Med Surg Advanced Flashcards
A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?
a. Urticaria
b. Lymphedema
c. Headaches
d. Mouth sores
b. Lymphedema
A nurse is preparing to administer lactated Ringer’s via continuous IV infusion at 200 mL/hr. The IV tubing has a drip factor of 10/drops/mL. How many gtts/min should the nurse set the IV pump to administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
33
A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching?
a. “I should lie down when I take this medication.”
b. “I can keep my medication for 1 year before replacing it.”
c. “I should discontinue this medication if I develop a headache.”
d. “I can take up to five tablets in 15 minutes before seeking medical
attention. ”
a. “I should lie down when I take this medication.”
A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
a. “You should use an incentive spirometer every 8 hours.”
b. “You can cross your legs at the ankles when sitting down.”
c. “Clean the incision daily with hydrogen peroxide.”
d. “Install a raised toilet seat in your bathroom.”
d. “Install a raised toilet seat in your bathroom.”
A nurse is planning care for a client following a cardiac catherization. Which of the following actions should the nurse take?
a. Limit the client’s fluid intake to 1 L per day.
b. Change the client’s dressing every 8 hr.
c. Keep the client on bed rest for 24 hr.
d. Maintain he client’s affected extremity in extension.
d. Maintain he client’s affected extremity in extension.
A nurse is caring for a client who has a lower extremity fracture and prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change?
a. “I will need to have my partner take over shopping for groceries and cooking the meals for us.”
b. “I feel bad that I have to ask my partner to keep the house clean.”
c. “These crutches will make it impossible to care for my child.”
d. “It’s going to be difficult to tell my parents I can’t take them to their appointments anymore.”
a. “I will need to have my partner take over shopping for groceries and cooking the meals for us.”
A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?
a. “Wash your perineal area two times each day with antimicrobial soap.”
b. “Change the water in your drinking glass every 4 hours.”
c. “Change your pet’s litter box daily.”
d. “Wash your toothbrush in the dishwasher once each month.”
a. “Wash your perineal area two times each day with antimicrobial soap.”
A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client’s urinary output was 4,000 mL over the past 24 hr. The nurse should anticipate a prescription for which of the following IV medications?
a. Nitroprusside
b. Epinephrine
c. Furosemide
d. Desmopressin
d. Desmopressin
A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports a nagging dry cough. Which of the following responses by the nurse is appropriate?
a. “Sucking on a lozenge may reduce the frequency of your cough.”
b. “Increasing your daily fluid intake may eliminate your cough.”
c. “Your cough may require that you stop or change your medication.”
d. “Your cough should go away in time.”
c. “Your cough may require that you stop or change your medication.”
A nurse is taking an admission history from a client who reports Raynaud’s disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud’s?
a. Eating a strict vegetarian diet
b. Taking amlodipine for hypertension
c. Using a nicotine transdermal patch
d. A history of herpes zoster
c. Using a nicotine transdermal patch
A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first?
a. Clamp the catheter.
b. Turn the client to his left side.
c. Perform an ECG.
d. Obtain ABG values.
a. Clamp the catheter.
A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client’s skin is intact. Which of the following interventions should the nurse include in the plan of care?
a. Support bony prominences with pillows.
b. Turn and reposition the client every 4 hr.
c. Massage the reddened areas three times daily.
d. Apply an occlusive dressing.
a. Support bony prominences with pillows.
A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take?
a. Discuss recommendations for eating and swallowing techniques.
b. List strategies for family coping when dealing with possible role changes.
c. Give the client information about the local National Multiple Sclerosis Society.
d. Review the use of adaptive grooming devices to promote client independence.
b. List strategies for family coping when dealing with possible role changes.
A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? (Click the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
a. Obtain a sputum sample for culture.
b. Administer ondansetron.
c. Initiate airborne precautions.
d. Prepare the client for a chest x-ray
c. Initiate airborne precautions.
