Med Surg CMA Practice

Question 1

A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm. Which of the following actions should the nurse take?

Use contact isolation while providing care

Move the client to the negative pressure room

Instruct the client to avoid eating raw fruit

Apply pressure to venipuncture sites for 10 min.

Answer 1

Instruct the client to avoid eating raw fruit

Rationale: LOW WBC count can be caused by cancer or cancer treatment and can increase the risk of infection.

Question 2

A nurse is teaching a group of clients who have cancer about radiation therapy. Which of the following activities should the nurse include in the teaching?

Decrease intake of fresh fruits and vegetables

Limit engaging in sport activities that can cause bruising

Decrease time spent outdoors

Limit socializing in large crowds

Answer 2

Limit engaging in sport activities that can cause bruising

Rationale: Radiation can cause thrombocytopenia and increase the risk of bleeding. Increase fluid intake, eat a balanced diet that includes fresh fruits and vegetables, and protect their skin from sun exposure.

Question 3

A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer?

Desmopressin

Regular insulin

Furosemide

Lithium

Answer 3

Desmopressin

Rationale: Desmopressin is a synthetic form of ADH. ADH regulates water balance in the body. Desmopressin helps reduce urine output and prevent dehydration by mimicking ADH.

Question 4

A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

A client who has pancreatitis reports pain in the left shoulder

A client who has peritonitis reports generalized abdominal pain

A client who is postoperative reports incisional pain

A client who has angina reports

Answer 4

A client who has pancreatitis reports pain in the left shoulder

Rational: Referred pain is pain that is left in a location different from its source due to shared nerve pathways or central nervous processing. A client who has pancreatitis may experience pain in the left shoulder due to irritation of the diaphragm by pancreatic enzymes or inflammation.

Question 5

A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?

Take a laxative to prevent constipation

Monitor heart rate once daily

Drink 2 to 3 L of fluids daily

Take an antacid 30 min before taking the medication.

Answer 5

Drink 2 to 3 L of fluids daily

Rationale: Drinking plenty of fluids can help flush out bacteria from the UTI and prevent dehydration. Taking an antacid can reduce the absorption of ciprofloxacin and make it less effective. Taking a laxative can cause diarrhea, which can worse dehydration and electrolyte imbalance.

Question 6

A nurse is caring for a client who has an IV in the left forearm and who’s infusion pump has alarmed several times. Which of the following actions should the nurse take first?

Check the IV site for redness

Flush the IV catheter

Ensure the tubing connections are secure

Reposition the client’s left arm

Answer 6

Ensure the tubing connections are secure

Rationale:
Chat GPT says ensure the tubing connections are secure

Quizlet says check the IV site for redness

Question 7

A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing an MI?

ST Segment

QRS Duration

PR Interval

T Wave

Answer 7

ST Segment

Rationale: ST segment represents early ventricular re-polarization, which occurs after ventricular contraction and before ventricular relaxation. ST segment can be elevated or depressed in cases of MI, indicating ischemia or injury to the myocardium due to reduced blood flow or oxygen supply.

Question 8

A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing intervention?

Wash hands with alcohol-based hand rub

Clean surfaces with chlorhexidine

Place the client in a protective environment

Obtain a stool specimen with gloves

Answer 8

Obtain a stool specimen with gloves

Chat GPT says obtain a stool specimen with gloves

Question 9

A PACU nurse is monitoring the drainage from a client’s NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

75 ml of greenish-yellow drainage

100 ml of red drainage

150 ml of serosanguineous drainage

200 ml of brown drainage

Answer 9

100 ml of red drainage

Rationale: This could indicate active bleeding int he GI tract, which is a serious condition that needs immediate medical attention.
75 ml of greenish-yellow drainage: This is typical for NG tubes as it reflects bile and stomach contents.
100 ml of red drainage: Red drainage indicates active bleeding, which is a significant concern, especially in the immediate postoperative period.
150 ml of serosanguineous drainage: This is a mix of blood and serum and is usually expected after surgery as the body heals.
200 ml of brown drainage: This may indicate old blood or intestinal contents, which can be concerning but isn’t as urgent as active bright red bleeding.

