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Terms in this set (90)
a nurse is caring for a client with DKA. Which of the following laboratory findings should the nurse expect?
BUN 32
A nurse and an AP are caring for a client with bacterial meningitis. The nurse should give the AP which of the following instructions?
Wear a mask
A nurse is providing instruction to a patient with type 2 DM and a new prescription for metformin. which statement by the client indicates an understanding of the teaching.
I should take this with food.
A nurse in a providers office is assessing a client who has hypertension and takes propanolol. Which finding should indicate an adverse reaction to this medicine.
report of a night cough - indication of heart failure.
A nurse is caring for client with a leg cast and is returning demonstration. place in order the steps
The client should first place their body weight on the crutches. Next, they should advance the unaffected leg onto the stair. Third, they should shift their weight from the crutches to the unaffected leg. Last, they should bring the crutches and the affected leg up to the stair.
A nurse in an emergency department is caring for a client who is experiencing a thyroid storm. Which manifestations should the nurse expect?(SATA)
**Fever is correct.
Nonpitting edema is incorrect.
**Hypertension is correct.
**Tachycardia is correct.
Hypoglycemia is
incorrect.
a nurse is caring for a client who has anorexia, low grade fever, night sweats, and a productive cough. Which action should the nurse take first?
initiate airborne precautions
A nurse is caring for a client who has a closed head injuryand an intraventricular catheter placed. which finding indicates the client is experiencing increased intracranial pressure?
Flat jugular veins is incorrect.
A Glasgow Coma Scale score of 15 is incorrect.
**Sleepiness exhibited by the client is correct.
**Widening pulse pressure is correct.
**Decerebrate posturing is correct
A nurse is caring for a client who is having a seizure. Which intervention is the nurse priority?
Turn the patient to the side.
The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration.
a nurse is providing discharge instructions to a client who has a partial thickness burn on the hand. Which of the following instructions should the nurse include?
wrap the fingers individually
to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand.
a home health nurse is assigned to a to a client who was recently discharged from a rehabilitation center after experiencing a right hemispheric stroke. which neurologic deficits should the nurse expect to find when assessing the patient.
**Visual spatial deficits is correct.
**Left hemianopsia is correct.
**One-sided neglect is correct.
An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?
Urine specific gravity is 1.045
a nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which finding?
Dysphagia
a nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. the nurse should instruct the client that the medication provides relief by which of the following actions.
suppressing gastric acid production.
a nurse is providing discharge instrucitons to a a client following an upper GI series with barium contrast. Which of the following information should the nurse provide?
increase fluid intake.
a nurse is caring for a client with 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.
A nurse is caring for a client who has bilateral pneumonia and a KaO2 of 85%. the client has dyspnea with a productive cough and is using accessory muscles to breath. Which of the following actions should the nurse take first.?
place the patient in high fowlers.
a nurse is providing teaching to a client who is recieving chemotherapy and has a new prescription for epoetin alfa. which of the following client statements indicates understanding of the teaching?
I will monitor my blood pressure while on this medication.
a nurse in a providers offive is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew.
naproxen
a nurse is providint dietary teaching to a client who is postoperatie following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet?
12 almonds
Anurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching.
I am dieting to lose weight.
a nurse is caring for a client who has pancreatitis. the nurse should expect which of the following laboratory results to be below the expectation.
CALCIUM
A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis.
a nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. which of the following statements should the nurse identify as an indication that the client understands the teaching?
wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation.
a nurse is caring for a client who is undergoing hemodialysis to treat end stage kidney disease. the client reports muscle cramps and a tingling sensation in their hands, which of the following medications should the nurse plan to administer.
calcium carbonate
hypocalcemia is a manifestation of end stage kidney disease.
a nurse is reviewing the laboratory results of a client who has cirrhosis. which of the following lab values should the nurse expect?
elevated bili level
Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice.
a nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium sparing diuretic. which of the following information should the nurse include in teaching.
try to walk at least 3 times per week for exercise.
a nurse has recieved change of shift report for a group of clients. which of the following should the nurse assess first.
the client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual nitroglycerin tablet
a nurse is caring for a client with a potassium level of 3. which of the following assessment findings should the nurse expect?
hypoactive bowel sounds.
a nurse is caring for a client who has a new diagnosis of hyperthyroidism. which of the following is a priority assessment finding that te nurse should report to the provider?
blood pressure 170/80
a nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. which of the following prescribed medications should the nurse instruct the client to withhold for 48 hours prior to cardioversion.