A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client risk?
a. Diet high in fiber
b. History of Crohn’s disease
c. Age 46 years
d. BMI of 24
b. History of Crohn’s disease
A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, “I’m not sure want to have a mastectomy.” Which of the following statements should the nurse make?
a. “I can give you additional information about the procedure.”
b. “You will be cancer-free if you have the procedure.”
c. “You should get a second opinion regarding the procedure.”
d. “I can give you a list of other people who had the same procedure.”
a. “I can give you additional information about the procedure.”
A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
a. Remain with the client for the first 15 to 30 min of the infusion.
b. Verify blood compatibility with another nurse.
c. Obtain the unit of packed RBCs from blood bank.
d. Obtain venous access using a 19-gauge needle.
e. Initiate transfusion of the unit of packed RBCs.
D,C,B,E,A
A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?
a. “I will have to wait 2 months before additional saline can be added to my breast expander.”
b. “I will perform strength-building arm exercises using a 15-pound weight.”
c. “I should expect less than 25 mL of secretions per day in the drainage devices.”
d. “I will keep my left arm flexed at the elbow as much as possible.”
c. “I should expect less than 25 mL of secretions per day in the drainage devices.”
A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow Coma Scale scores should the nurse assign the client?
a. 2
b. 5
c. 13
d. 10
b. 5
A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake 2 grams per day. Which of the following statements by the client indicates an understanding of the teaching?
a. “I can season my foods with garlic and onion salts.”
b. “I can drink vegetable juice with a meal.”
c. “I can have a frozen fruit juice bar for dessert.”
d. “I can have mayonnaise on my sandwiches.”
c. “I can have a frozen fruit juice bar for dessert.”
A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?
a. Collect information about the irritant that caused the injury.
b. Place a strip of pH paper onto the cul-de-sac of the affected eye.
c. Administer proparacaine eyedrops into the affected eye.
d. Instill 0.9% sodium chloride solution into the affected eye
d. Instill 0.9% sodium chloride solution into the affected eye
A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately?
a. SaO2 92%
b. Stridor
c. Rhonchi
d. Sore throat
b. Stridor
A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
a. Decreased serum amylase
b. Elevated blood glucose
c. Elevated serum calcium
d. Decreased erythrocyte sedimentation rate
b. Elevated blood glucose
A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?
a. Hypothermia
b. Urine specific gravity 1.001
c. BUN 15
d. Elevated blood pressure
b. Urine specific gravity 1.001
A nurse is planning care for a client who has a pulmonary embolism. Which of the following interventions should the nurse include?
a. Initiate a continuous IV heparin infusion.
b. Position the client on the left side.
c. Measure vital signs every 4 hr.
d. Instruct the client to massage the lower extremities.
a. Initiate a continuous IV heparin infusion.
A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include?
a. Limit alcohol intake to one drink per day.
b. Limit fluids to 1.5 L per day.
c. Avoid extremely hot or cold temperatures.
d. Avoid getting a flu vaccination.
c. Avoid extremely hot or cold temperatures.
A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first?
a. Insert a large-bore IV catheter.
b. Obtain a blood specimen for type and crossmatch.
c. Administer IV therapy.
d. Monitor urine output.
a. Insert a large-bore IV catheter.
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulations of the graft?
a. Normotensive blood pressure
b. Dilated appearance of the graft
c. Absence of a bruit
d. Palpable thrill
d. Palpable thrill
A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia?
a. Muscle weakness
b. Oliguria
c. Hypertension
d. Positive Chvostek’s sign
a. Muscle weakness
A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
a. Initiate a continuous IV insulin infusion.
b. Begin bicarbonate continuous IV infusion.
c. Administer 0.9% sodium chloride.
d. Check potassium levels.
c. Administer 0.9% sodium chloride.
A nurse is providing discharge teaching to a client who has ileostomy. Which of the following client statements indicates and understanding of the teaching?
a. “I will take a laxative when I’m constipated.”
b. “I will empty my bag when it is full.”
c. “I will expect my stools to be loose.”
d. “I will eat a high-fiber diet.”
c. “I will expect my stools to be loose.”
