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Terms in this set (47)
While performing an admission assessment for a client with an exacerbation of asthma, the nurse learns the client has several food allergies. The most important nursing action in promoting this client's safety is to do which of the following?
a. place an allergy bracelet on the client's wrist
b. provide the dietitian with a list of the client's allergies
c. observe the client carefully for signs of anaphylaxis
d. have epinephrine available on the clinical unit
provide the dietitian with a list of the client's allergies
A client who works in carpentry is seen by the triage nurse. The client complains of severe right eye pain with a gritty sensation. When obtaining a history from this client, which question has the highest priority?
a. do you have any allergies?
b. what were you working with at the time the manifestations occurred?
c. were you wearing goggles or glasses at your job?
d. did you flush your eye at work?
did you flush the eye at work
A nurse is caring for a client who has undergone a hip arthroplasty. The nurse explains to the client that the purpose of an abduction pillow following arthroplasty is to do which of the following?
a. raise the bed linens off the client's feet preventing plantar flexion
b. keep the client's heels off the bed to prevent pressure ulcers
c. position the client off of the operative site while in bed
d. prevent dislocation of the hip during position changes or movement
prevent dislocation of the hip during position changes or movement
A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse the reason for having two chest tubes. The nurse's response is based on the knowledge that the lower chest tube is placed to do which of the following?
a. remove air from the pleural space
b. create access for irrigating the chest cavity
c. evacuate secretions from the bronchioles and alveoli
d. drain blood and fluid from the pleural space
drain the blood and fluid from the pleural space
A client who had a craniotomy is sitting in a chair with the nurse present in the room. While the client is sitting, he begins to experience a grand mal seizure. At this time, the most important nursing intervention is which of the following?
a. provide oxygen
b. turn the client onto his side
c. provide privacy
d. lower the client to the floor
lower the client to the floor
A nurse is caring for a client with thrombophlebitis who is receiving a continuous IV heparin drip and is also started on an IV antibiotic for a wound infection. When checking compatibility of these two medications, the nurse determines that the prescribed antibiotic is not compatible in the same IV as the heparin. The nurse should plan to do which of the following?
a. insert another IV line
b. turn off the heparin drip while the antibiotic is infusing
c. ask the provider to prescribe a different, compatible antibiotic
d. refuse to give the antibiotic
insert another IV line
A client in a community clinic tests positive on a Mantoux skin test but does not demonstrate active lesions on a chest x-ray. The provider prescribes tuberculosis (TB) prophylaxis for the client in the form of isoniazid (INH) therapy. In planning care for this client, the nurse will need to teach the client that isoniazid will have to be taken for which of the following time frames?
a. for the rest of the client's life
b. until the client has a negative sputum sample
c. daily for approximately 1 year
d. until the client has a non-reactive Mantoux
daily for approximately 1 year
A client is experiencing stomatitis as a result of chemotherapy and radiation therapy. Which statement made by the client indicates to the nurse that additional teaching is necessary?
a. I will use a soft toothbrush or toothette for oral care
b. I will use lemon and glycerine swabs after meals
c. I will remove my dentures except while eating
d. I will rinse my mouth frequently with hydrogen peroxide
I will use lemon and glycerine swabs after meals
A client arrives at the emergency department with fruity breath odor, dry mouth, and extreme thirst. The nurse should do which of the following?
a. Check the client's blood glucose using a glucometer
b. Check the client's oxygen level using a pulse oximeter
c. Check the client's deep tendon reflexes
d. Check the client's renal function laboratory values
check the client's blood glucose using a glucometer
A nurse is teaching a client how to perform a breast self examination. Which finding should the nurse instruct the client to report promptly to her provider?
a. Lumps that are mobile and tender upon palpation prior to a menstrual period
b. multiple round masses that are tender and found in both breasts
c. bilaterally darkened areolas
d. one non-tender, hard lump that is palpated in the upper-outer quadrant of the breast
one non-tender, hard lump that is palpated in the upper outer quadrant of the breast
A nurse is caring for a client who was diagnosed with cervical cancer and has a radioactive vaginal implant. The client questions the nurse in regard to the reason for insertion of an indwelling urinary catheter. Which of the following reasons is appropriate for the nurse to provide?
a. to prevent dislodgement of the implant
b. to prevent urine leakage
c. to make elimination easier
d. to provide a means to accurately measuring I&O
to prevent dislodgement of the implant
A nurse is admitting a client to the burn treatment center following the client's rescue from a house fire. Which assessment is the highest priority?
