the provider? Apply 6.8 kg (15 lb) of weight to the skin traction A client newly diagnosed with heart failure is being discharged home with a prescription for a potassium-sparing diuretic. Which of the following should the nurse include in the discharge teaching? Try to walk at least three times per week for exercise A nurse is assessing a client who has pruritic macular rash and erythema over his trunk and forearms. While interviewing the client, which of the following questions should the nurse ask? "What medications are you currently taking?" A nurse is caring for a male client who has heart failure and has a prescription for digoxin. Which of the following findings indicates the client is at risk for digoxin toxicity? Serum creatinine 1.8 mg/dL A nurse is caring for a client receiving oxygen therapy for respiratory acidosis related to an exacerbation of asthma. Which of the following ABG values indicates a therapeutic response to the treatment? A nurse in the emergency department is assigned to triage clients from an external disaster. The nurse should place a red tag on which of the following clients? A client who has an incomplete amputation of the arm A nurse is caring for a client who is receiving peritoneal dialysis while resting in bed. The nurse notices the peritoneal fluid is sluggish in draining. Which of the following actions should the nurse take to facilitate drainage? Turn the client onto her side A nurse is caring for a client who is undergoing chronic renal dialysis. The client reports muscle cramps and a tingling sensation in his hands. Which of the following medications should the nurse plan to administer? A nurse is caring for a client who has bilateral pneumonia and a PaO2 of 80 mm Hg. The client is dyspneic with a productive cough and is using accessory muscles to breathe. Which of the following nursing interventions has the highest priority? Administer oxygen per nasal cannula A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values indicates a desired outcome for this therapy? A nurse is caring for a client who has pneumonia and has been prescribed incentive spirometry. Which of the following findings indicates the desired outcome of this intervention? The client has clear breath sounds in the lung bases bilaterally A nurse is obtaining a nursing history from a client who has suspected cholecystitis. Which of the following findings should the nurse expect? Vague pain radiating to the right shoulder A nurse is preparing to administer pentobarbital 3 mg/kg IV bolus to a client who weighs 110 lb. Available is pentobarbital injection 50 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number.) A nurse is preparing to perform gastric lavage for a client who has upper GI bleeding. Which of the following actions is appropriate for the nurse to take? Insert a large-bore nasogastric tube A nurse is caring for a client who is 2 hr postoperative following a traditional open approach cholecystectomy. Which of the following indicates the need for further nursing assessment? The client has unilateral swelling of a lower extremity |
A nurse in the emergency department is caring for a client who has myasthenia gravis
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