A nurse is caring for a client who is receiving total parenteral nutrition through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take?
a. Decrease the rate of infusion to last until the new bag is available.
b. Switch the infusion to a 10% dextrose solution.
c. Start an infusion of 0.45% sodium chloride solution.
d. Discontinue the infusion and flush the line.
b. Switch the infusion to a 10% dextrose solution.
A nurse is caring for a client who is 6 hr postoperative following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of the following electrolyte imbalances?
a. Hypocalcemia
b. Hypermagnesemia
c. Hypernatremia
d. Hypokalemia
a. Hypocalcemia
A nurse in a provider’s office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and the service animal?
a. Command the dog to sit while talking with the client.
b. Consult the client before approaching the dog.
c. Pet the dog briefly to demonstrate acceptance.
d. Offer the dog a bowl of water to demonstrate caring.
b. Consult the client before approaching the dog.
A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?
a. “I should take my daily aspirin on an empty stomach.”
b. “I should lie down before taking a dose of isosorbide dinitrate.”
c. “I should withhold my metoprolol if my heart rate is above 100 beats per minute.”
d. “I should place a nitroglycerin tablet under my tongue every 10 minutes for up to four doses.”
b. “I should lie down before taking a dose of isosorbide dinitrate.”
A nurse in the postanesthesia care unit is assessing a client following an appendectomy and finds a 2-cm (3/4-in) area if blood on the postoperative dressing. Which of the following actions should the nurse take?
a. Loosen the dressing.
b. Circle the drainage.
c. Apply a new dressing.
d. Apply pressure.
d. Apply pressure.
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement?
a. Maintain the client in supine position.
b. Empty water from the ventilator tubing daily.
c. Perform oral care every 2 hr.
d. Suction the client’s airway every 4 hr.
c. Perform oral care every 2 hr.
A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include?
a. Provide a diet of fresh fruits and vegetables for the client.
b. Limit visitation time for the client’s children to 40 min per day.
c. Clean the equipment in the client’s room once per week.
d. Apply new gloves when alternating between wound care sites.
d. Apply new gloves when alternating between wound care sites.
A nurse is providing teaching for a client who has tuberculosis and a new prescription for pyrazinamide. The nurse should instruct the client to notify the provider if which of the following effects occurs?
a. Jaundice
b. Polyuria
c. Weight gain
d. Hair loss
a. Jaundice
A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care?
a. Place a plate guard on the client’s meal tray.
b. Provide the client with a short-handed reacher.
c. Position the bedside table on the client’s left side.
d. Remind the client to use a cane on his left side while ambulating.
a. Place a plate guard on the client’s meal tray.
A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take?
a. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal.
b. Point the tip of the syringe toward the top of the ear canal.
c. Use cool fluid for irrigation.
d. Tilt the client’s head 45o.
b. Point the tip of the syringe toward the top of the ear canal.
A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
a. Sertraline
b. Methylprednisolone
c. Ondansetron
d. Diphenhydramine
c. Ondansetron
A nurse is preparing to discharge a client who has a halo device and is reviewing new prescription from the provider. The nurse should clarify which of the following prescriptions with the provider?
a. Take tub baths instead of showers.
b. May place a small pillow under the head when sleeping.
c. Increase intake of fiber-rich foods.
d. May operate a motor vehicle when no longer taking analgesics.
d. May operate a motor vehicle when no longer taking analgesics.
A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following information should the nurse include in the teaching?
a. “Your provider will discontinue your medications after 3 months of therapy.”
b. “You can drink alcohol after the first 6 weeks of treatment.”
c. “You should wear an N95 respirator mask when you are at home.”
d. “You will need to return in 2 weeks to provide a sputum specimen.”
d. “You will need to return in 2 weeks to provide a sputum specimen.”
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
a. Bradycardia
b. Frothy sputum
c. Jugular vein distention
d. Flushed skin
b. Frothy sputum
A nurse is planning care for a client who has osteoarthritis of the knees. Which of the following interventions should the nurse include in the plan?
a. Place a large pillow under the client’s knees when resting.
b. Apply an ice pack directly to the client’s knees.
c. Administer acetaminophen for pain management.
d. Avoid using a topical salicylate cream.
c. Administer acetaminophen for pain management.