Question 10

A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?

“You will need to increase your fluid intake to resolve this problem”

“This is an expected adverse effect of this medication”

“This finding may indicate possible medication toxicity”

‘Your provider will prescribe a different medication regimen”

Answer 10

“This is an expected adverse effect of this medication”

Rationale: This antibiotic is used to treat TB, can cause a harmless re-orange discoloration of body fluids, including urine, sweat, tears, and saliva.

Question 11

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 minutes after the following actions should the nurse take first?

Stop the infusion

Administer oxygen to the client

Collect a urine sample

Check the client’s vital signs

Answer 11

Stop the infusion

Rationale: The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency.

Question 12

A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, “ I’m not sure I want to have a mastectomy.” Which of the following statement should the nurse make?

“You should get a second opinion regarding the procedure”

“I can give you a list of other people who had the same procedure”

“I can give you additional information about the procedure”

“You will be cancer-free if you have the procedure”

Answer 12

“I can give you additional information about the procedure”

Rationale: You don’t tell patients what to do. You cannot guarantee positive outcomes to patients. You cannot disclose other patient’s information without their consent.

Question 13

A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2 gram sodium diet. Which of the following statements should the nurse identify as an understanding of the teaching?

“I should use salt sparingly while cooking”

“I can season my foods with lemon juice”

“I can use baking soda when I bake”

“I should used canned instead of frozen vegetables”

Answer 13

“I can season my foods with lemon juice”

Rationale:
“I should use salt sparingly while cooking”: Even small amounts of salt can quickly add up, so it’s better to avoid adding any salt during cooking on a sodium-restricted diet.
“I can season my foods with lemon juice”: This is correct because lemon juice adds flavor without adding sodium.
“I can use baking soda when I bake”: Baking soda contains sodium and should be avoided in a low-sodium diet.
“I should use canned instead of frozen vegetables”: Canned vegetables often contain added salt, while frozen vegetables usually do not have added sodium (as long as they are not in sauces).

Question 14

A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client’s immobility?

Polyuria

Blurred vision

Confusion

Diarrhea

Answer 14

Confusion

Rationale: Confusion can be a sign of delirium, which is common complication of immobility in older adults due to sensory deprivation, sleep disturbance, medication side effects, or dehydration.

Question 15

A nurse is checking a client’s ventilator settings. The nurse should understand the positive end-expiatory pressure has which of the following purposes?

To control the rate of ventilations

To provide positive airway pressure during inspiration

To prevent alveolar collapse

TO deliver set tidal volume

Answer 15

To prevent alveolar collapse

Rationale: PEEP is a mode of mechanical ventilation that maintains a positive pressure in the airways a the end of expiration, preventing alveolar collapse and improving oxygenation.

Question 16

A nurse is preparing to administer a unit of packed RBC’s to a client. Which of the following actions should the nurse plan to take?

Initiate venous access with a 21-gauge needle

Administer the unit of packed RBC’s over 1 hour

Use Y tubing with 0.9% sodium chloride when administering to transfusion

Obtain the client’s first set of vital sings 1 hour after initiating the transfusion

Answer 16

Use Y tubing with 0.9% sodium chloride when administering to transfusion

Rationale:

Initiate venous access with a 21-gauge needle: This is incorrect. Blood products are usually administered through a larger gauge needle (18 to 20-gauge) to prevent hemolysis and ensure the blood can flow adequately.

Administer the unit of packed RBC’s over 1 hour: This is incorrect. Packed RBCs are typically administered over 2 to 4 hours to avoid fluid overload and other complications. Rapid transfusion is only recommended in emergencies.