a. estimation of burn injury
b. characteristics of the cough and sputum
c. extent of edema formation
d. level of pain
characteristics of the cough and sputum
A nurse is preparing to make rounds after receiving report from the previous shift. Which of the following clients should the nurse see first? The client with
a. benign prostate hypertrophy (BPH) who reports dysuria
b. ulcerative colitis who reports diarrhea
c. emphysema who reports dyspnea
d. esophageal cancer who reports dysphagia
emphysema who reports dyspnea
An obese client who has decreased mobility secondary to osteoarthritis of the knees has been on a weight management program for 2 months. During the past week, the client regained 3 lb. In regard to the client's weight gain, an appropriate response by the nurse is which of the following?
a. you should try a little harder to stick to your diet
b. i see you've gained back 3 pounds this week
c. were there any issues last week that kept you from focusing on your diet?
d. you were doing so well. what happened?
were there any issues last week that kept you from focusing on your diet
A nurse is asked to assist in changing the bed linens of a client with acquired immune deficiency syndrome (AIDS) who has been incontinent of a formed stool. Prior to entering the room, the nurse first performs thorough handwashing then dons which of the following? Select all that apply:
d. hair cover
A client with type 1 diabetes mellitus has a capillary blood glucose reading of 48 mg/dL. Which of the following should the nurse expect to find?
a. Kussmaul respirations
c. decreased skin turgor
A client diagnosed with viral encephalitis secondary to West Nile Virus is admitted to the hospital for treatment. When developing a nursing care plan, which interventions are consistent with the client's diagnosis? Select all that apply
a. place the client on respiratory isolation
b. monitor vital signs every 4 hr
c. assess neurological status every 4 hr
d. assess of Brudzinski's sign
e. implement seizure precautions
monitoring vital signs every 4 hours
assessing neurological status every 4 hr
assessing Brudzinski's sign
implementing seizure precautions
A nurse is caring for a client with hypoparathyroidism. Because of the potential electrolyte disturbance associated with this diagnosis, the nurse should assess the client for evidence of which of the following?
a. elevated blood pressure
b. involuntary muscle spasms
c. cold intolerance
d. weight loss
involuntary muscle spasms
A provider is planning to remove a client's chest tube. Which instruction should the nurse give the client to ensure understanding regarding the removal procedure?
a. breathe in through pursed lips
b. take a deep breathe and hold it
c. exhale and bear gently
d. take shallow, rapid breaths
exhale and bear down gently
A client has left a used insulin syringe on the bedside table. At this time, the appropriate nursing action is to do which of the following?
a. cap the syringe and take to the puncture-proof sharps disposal container
b. have a nurse administer future injections for this client
c. explain to the client that the syringe should be disposed of in the bathroom trash can
d. place the uncapped syringe in the puncture-proof sharps disposal container
place the uncapped syringe in the puncture-proof sharps disposal container
A client who is admitted to the hospital after experiencing a tonic clonic seizure is scheduled for a routine electroencephalogram (EEG). In preparing the client for the EEG, the nurse should explain that the client will undergo which of the following?
a. remain NPO for 6 to 8 hr prior to the EEG
b. receive a sedative the night prior to the EEG
c. receive a thorough shampoo prior to the EEG
d. have no dietary restrictions prior to the test
receive a thorough shampoo prior to the EEG
A provider has ordered a client with diabetes to be discharged on a 2,000 calorie ADA diet. Which of the following actions should the nurse take first when developing a teaching plan for this client's diet?
a. obtain sample diabetic menus from the dietitian to give to the client
b. ask the client to identify the types of foods usually eaten and preferred
c. explore the client's feelings regarding changing all previous eating habits
d. advise the client to only buy foods labeled as diabetic
ask the client to identify the types of foods usually eaten and preferred
A nurse is teaching a client about transmission prevention of hepatitis A. By which of the following routes is hepatitis A transmitted?
a. nasal discharge
b. fecal/oral contamination
c. genital sexual contact
d. exposure to contaminated blood
A client is diagnosed with endocarditis following rheumatic heart disease. Which comment made by the client indicates to the nurse that she understands discharge teaching in relation to endocarditis?