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first?
a. Increase the client’s fluid intake.
b. Administer PRN pain medication.
c. Reposition the client in bed.
d. Check the client’s urine output.
d. Check the client’s urine output.
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which oof the following statements by the client indicates an understanding of the teaching?
a. “I use my heating pad on a low setting to keep my feet warm.”
b. “I rest in my recliner with my feet elevated for about an hour every afternoon.”
c. “I soak my feet in hot water before trimming my toenails.”
d. “I apply a lubricating lotion to the cracked areas on the soles of my
feet every morning.”
b. “I rest in my recliner with my feet elevated for about an hour every afternoon.”
A nurse in a provider’s office is teaching a client about the self- management of GERD. Which of the following instructions should the nurse include?
a. “Lie down for 30 minutes after each meal.”
b. “Eat a light meal 1 hour before bedtime.”
c. “Sleep with the head of your bed elevated 6 inches.”
d. “Increase your caloric intake by 250 calories per day.”
c. “Sleep with the head of your bed elevated 6 inches.”
A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
a. High-pitched sound on inspiration
b. Hypoactive bowel sounds
c. Loose tracheal secretions
d. Client report of pain at the incision site
a. High-pitched sound on inspiration
A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?
a. “The elastic bandage will prevent a postoperative wound infection.”
b. “The elastic bandage will prevent excessive edema.”
c. “The elastic bandage will keep you from seeing the surgical site.”
d. “The elastic bandage will keep the sutures from loosening.”
b. “The elastic bandage will prevent excessive edema.”
A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?
a. Examine the surgical incision for drainage.
b. Palpate pulses distal to the graft donor site.
c. Measure the client’s core body temperature.
d. Auscultate breath sounds.
b. Palpate pulses distal to the graft donor site.
A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?
a. “You will need three follow-up blood tests within a 24-month period.”
b. “You will need to be monitored for 15 minutes after receiving each medication dose.”
c. “You will need cryotherapy for 1 to 2 weeks.”
d. “You will need to take an antiviral medication 6 months.”
b. “You will need to be monitored for 15 minutes after receiving each medication dose.”
A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?
a. Reverse Trendelenburg
b. Feet elevated
c. High-Fowler’s
d. Side-lying
b. Feet elevated
A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?
a. Dark red granulation tissue
b. Light yellow exudate
c. Dry brown eschar
d. Wound tissue firm to palpation
a. Dark red granulation tissue
A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?
a. “I’ll insert the obturator after cleaning my stoma.”
b. “I’ll cleanse the cannula with half-strength hydrogen peroxide.”
c. “I’ll remove the soiled tracheostomy ties prior to cleaning my stoma.”
d. “I’ll cut a slit in a clean gauze pad to use as stoma dressing.”
c. “I’ll remove the soiled tracheostomy ties prior to cleaning my stoma.”
A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contraindication for receiving the medication?
a. Sodium 136 mEq/L
b. Creatinine 0.8 mg/dL
c. Potassium 3.2 mEq/L
d. BUN 18 mg/dL
c. Potassium 3.2 mEq/L
A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse?
a. Bilateral pupil diameter changes from 4 to 2 mm
b. Pulse pressure changes from 30 to 20 mm Hg
c. WBC count changes from 9,000 to 16,000/mm3
d. Glasgow Coma Scale score changes from 14 to 9
d. Glasgow Coma Scale score changes from 14 to 9
A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?
a. “I’ve been having problems with bladder control.”
b. “I have a hard time with brushing my hair.”
c. “I would rather be in a wheelchair than use a walker to get around.”
d. “I have difficulty swallowing food.”
b. “I have a hard time with brushing my hair.”
A nurse is providing discharge teaching to a client who will be self- administering insulin at home. Which of the following information should the nurse include regarding needle disposal?
a. “You can discard needles in an empty bleach bottle with a lid.”
b. “Remove the needle from the syringe before you place it in the trash.”
c. “Secure the cap tightly over the needle before you discard it.”
d. “Place your storage container in a recycle bin when it is full.”
a. “You can discard needles in an empty bleach bottle with a lid.”