Use Y tubing with 0.9% sodium chloride when administering the transfusion: This is correct. Y tubing is specifically designed for blood administration, and 0.9% sodium chloride is the only compatible IV solution to prevent hemolysis and clotting.

Obtain the client’s first set of vital signs 1 hour after initiating the transfusion: This is incorrect. The nurse should check the client’s vital signs before the transfusion, 15 minutes after starting the transfusion, and then frequently (usually every 30 to 60 minutes) until the transfusion is complete. The first 15 minutes are critical for detecting any adverse reactions.

Question 17

A nurse is preparing to assist with the insertion of a non-tunnel central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?

Cleanse the site with a hydrogen peroxide solution

Confirm the correct position of the line by obtaining a blood sample

Instruct the client to cough as the catheter is inserted

Place the head of the client’s bed lower than the foot

Answer 17

Place the head of the client’s bed lower than the foot

Rationale: Cleanse the site with a hydrogen peroxide solution: This is incorrect. The site should be cleansed with an antiseptic solution, such as chlorhexidine, not hydrogen peroxide, which is not typically used for this procedure.

Confirm the correct position of the line by obtaining a blood sample: This is incorrect. Correct placement of the central venous catheter is confirmed by chest X-ray, not by obtaining a blood sample.

Instruct the client to cough as the catheter is inserted: This is incorrect. The client should be instructed to perform the Valsalva maneuver (holding breath and bearing down) during insertion, not cough, as this helps prevent air embolism.

Place the head of the client’s bed lower than the foot: This is correct. Placing the client in the Trendelenburg position helps distend the veins and reduces the risk of air embolism during insertion of the central venous catheter.

Question 18

A nurse is reviewing the medical record of a client who is scheduled for CT scan which contrast media. Which of the following medications should the nurse instruct the client to withhold for 48 hr following the procedure.

Metmorfin

Furosemide

Clopidogrel

Carvedilol

Answer 18

Metmorfin

Rationale:
Metformin: This is the correct answer. Metformin, a medication used to treat type 2 diabetes, should be withheld for 48 hours after a procedure involving contrast media because of the risk of contrast-induced nephropathy. If the kidneys are affected, metformin can accumulate in the body, leading to a serious condition called lactic acidosis.

Furosemide: This is incorrect. Furosemide is a diuretic, and while it can affect kidney function, it is not specifically contraindicated with contrast media. However, the healthcare provider might monitor kidney function closely.

Clopidogrel: This is incorrect. Clopidogrel is an antiplatelet drug and does not interact with contrast media in a way that requires withholding the medication after the procedure.

Carvedilol: This is incorrect. Carvedilol is a beta-blocker and does not need to be withheld before or after a CT scan with contrast.

Question 19

A nurse is caring for a client who has newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider?

Vigorously strip the chest tube twice daily

Administer morphine 2 mg IV bolus every 3 hr PRN for pain

Notify the provider when tidaling ceases

Assist the client out of the bed three times daily

Answer 19

Vigorously strip the chest tube twice daily

Rationale: Stripping or milking the chest tube is no longer recommended in most clinical settings because it can increase negative pressure in the pleural space, potentially causing tissue damage and worsening complications like pneumothorax. Instead, chest tubes should be maintained without manipulation unless there is a clear indication from the provider, such as clot formation. If necessary, it should be done gently and with the provider’s guidance.

Question 20

A nurse is teaching a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication.

Cloudy effluent

Fever

Generalized abdominal pain

Increased heart rate

Answer 20

Cloudy effluent

Rationale:

Cloudy effluent is often the first sign of peritonitis, as the infection leads to an accumulation of white blood cells in the dialysate fluid, making it appear cloudy.

Peritonitis is an inflammation of the peritoneum, which is the thin layer of tissue lining the inner wall of the abdomen and covering most of the abdominal organs. It is usually caused by an infection, and it can be a life-threatening condition if not treated promptly.