a. I will force fluids to prevent dehydration
b. I will notify my doctor before I have invasive surgery or dental procedures
c. I will stay on a low-protein and low-potassium diet
d. I will wear a mask when I go out in crowds
I will notify my doctor before I have invasive surgery or dental procedures
A nurse is planning to teach a client with a history of urolithiasis with uric acid stones how to prevent development of stone in the future. Which of the following suggestions by the nurse would be appropriate to include? (Select all that apply)
a. take allopurinol as prescribed for gout
b. plant for moderate exercise several times a week
c. limit intake of foods high in protein and purine
d. drink 2 glasses of water at bedtime
e. avoid citrus juices
take allopurinol as prescribed for gout
plan for moderate exercise several times a week
limit intake of foods high in protein and purine
drink 2 glasses of water at bedtime
A nurse is providing teaching to a client recently diagnosed with systemic lupus erythematosus (SLE). Which statement made by the client indicates to the nurse an accurate understanding of the home management of SLE?
a. I will need to take prednisone when I am having an exacerbation of the disease
b. I'm thankful this condition only affects the skin because I will just need to stay out of the sun
c. A warm shower for 10 to 15 minutes every evening will really help to loosen up my joints
d. A mild fever is common with SLE and usually does not require medical intervention
I will need to take prednisone when I am having an exacerbation of the disease
A client questions the nurse concerning the usual course of multiple sclerosis (MS). Which of the following is an appropriate response by the nurse?
a. Each client is different; we cannot predict what will happen
b. I can see that you are worried, but it's too soon to predict what will happen
c. acute episodes are usually followed by remissions, which may last varying lengths of time
d. It's too early to think about the future; let's focus on the present and take one day at a time
acute episodes are usually followed by remissions, which may last varying lengths of time
A client is diagnosed with active pulmonary tuberculosis and begins a treatment regimen of rifampin (Rifadin) and ethambutol (Myambutol). The nurse should instruct the client to report which of the following adverse effects to the provider?
a. red-orange discoloration of body fluids
d. decreased visual acuity
decreased visual acuity
A low cholesterol diet is prescribed for a client who has recently suffered a myocardial infarction. The nurse understands that effective teaching has occurred if the client selects which of the following for a meal?
a. chicken breast and mashed potatoes
b. lobster and rice
c. steak and a tossed salad with blue cheese dressing
d. liver with onions and coleslaw
chicken breast and mashed potatoes
A nurse is caring for a client with arteriosclerosis. When reviewing the client's chart, which of the following factors should the nurse realize is associated with the development of arteriosclerosis?
a. cholesterol level is 195 mg
b. HDL serum levels are elevated
c. LDL serum levels are elevated
d. cholesterol level is 135 mg
LDL serum levels are elevated
A client with chronic renal failure is undergoing peritoneal dialysis. Which nursing measure will be helpful in promoting outflow drainage of the dialyzing solution?
a. turn the client from side to side
b. elevate the height of the dialysate bag
c. apply manual pressure to the client's lower abdomen
d. push the peritoneal catheter in approximately 1 inch further
turn the client from side to side
A client diagnosed with chronic lymphocytic leukemia has a platelet count of 18,000 cells/mL. An appropriate nursing intervention is to do which of the following?
a. avoid intramuscular injections
b. administer oxygen via nasal cannula
c. maintain a no visitors policy
d. provide meticulous oral hygiene every 3 to 4 hr
avoid intramuscular injections
A nurse is completing the evening assessment on a client in balanced skeletal traction who was admitted the previous evening for a fractured left femur. Which assessment finding should the nurse report to the surgeon?
a. swelling and bruising of the thigh
b. report of leg pain and at the pin site
c. dyspnea and chest petechiae
d. report of muscle spasms in the affected leg
dyspnea and chest petechiae
In preparation for a sigmoid colon resection, the nurse is giving the client instructions about the colostomy that will be performed. Which statement by the client will require further clarification?
a. Because most of my colon is still intact and functioning, my stool will be formed
b. My stoma will appear large at first, but it will shrink over the next few weeks
c. My colostomy will begin to function 2 to 4 days after surgery
d. My diet will have to change dramatically
my diet will have to change dramatically
A nurse is caring for a client admitted 3 days ago for debridement of a large, stage III pressure ulcer of the heel. The wound was surgically debrided yesterday and the nurse is preparing to perform post-op wound care today. Which action should the nurse perform prior to changing the dressing?
a. check the results of the wound culture obtained during surgery
b. obtain vital signs and compare to the client's previous values
c. assess the client's level of pain and medicate as needed
d. administer the prescribed IV antibiotic
assess the client's level of pain and medicate as needed
Supportive therapy provided by the nurse for a client during a sickle cell crisis would include which of the following?