A nurse is assessing a client who has an arteriovenous (AV) graft in the left forearm. Which of the following findings should indicate to the nurse a complication of vascular access?
a. Dilated appearance of the AV site
b. 2+ left radial pulse
c. Absence of a bruit
d. Presence of a palpable thrill
c. Absence of a bruit
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
a. Familiarize themselves with commonly use signed language.
b. Obtain a board that uses colored pictures as communication.
c. Request an interpreter during the initial assessment.
d. Ask a family member to be present during the admission.
c. Request an interpreter during the initial assessment.
A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?
a. Position the mouthpiece 2.5 cm (1 in) from the mouth.
b. Exhale slowly through pursed lips.
c. Hold breaths about 3 to 5 seconds before exhaling.
d. Place hands on the upper abdomen during inhalation.
c. Hold breaths about 3 to 5 seconds before exhaling.
A nurse is caring for a client who sustained a spinal cord injury in a diving accident. Which of the following actions should the nurse take?
a. Assess the client’s neurological status every 8 hr.
b. Log roll the client every 4 hr.
c. Provide the client with a low-fiber diet.
d. Monitor urine output hourly.
d. Monitor urine output hourly.
A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care?
a. Change the dressing every 24 hr.
b. Cleanse the site with povidone-iodine.
c. Use clean technique when changing the dressing
d. Flush the catheter using a 10-mL syringe.
d. Flush the catheter using a 10-mL syringe.
A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following actions should the nurse take first?
a. Check the color of the client’s skin.
b. Remove all of the client’s clothing.
c. Administer an opioid analgesic.
d. Prepare the client for peritoneal lavage.
b. Remove all of the client’s clothing.
A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?
a. Inform the client they might experience a low-grade fever.
b. Provide the client with sips of water.
c. Check the client’s gag reflex.
d. Instruct the client to report bleeding.
c. Check the client’s gag reflex.
A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching?
a. “Use peroxide to clean the mouthpiece of your inhaler.”
b. “Exhale fully before bringing the inhaler to your lips.”
c. “Depress the canister after you inhale.”
d. “Do not shake your inhaler before use.”
b. “Exhale fully before bringing the inhaler to your lips.”
A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick day rules. Which of the following statements by the client indicates an understanding of the teaching?
a. “I will monitor my blood glucose every 8 hours.”
b. “I will not take my diabetes medications while I am sick.”
c. “I will check my urine ketones if my blood glucose is greater than 240 mg/dL.”
d. “I will consume 250 grams of carbohydrates daily while I’m sick.”
c. “I will check my urine ketones if my blood glucose is greater than 240 mg/dL.”
A nurse is reviewing ABG results for a client who has COPD. Which of the following findings should the nurse expect?
a. pH 7.38
b. PaO2 85 mm Hg
c. PaCO2 48 mm Hg
d. HCO3 25 mEq/L
c. PaCO2 48 mm Hg
A nurse is admitting a client to a medical unit following placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse?
a. Presence of intrinsic P waves following QRS complex on the ECG
b. Hiccups
c. Sneezing
d. Presence of a sharp spike prior to the ORS complex on the ECG
b. Hiccups
A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold?
a. Valproic acid
b. Metformin
c. Fluticasone
d. Metoprolol
b. Metformin
A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?
a. Place the pillows under the client’s knees.
b. Apply compression stockings to the lower extremities.
c. Avoid use of anticoagulants.
d. Discourage leg exercises while in bed.
b. Apply compression stockings to the lower extremities.
A nurse is caring for a client who has a duodenal ulcer. Which of the following actions should the nurse take? (Click the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
a. Offer a snack before bedtime.
b. Administer the client’s naproxen prescription.
c. Restrict the client’s fluid intake to 1,000 mL/day.
d. Infuse packed RBC’s.
d. Infuse packed RBC’s.