Question 21

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?

Attach a dosimeter badge to the client’s gown

Move the client’s soiled linens to a designated container outside the room

Leave unused equipment in the client’s room until discharge

Place long-handled forceps at the client’s bedside

Answer 21

Place long-handled forceps at the client’s bedside

Rationale: In case the sealed radiation implant (such as a brachytherapy device) becomes dislodged, long-handled forceps are used to safely handle and contain the radioactive source without direct exposure to the nurse or other staff. This is a key safety measure to reduce radiation exposure.

The other actions require clarification:

Attaching a dosimeter badge to the client’s gown: Incorrect. The dosimeter badge should be worn by healthcare personnel to measure their own radiation exposure, not attached to the client’s gown.
Moving the client’s soiled linens to a designated container outside the room: Incorrect. Linens contaminated with bodily fluids may also be radioactive, so they should be handled with care and disposed of according to radiation safety protocols, typically within the room or designated area for radioactive materials.
Leaving unused equipment in the client’s room until discharge: Incorrect. Any unnecessary equipment should be removed from the room to minimize contamination and reduce the risk of radiation exposure.

Question 22

A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify which of the following statements by the client indicates an understanding of the teaching?

“I soak my feet in hot water before trimming my toenails”

“I rest in my recliner with my feet elevated for about an hour every afternoon”

“I use my heating pad on a low setting to keep my feet warm”

“I apply a lubricating lotion to the cracked areas on the soles of my feet every morning”

Answer 22

“I apply a lubricating lotion to the cracked areas on the soles of my feet every morning.”

Rationale: Applying lotion helps to prevent skin dryness and cracking, which can reduce the risk of infection in clients with peripheral arterial disease (PAD), a condition that impairs blood flow to the extremities. It’s important to keep the feet moisturized, though lotion should not be applied between the toes, as this can increase the risk of fungal infections.

“I soak my feet in hot water before trimming my toenails”: Incorrect. Clients with PAD should avoid soaking their feet in hot water because reduced circulation can make them less sensitive to heat, increasing the risk of burns.
“I rest in my recliner with my feet elevated for about an hour every afternoon”: Incorrect. Elevating the legs can reduce blood flow further, which may worsen symptoms of PAD. It is generally recommended to keep the feet in a neutral or slightly dependent position to improve circulation.
“I use my heating pad on a low setting to keep my feet warm”: Incorrect. Heating pads should be avoided because clients with PAD may have decreased sensation and be at risk for burns.

Question 23

A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the following findings should the nurse identify as an indication that the medication is effective?

Increased potassium level

Decreased blood pressure

Increased heart rate

Decreased urinary output

Answer 23

Decreased blood pressure

Rationale:
Rationale: Valsartan is an angiotensin II receptor blocker (ARB), which works by relaxing blood vessels, reducing blood pressure, and decreasing the workload on the heart. Lowering blood pressure is a key therapeutic effect in clients with heart failure, as it helps reduce strain on the heart and improves the efficiency of heart function.

Increased potassium level: While ARBs can cause potassium levels to rise (a potential side effect), this is not an indication of the medication’s effectiveness. In fact, elevated potassium can lead to hyperkalemia, which may require monitoring.
Increased heart rate: This would not indicate effective treatment of heart failure, as the goal is typically to reduce strain on the heart, not to increase heart rate.
Decreased urinary output: This could indicate worsening heart failure or renal dysfunction, which would be a concerning sign, not a positive effect of valsartan.

Question 24

A nurse is reviewing the medical record of a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?

Serosanguineous exudate noted on dressing change

Reports pain of 4 on a scale from 0 to 10 when coughing

WBC count 8,400/mm

Hemoglobin 10 mg/dL

Answer 24

Hemoglobin 10/dL

Rationale:

A hemoglobin level of 10 mg/dL is lower than the normal range (typically 12-16 g/dL for women and 13.5-17.5 g/dL for men). This indicates that the client may be anemic, possibly due to blood loss during surgery or another underlying issue. While not critically low, it is important to notify the provider to determine if further evaluation or intervention is needed.