a. scheduling frequent walks
b. applying cold compresses to painful joints
c. administering NSAIDS
d. encouraging the client to drink a lot of fluids
encouraging the client to drink a lot of fluids
A middle-adult assistive pesonnel (AP) is assigned to give a bath to a client with herpes zoster (shingles). The AP asks if this disease is contagious because there is an isolation sign on the client's door. Which response by the nurse would be appropriate at this time?
a. Adults have a natural immunity from casual exposure to children who have had chickenpox
b. You should have immunity from the varicella vaccination you received as an infant
c. You cannot get shingles if you have had chickenpox
d. If you have had chickenpox, then you can care for this client without concern
If you have had chickenpox, then you can care for this client without concern
A client diagnosed with emphysema is being prepared for discharge. Which instruction given by the nurse would be beneficial for improving the client's gas exchange?
a. teaching the client pursed lip breathing
b. encouraging the client to limit fluids to 1500 mL per day
c. demonstrating the proper technique for chest breathing
d. teaching home oxygen therapy at 5 L/min
teaching the client pursed lip breathing
When a nurse brings a hospitalized client with AIDS the morning dose of zalcitabine (Hivid), the client states, "I have this awful burning sensation in my fingers and toes. They are numb and tingling." What response by the nurse is appropriate at this time?
a. I'll just give you half of the prescribed dose this morning
b. Take the medication. It should begin to help the manifestations caused by AIDS soon
c. I'll hold the medication and notify your provider immediately
d. Let me know when the feelings subside, and I'll bring the medication back
I'll hold the medication and notify your provider immediately
A nurse is caring for a client who underwent a transurethral resection of the prostate (TURP) for benign prostatic hypertrophy (BPH). The client's bladder is continuously irrigated with saline via a three-way catheter PRN. Which of the following findings should be reported immediately to the provider?
a. an output less than the input coming from the catheter
b. report bladder spasms
c. drainage that resembles ketchup coming from the catheter
d. a report of feeling a strong urge to urinate
drainage that resembles ketchup coming from the catheter
In providing health teaching to a group of clients, it is important for the nurse to emphasize that melanoma is characterized by lesions that have which of the following appearances?
a. are predominantly one solid color
b. are symmetrical in shape
c. are less than 6 mm in diameter
d. have an irregular border
have an irregular border
Following a transient ischemic attack (TIA), a client is alert, slightly confused, and has a blood pressure of 204/102 mm Hg. The client is also incontinent of urine. In planning this client's care, which nursing action would be appropriate?
a. offer the client a bedpan every 2 hr
b. place an adult diaper on the client and check every 2 hr
c. request a prescription for an indwelling urinary catheter from the client's provider
d. ambulate the client to the bathroom every 4 hr
offer the client a bedpan every 2 hours
The client's arterial blood gas (ABG) levels are pH 7.5, pCO2 32, bicarbonate (HCO3) 24. The nurse interprets that the client is in which of the following?
a. respiratory alkalosis
b. metabolic acidosis
c. respiratory acidosis
d. metabolic alkalosis
A client has undergone a below the knee amputation (BKA) because of peripheral vascular disease. The provider prescribes a wet to dry dressing changes twice a day. The nurse knows that it is appropriate to perform these dressing changes using which of the following?
a. clean technique and nonsterile gloves
b. sterile technique and sterile gloves
c. sterile technique for the first week of post-op, then clean technique
d. mask and gown for all dressing changes
sterile technique and sterile gloves
Which nursing action is appropriate when trying to control epistaxis?
a. have the client lean forward and gently blow clots from the nose
b. instruct client to sit with head hyperextended
c. apply ice compress to the client's forehead and back of neck
d. pinch the soft portion of the nares for 10 to 15 mins
pinch the soft portion of the nares for 10 to 15 mins
A nurse is caring for a client with an upper gastrointestinal bleed who has an admission hematocrit of 24%. Prior to initiating a blood transfusion of whole blood, which of the following actions should the nurse take? Select all that apply
a. assess and document the client's vital signs
b. restart the IV with a 22-guage needle
c. verify the blood type and Rh to be given with another nurse
d. hang a bag of lactated Ringer's solution
e. change IV tubing to a set that has a filter
assess and document the client's vital signs
verify the blood type and Rh to be given with another nurse
change IV tubing to a set that has a filter
A nurse is caring for a client who has lost several pounds in the last few weeks due to an exacerbation of Crohn's disease. The client is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC line). Two days after starting the TPN, the client has developed excessive thirst, confusion, and an increased urine output. Due to these medications, the nurse plans to obtain which of the following from the client?
a. oral temperature
b. capillary blood glucose
c. blood pressure
d. pulse oximetry
capillary blood glucose
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