A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse’s priority?
a. “I’ve noticed that there is a gray ring around the colored part of my eye.”
b. “In the last day, I have had a severe headache and pain around my right eye.”
c. “I’m having more difficulty telling the difference between blues and greens.”
d. “I can’t seem to get reading materials far enough away to see the words.”
b. “In the last day, I have had a severe headache and pain around my right eye.”
A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse anticipate?
a. Potassium 6.8 mEq/L
b. Creatinine 0.4 mg/dL
c. Hgb 20 g/dL
d. BUN 8 mg/dL
a. Potassium 6.8 mEq/L
A nurse is planning care for an older adult client who has Meniere’s disease. Which of the following interventions should the nurse include in the plan?
a. Limit the client’s fluid intake to 1,500 mL/day.
b. Administer aspirin if the client reports a headache.
c. Encourage the client to change positions slowly.
d. Perform range-of-motion exercises to the client’s neck every 4 hr.
c. Encourage the client to change positions slowly.
A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations? (You will find hit spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
Spot B at the top of abdomen left side
A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure?
a. Prepare the client for an intravenous pyelogram.
b. Insert a urinary catheter.
c. Initiate beta blocker therapy.
d. Administer IV fluids to the client.
d. Administer IV fluids to the client.
A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following actions should the nurse plan to take?
a. Complete the transfusion within 2 hr.
b. Slow the transfusion rate if the client reports itching.
c. Prime the IV tubing with 0.45% sodium chloride.
d. Administer through a 22-gauge IV catheter.
a. Complete the transfusion within 2 hr.
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
a. Increase phosphorus intake.
b. Decrease carbohydrate intake.
c. Increase potassium intake.
d. Decrease protein intake.
d. Decrease protein intake.
A nurse is caring for an older adult client who has dementia. Which of the questions should the nurse ask to assess the client’s abstract thinking?
a. “What do you understand about your condition?”
b. “Can you tell me the state where you were born?”
c. “Can you count backwards from 100 in intervals of 7?”
d. “What is meant by the saying, “Don’t beat around the bush?”
d. “What is meant by the saying, “Don’t beat around the bush?”
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
a. Instruct visitors to remain 3 feet from the client.
b. Discard the radioactive device in the client’s trash can.
c. Keep soiled bed linens in the client’s room.
d. Limit time for visitors to 2 hr per day.
c. Keep soiled bed linens in the client’s room.
A nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of the following actions should the nurse take?
a. Attach a dosimeter badge to the client’s gown.
b. Move the client’s soled linens to a designated container outside the room.
c. Place long-handled forceps at the client’s bedside.
d. Leave unused equipment in the client’s room until discharge.
a. Attach dosimeter badge to the client’s gown.
A nurse is teaching a client who has Graves’ disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
a. Hypotension
b. Decreased heart rate
c. Lethargy
d. Increase temperature
d. Increase temperature
A nurse in a clinic is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client what which of the following immunizations are recommended for healthy adults after age 60? (SATA)
a. Human papillomavirus.
b. Pneumococcal polysaccharide.
c. Influenza
d. Herpes zoster
e. Meningococcal.
b. Pneumococcal polysaccharide.
c. Influenza
d. Herpes zoster
A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding?
a. Weight gain
b. Loss of skin turgor
c. Hypotension
d. Bradycardia
a. Weight gain
A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse’s priority to include?
a. Admin phenytoin IV bolus to the client.
b. Provide the client O2 at 6 L/min using a nasal cannula.
c. Admin diazepam IV to the client.
d. Turn the client to the lateral position during seizure activity.
d. Turn the client to the lateral position during seizure activity.
A nurse is assessing a client who has a new diagnosis of type 1 DM. Which of the following findings indicate that the client is experiencing hypoglycemia?
a. Fruity odor to breath
b. Increased perspiration
c. Abdominal cramping
d. Dehydration
b. Increased perspiration
A nurse is caring for a client who is receiving epidural analgesia. Which of the following assessment findings is the nurse’s priority?
a. Hypotension.
b. Weakness to the lower extremities.
c. Hypoactive bowel sounds.
d. Bladder distention.
a. Hypotension.