Digoxin
Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion.
a nurse is caring for a client who has viral pneumonia. the clients pulse ox readings have fluctuated between 79% and 88% for the last 30 minutes. which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen.
nonrebreather mask
to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask.
a nurse is planning care for a client who has extensive burn injuries and is immunocompromised. which of the following precautions should the nurse include in the plan of care to prevent pseudomonas aeruginosa infection?
avoid placing plants and flowers in the patients room.
a nurse is caring for a client who has 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 has portal hypertension. the client is vomiting blood mixed with food after a meal. which of the following actions should the nurse take first?
obtain vital signs
a nurse is assessing a client who had extracorporeal shock wave lithotripsy 6 hours ago. which of the following findings should the nurse expect?
stone fragments in the urine
a nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching?
void before and after intercourse.
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?
respiratory paralysis
a nurse is caring for a client who has emphysema and is recieving mechanical ventilation. the client appears anxious and restless, and the high pressure alarm is sounding. which of the following actions should the nurse take first.
instruct the client to allow the machine to breath for them.
a nurse is planing care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. which of the following actions should the nurse include in the clients plan of care.
wear a lead apron while providing care.
a nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority?
tachycardia
a nurse is caring for a client who is postoperative following a total hip arthroplasty. which of the following laboratory values should the nurse report to the provider?
Hgb 8
a nurse in an emergency department is caring for a client who has full thickness burns covering 20% of their total body surface area. after ensuring patent airway and administering oxygen, which of the following items should the nurse prepare to administer first?
IV fluids
a nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. which of the following interventions should the nurse include in the plan.
monitor the clients temp every 4 hours.
a nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change?
i used to never worry about my feet, now i inspect them every day with a mirror.
a nurse is performing a dressing change for a client who is recovering from a hemicolectomy. when removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. which of the following actions should the nurse take first?
call for help
a nurse is caring for a client who has HIV. which finding indicates a positive response to the prescribed HIV treatment?
decreased viral load
a nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. to help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client to avoid?
aged cheese
what do the eyeballs look like of a patient with exophthalmos?
The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve.
a nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. which of the following interventions should the nurse include in the plan?
tell the client it is possible to return to similar previous levels of activity.
a nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. which of the following statements should the nurse include in the teaching?
cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine.
a nurse is caring for a client who is experiencing SVT. upon assessing the client, the nurse observes the following findings: heart rate 200 / min, blood pressure 78/40, and respiratory rate 30/min. which of the following actions should the nurse take.
perform synchronized cardioversion
a nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. which of the following statements by the client indicated n understanding of the teaching?
I am taking this medication to increase my energy level
it increases the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance.
a nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. which of the following information should the nurse include in the teaching?
you should void every 4 hours to decrease the risk of urinary retention.
a nurse is teaching a young adult male how to performtesticular self examination(TSE). which of the following instructions should the nurse include?
roll each testicle between the thumb and fingers.
a nurse is preparing to administer a unit of packed red blood cells to a client. which of the following actions should the nurse take?
remain with the client for the first 15 to 30 min of the infusion
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 supplements can interfere with the effectiveness of this medication?
calcium
a nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. the nurse should identify that which of the following findings requires further assessment.
history of asthma
greater risk of reacting to the contrast dye used during the procedure
a nurse in an ICU is assessing a client who has a traumatic brain injury. which of the following findings should the nurse identify as a component of cushings triad.
bradycardia
The other components of Cushing's triad are severe hypertension and a widened pulse pressure.
a nurse in a providers office is caring for a client who request sildenafil to treat erectile dysfunction. which of the following statements should the nurse make?
you can not use this if you are taking nitroglycerin.
a nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure ulcer. which of the following actions should the nurse take
use a 30ml syringe
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.
a nurse is teaching a client who has venous insufficiency about self care. which of the following statements should the nurse identify as an indication that the client understands the teaching?