Serosanguineous exudate noted on dressing change: This is common during the early stages of wound healing after surgery and does not necessarily indicate a complication unless it becomes excessive, purulent, or shows other signs of infection.
Reports pain of 4 on a scale from 0 to 10 when coughing: Mild to moderate pain is expected after surgery, especially when coughing or moving. This level of pain is manageable, but the nurse should continue monitoring and providing pain management.
WBC count 8,400/mm³: This is within the normal range (typically 4,500 to 11,000/mm³) and does not indicate an infection or other abnormality at this time.

Question 25

A nurse is preparing to assist the provider with a thoracentesis for a client who has left pleural effusion. Which of the following interventions is priority for the nurse? Describe the sensations the client will feel during the procedure Determine whether the client has an allergy to local anesthetic's Reinforce the importance of lying still during the procedure Administer a sedative medication

Answer 25

**Determining allergies to local anesthetics is the priority because it directly impacts the safety of the procedure.** Rationale: Thoracentesis involves using a local anesthetic to numb the area where the needle will be inserted. If the client has an allergy to the anesthetic, it could cause a severe allergic reaction, which would require immediate intervention. Describing the sensations the client will feel during the procedure: This helps alleviate anxiety, but it is not the top priority compared to verifying the safety of the local anesthetic. Reinforcing the importance of lying still during the procedure: This is important to prevent complications during the thoracentesis, but it does not take precedence over addressing potential allergies. Administering a sedative medication: If prescribed, this is important for client comfort, but safety concerns (like potential allergic reactions) must be addressed first.

Question 26

A nurse is reviewing the following ABG results for a postoperative client: pH 7.27, PaCO2 49 mm Hg, PaO2 65 mm Hg, HCO-3 22mEq/L. The nurse should interpret the findings as which of the following imbalances. Metabolic acidosis Respiratory acidosis Metabolic Acidosis Respiratory alkalosis

Answer 26

**Respiratory Acidosis** Rationale: ABG Analysis: pH 7.27: Indicates acidosis (normal pH range: 7.35-7.45). PaCO2 49 mm Hg: Elevated, indicating hypercapnia (normal PaCO2 range: 35-45 mm Hg), which suggests a respiratory cause for the acidosis. HCO₃ 22 mEq/L: Normal (normal range: 22-26 mEq/L), which suggests that the kidneys have not yet compensated for the acidosis. PaO2 65 mm Hg: Indicates hypoxemia (normal PaO2 range: 80-100 mm Hg), suggesting impaired gas exchange, which can be seen in respiratory conditions. These ABG results indicate respiratory acidosis, which occurs when there is an accumulation of CO2 in the blood due to inadequate ventilation (hypoventilation), leading to decreased pH. This condition can be seen in postoperative clients who may have respiratory depression due to anesthesia, pain medications, or shallow breathing.

Question 27

A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? SATA Drink more fructose cranberry juice Take a warm bubble bath daily Void every 6 hr during the day Wipe the perineal area from front to back after urinating Drink 3 L of fluids daily

Answer 27

**Wipe the perineal area from front to back after urinating** **Drink 3 L of fluids daily** Rationale: Wipe the perineal area from front to back after urinating: This helps prevent bacteria from the rectal area from entering the urethra, which is a common cause of UTIs in women. Drink 3 L of fluids daily: Adequate hydration helps flush out bacteria from the urinary tract, reducing the risk of infection. Drink more fructose cranberry juice: While unsweetened cranberry juice may help prevent UTIs in some people by preventing bacteria from adhering to the bladder wall, fructose-sweetened cranberry juice can promote bacterial growth and is not recommended. Take a warm bubble bath daily: Bubble baths can irritate the urethra and increase the risk of UTIs, so they should be avoided. Void every 6 hours during the day: This interval is too long. Urinating more frequently (every 2-3 hours) is recommended to flush out bacteria and reduce the risk of UTIs.