A nurse is caring for a client following a cardiac catheterization who has hives and urticarial following the admin of IV contrast dye. Which of the following meds should the nurse plan to administer?
a. Spironolactone
b. Diphenhydramine
c. Desmopressin
d. Metoclopramide
b. Diphenhydramine
A nurse is caring for a client who is postop following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
a. Serosanguinous drainage.
b. Client report of incisional pain.
c. Client report of nausea.
d. Muscle twitching.
d. Muscle twitching.
A nurse is caring for a female client who is receiving TPN without fat emulsion. Which of the following findings should the nurse report?
a. Triglyceride 110 mg/dL.
b. Weight gain of 1.3 kg (3 lbs.) over the past 7 days.
c. Bowel sounds absent in lower quadrants.
d. Crackles in the bilateral lung bases.
d. Crackles in the bilateral lung bases.
A home care nurse is planning to use nonpharmacological pain relief measures for an older adult client who has severe chronic back pain. Which of the following guidelines should the nurse use?
a. Pain relief from the use of heat and cold continues for several hours
after removal of the stimulus.
b. Use imagery with clients who have difficulty with focus and concentration.
c. Discontinue opioids before trying nonpharmacological methods of pain relief.
d. Distraction changes the client’s perception of pain, but doesn’t affect the cause.
c. Discontinue opioids before trying nonpharmacological methods of pain relief.
A nurse in the PACU is assessing a client who is postoperative following general anesthesia. Which of the following findings is the priority to address?
a. Indistinct, rambling speech
b. Piloerection of the skin
c. Decreased body temperature
d. Vomiting upon arousal
d. Vomiting upon arousal
A nurse is caring for a client following a below the knee amputation. The client states, “My life is over.” Which of the following responses should the nurse make?
a. “Would you like to meet with another client who is an amputee?”
b. “You are upset. We can talk about this later.”
c. “Most people can adjust following this surgery.”
d. “Why do you think your life is over?”
d. “Why do you think your life is over?”
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?
a. Assist the client with toileting at least once every 4 hours.
b. Request a prescription for a nightly sedative.
c. Place the client’s bed at the lowest height.
d. Turn off all lights in the client’s room at night
c. Place the client’s bed at the lowest height.
A nurse is teaching about measures to prevent recurring UTIs with a female client. Which of the following info should the nurse include in the teaching? (SATA)
a. Take a warm bubble bath daily.
b. Drink 3 L of fluids daily
c. Drink low fructose cranberry juice
d. Void every 6 hours during the day.
e. Wipe the perineal area from front to back after urinating
b. Drink 3 L of fluids daily
c. Drink low fructose cranberry juice
e. Wipe the perineal area from front to back after urinating
A nurse is preparing a client for a lumbar puncture. Which of the following images indicates the position the nurse should assist the client into for this procedure?
Lateral recumbent or sitting upright
A nurse is reviewing ECG rhythm strips for a group of clients. The nurse should identify that which of the following rhythms indicate bradycardia?
slow rhythm, spaced out PQRST
A nurse is caring for a client who has a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation?
a. Remove the wedge divide when turning
b. Encourage the client to lean forward when attempting to stand
c. Place two bed pillows between the legs when in bed
d. Elevate the knees higher than the hips when sitting
c. Place two bed pillows between the legs when in bed
A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer. Which of the following actions should the nurse plan to take?
a. Insert a large bore nasogastric tube
b. Ensure that the client has a 22-gauge IV line in place
c. Administer nitroprusside IV based on the client’s weight
d. Provide ketorolac for abdominal pain
a. Insert a large bore nasogastric tube
A nurse is preparing to administer piperacillin 3.375 g by intermittent IV bolus every 6 hr. Available is piperacillin 3.375 g in dextrose 5% in water (D5W) 100 mL to infuse over 30 min. The nurse should set the IV pump to deliver how many mL/hr? Round to the nearest whole number
200
A nurse is caring for a client who has chronic renal failure. The client displays the following ABG results: pH 7.24, PaCO2 44 mm Hg, Pa02 84 mmHg, HCO3 18 mEq/L, base excess-2 and 02 saturation 95%. The nurse should conclude that the client has which of the following acid base imbalance?