i will wear a clean pair of graduated compression stockings each day
a nurse is caring for a client who is 8 hours postoperative following a craniotomy. which of the following actions should the nurse take?
place a pillow between the clients legs.
a nurse is performing a cardiac assessment for a client who had an MI 2 days ago. which of the following actions should the nurse take after hearing this sound?
listen to the client on their left side.
a nurse is caring for a client who has chronic glomerulonephritis with oliguria. which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis?
hyperkalemia
a nurse is providing preoperative teaching to a client who is scheduled for a open cholecystectomy. which of the following actions should the nurse take?
demonstrate ways to deep breath and cough.
a nurse is caring for a client who is recieving TPN. A new bag is not available when the current infusion is nearly completed. which of the following actions should the nurse take?
dextrose 10% in water
a nurse is providing teaching to a client who has IBS. which of the following instructions should the nurse include in the teaching?
increase fiber intake to 30G
a nurse in an emergency department is reviewing the providers prescriptions for a client who sustained a rattlesnake bite to the lower leg. which of the following prescriptions should the nurse expect?
opioid analgesic
to promote comfort following a rattlesnake bite.
a nurse is providing teaching to a female client who has a history of urinary tract infection. which of the following information should the nurse include in the teaching?
take daily cranberry supplements
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 findings is an adverse effect of this medication?
hypokalemia
a nurse is assessing a client who has had a plaster cast applied to their left leg 2 hours ago. which of the following actions should the nurse take?
check that one finger fits between the cast and the leg.
a nurse is caring for a client who is recieving morphine for daily dressing changes. the client tells the nurse "I don't want anymore morphine because i don't want to become addicted". which of the following actions should the nurse take?
instruct the client on alternative therapies for pain reduction.
a nurse is reviewing the health record of a client who is scheduled for allergy skin testing. the nurse should postpone the testing and report to the provider which of the following findings?
current medications
ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens
a nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit.
heart rate 110
a nurse is caring for a client who has a prescription for enalapril. the nurse should identify which of the following findings as an adverse effect of the medication?
orthostatic hypotension
a nurse is caring for a client who is experiencing a tonic clonic seizure. which of the following actions should the nurse take?
loosen restrictive clothing
a nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. which of the following instructions should the nurse include?
remind the patient to scan to look over their complete range of vision during ambulation.
a nurse is caring for a client who presents to a clinic for a 1 week follow up visit after hospitalization for heart failure. based on the info in the clients chart, which of the following findings should the nurse report to the provider?
heart rate 55
know where to palpate for an inguinal hernia
C. top of pelvic area.
a nurse is caring for a client who is on bedrest and has a new prescription for enoxaparin subcutaneous. which of the following actions should the nurse take?
inject the medication into the anterolateral or posterolateral abdominal wall
a nurse in an emergency department is assessing a client who has a detached retina. which of the following should the nurse expect the client to report?
its like a curtain closed over my eye.
a nurse is caring for a client who has a stage III pressure injury. which of the following findings contributes to delayed wound healing?
urine output of 25ml
a nurse is caring for a group of clients. the nurse should plan to make a referral to physical therapy for which of the following clients?
patient recieving preoperative teaching for a knee arthroplasty
a nurse is caring for a client who has a new prescription for TPN. the client is to recieve 2000 kcal per day. the TPN solutionhas 500 kcal/l. the IV pump should be set at how many ml/hr.
167
a nurse is teaching a class about client rights. which of the following instructions should the nurse include?
a client should sign an informed consent before recieving a placebo
a nurse in an acute care facility is caring for a client who is at risk for seizures.which of the following precautions should the nurse implement?
ensure the client has a patent IV
a nurse is teaching a client who has a family history of colo-rectal cancer. to help mitigate this risk, which of the following dietary alterations should he nurse recommend?
add cabbage to the diet.
high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.
a nurse is caring for a client 1 hour following a cardiac catheterization, the nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity, which of the following interventions is the nurse's priority?
apply firm pressure to the insertion site.
a nurse is assessing a group of clients for indications of role changes. the nurse should identify that which of the following clients is at risk for experiencing a role change.
a client with MS that is having difficulty ambulating
a nurse is preparing to admit a client with dysphagia. which item should be at the patients bedside?
suction machine
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