Question 28

Question 78 Picture where you identify where you will assess a client for tetany.

Answer 28

B

Question 29

A nurse is providing discharge teaching for a client who has osteomyelitis in the left leg. Which of the following findings should the nurse identify as requiring a referral? The client has type 2 diabetes mellitus and a HbA1c of 6% The client has a WBC count of 20,000/mm3 The client has a prescription for furosemide The client has a prescription for long-term IV antibiotic therapy

Answer 29

**The client has a WBC count of 20,000/mm3** Rationale: A WBC count of 20,000/mm³ is significantly elevated (normal range: 4,500-11,000/mm³) and indicates an active infection or an inflammatory process. This finding warrants a referral to address potential complications and ensure effective management of the infection. The client has type 2 diabetes mellitus and a HbA1c of 6%: This is a well-controlled HbA1c level (target HbA1c for diabetics is generally below 7%), so it does not indicate a need for referral. The client has a prescription for furosemide: This is a diuretic commonly used for conditions such as heart failure or hypertension. It does not directly impact osteomyelitis management or require a referral unless there are specific concerns about kidney function or fluid balance. The client has a prescription for long-term IV antibiotic therapy: Long-term IV antibiotics are a standard treatment for osteomyelitis, and while home health support may be needed for administration, this alone does not require a referral.

Question 30

A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first? Check the gage reflex Inform the client they might experience a low-grade fever Provide the client with sips of water Instruct the client to report bleeding

Answer 30

**Check the gag reflex** Rationale: After a bronchoscopy, the client’s throat and airway are typically numbed with a local anesthetic, which suppresses the gag reflex. Assessing the gag reflex is the priority to ensure that the client can safely swallow and protect their airway before offering any fluids or food. If the gag reflex is absent, there is a risk of aspiration.

Question 31

A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements but the client indicates an understanding of the teaching? "I will have to wait 2 months before additional saline can be added to my breast expander" "I should expect less than 25 mL of secretions per day in the drainage devices" "I will perform strength-building arm exercises using 15-pound weight" "I will keep my left arm arm flexed at the elbow as much as possible"

Answer 31

**"I should expect less than 25 mL of secretions per day in the drainage devices"** Rationale: After a mastectomy, surgical drains are typically placed to remove excess fluid and reduce the risk of complications such as seroma formation. The nurse will instruct the client to monitor the drainage, and a decrease to less than 25 mL per day is usually an indicator that the drains can be removed. "I will have to wait 2 months before additional saline can be added to my breast expander": Incorrect. Saline is usually added gradually, starting a few weeks after surgery. The timing depends on the provider's assessment and the client’s healing. "I will perform strength-building arm exercises using 15-pound weights": Incorrect. Initially, after surgery, light exercises focusing on range of motion are recommended. Heavy lifting or strength-building exercises (like using 15-pound weights) are typically avoided until full healing has occurred. "I will keep my left arm flexed at the elbow as much as possible": Incorrect. The client should avoid keeping the arm flexed for prolonged periods to prevent complications like lymphedema or contractures. Gentle range-of-motion exercises and keeping the arm elevated are usually encouraged.

Question 32

A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first? Listen to the client's bowel sounds Check the client's hand grasps Administer an IV potassium drip Initiate cardiac monitoring for the client

Answer 32

**Initiate cardiac monitoring** Rationale: A serum potassium level of 2.8 mEq/L indicates hypokalemia, which can lead to dangerous cardiac arrhythmias. Since potassium plays a critical role in heart function, hypokalemia can cause irregular heart rhythms, and the most urgent concern is detecting and preventing these life-threatening complications. Cardiac monitoring allows for real-time assessment of the client's heart rhythm and helps to quickly identify any abnormalities. Administer an IV potassium drip: This is essential for correcting the potassium deficiency, but the client should be on cardiac monitoring first to observe any effects of potassium replacement on heart function. Listen to the client’s bowel sounds: Hypokalemia can lead to decreased gastrointestinal motility, but this is not the most urgent concern compared to the risk of cardiac issues. Check the client’s hand grasps: Muscle weakness is a symptom of hypokalemia, but addressing the potential for life-threatening arrhythmias takes priority.