a. Metabolic alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Respiratory alkalosis
c. Metabolic acidosis
A nurse is teaching a client who has endometriosis about adverse effects of leuprolide. Which of the following manifestations should the nurse include in the teaching?
a. Increased appetite
b. Hypoglycemia
c. Bone Loss
d. Pallor
c. Bone Loss
A nurse is providing teaching to a client who recently had a myocardial infarction and has a new prescription for nitroglycerin sublingual tablet to manage chest pain at home. Which of the following client statements indicates an understanding of the teaching?
a. I should wait 20 minutes between taking the tablets
b. I can keep the tablets in my plastic pill box
c. I should replace my open bottle of tablets every 6 months
d. I can take up to 4 tablets when I have chest pain
c. I should replace my open bottle of tablets every 6 months
A nurse is preparing to perform gastric lavage for a client who has a
bleeding gastric ulcer. Which of the following equipment should the nurse plan to use for the procedure?
Image of a rolled-up tube
A nurse is planning the discharge of a client who has an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy?
a. Diuretic
b. Antithrombotic
c. Anticonvulsant
d. Opioid analgesic
b. Antithrombotic
A nurse is planning care for an older adult client who has Meniere’s disease (vertigo). Which of the following interventions should the nurse include in the plan?
a. Administer aspirin if the client reports a headache
b. Encourage the client to change positions slowly
c. Perform range of motion exercises to the clients neck every 4 hours
d. Limit the client’s fluid intake to 1,500 mL/day
b. Encourage the client to change positions slowly
A nurse is assessing a client who has pericarditis. In which of the following areas of the client’s chest should the nurse place the stethoscope to best hear a pericardial friction rub?
a. IMAGE: The pericardial rub is best auscultated with the diaphragm of
the stethoscope over the left lower sternal border in end expiration
with the patient leaning forward. It has a rasping or creaking sound
similar to leather rubbing against leather.
A nurse is caring for a client who is experiencing a hypertensive crisis. Which of the following actions should the nurse take?
a. Place the client supine
b. Perform neurological assessments
c. Begin an IV bolus of lactated ringers
d. Initiate an IV dopamine infusion
b. Perform neurological assessments
A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change?
a. “I will need to have my partner take over shopping for groceries and cooking the meals for us”
b. “It’s going to be difficult to tell my parents i can’t take them to their appointments anymore”
c. “There crutches will make it impossible to care for my child”
d. “I feel bad that i have to ask my partner to keep the house clean”
a. “I will need to have my partner take over shopping for groceries and cooking the meals for us”
A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the clients abstract thinking?
a. “Can you count backwards from 100 in intervals of 7?”
b. “Can you tell me the state where you were born?”
c. “What is meant by the saying don’t beat around the bush?”
d. “What do you understand about your condition?”
c. “What is meant by the saying don’t beat around the bush?”
A nurse is reviewing discharge teaching with a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?
a. I will increase green leafy vegetables in my diet
b. I know this medication increase my risk for blood clots
c. I should avoid taking acetaminophen while taking this medication
d. I will return in 1 month to have my blood tested
d. I will return in 1 month to have my blood tested
A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take?
a. Instruct the client to avoid eating raw fruit
b. Move the client to a negative pressure room
c. Use contact isolation while providing care
d. Apply pressure to venipuncture sites for 10 min
a. Instruct the client to avoid eating raw fruit
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
a. The client reports a pain level of 7 on a scale from 0 to 10 at the
operative site.
b. The client has 100 mL blood in the closed suction drain
c. The clients capillary refill in the left toe is 6 seconds
d. The client has an oral temperature of 38.3 C (100.9 F)
c. The clients capillary refill in the left toe is 6 seconds
A nurse is providing teaching to a client who is receiving opioids for pain management. Which of the following information should the nurse include in the teaching?
a. Monitor urinary output for retention
b. Restrict fluid intake if you experience constipation
c. Itching indicates you are having an allergic reaction to the
medication
d. Avoid taking antiemetics with the medication
a. Monitor urinary output for retention