Question 33

A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse? Administer 0.9% sodium chloride Check potassium levels Initiate a continuous IV insulin infusion Begin bicarbonate continuous IV infusion

Answer 33

**Administer 0.9% sodium chloride** Rationale (Brainly): Administer 0.9% sodium chloride Rationale (Chat GPT): Insulin is the key treatment for DKA, as it helps to reduce blood glucose levels, decreases ketone production, and corrects the underlying metabolic acidosis. While other interventions are also important, the administration of insulin is crucial for reversing the state of DKA.

Question 34

A nurse is assessing a client who has a serum sodium level of 120 mEq/L. Which of the following findings should the nurse expect? Increased central venous pressure Decreased bowel sounds Confusion Hyperreflexia

Answer 34

**Confusion** Rationale: A serum sodium level of 120 mEq/L indicates hyponatremia, which can lead to neurological symptoms due to swelling of brain cells. Common neurological manifestations of hyponatremia include confusion, disorientation, seizures, and in severe cases, coma.

Question 35

A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status? Cheyne-strokes respirations Altered level of consciousness Pupillary dilation Decorticate posturing

Answer 35

**altered level of consciousness** Rationale: An altered level of consciousness is often the earliest and most sensitive indicator of changes in neurological status. As intracranial pressure rises, it can affect brain function and lead to confusion, lethargy, or decreased responsiveness. Cheyne-Stokes respirations: These are a pattern of breathing that can occur as a result of brainstem involvement but are typically observed after more significant deterioration. Pupillary dilation: This can occur later in the process as pressure increases, especially if the pressure affects cranial nerves. Decorticate posturing: This is a sign of severe brain injury and indicates significant neurological compromise, often seen after altered consciousness has already occurred.

Question 36

A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take? Hang the drainage bag below the client's abdomen Chill the dialysate before administration Place the client in high-Fowler's position Use clean technique to access the catheter

Answer 36

**Hang the drainage bag below the client's abdomen** Rationale: Hanging the drainage bag below the client's abdomen facilitates proper drainage of the dialysate fluid from the peritoneal cavity due to gravity, which helps ensure effective dialysis. Chill the dialysate before administration: This is incorrect. The dialysate should be warmed to body temperature (not chilled) before administration to prevent discomfort and abdominal cramping. Place the client in high-Fowler's position: This position is generally not recommended for peritoneal dialysis. The client is usually positioned supine or in a semi-Fowler's position to facilitate the flow of dialysate. Use clean technique to access the catheter: While sterile technique is essential for accessing the catheter to prevent infection, the specific terminology used here can be misleading. For peritoneal dialysis, aseptic technique should be employed.

Question 37

A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client report sharp lower abdominal pain. Which of the following actions should the nurse take first? Increase the client's fluid intake Administer PRN pain medication Check the client's urine output Reposition the client in bed

Answer 37

**Check the client's urine output** Rationale: Following a transurethral resection of the prostate (TURP) with continuous bladder irrigation (CBI), sharp lower abdominal pain could indicate bladder distention or obstruction due to a clot or inadequate drainage. Checking the urine output will help assess if the irrigation is effective and if the bladder is adequately draining. If there is a significant decrease in urine output, further interventions (such as troubleshooting the irrigation system or checking for clots) may be necessary. Increase the client's fluid intake: While increasing fluid intake may help, it is more critical to assess the current urine output first to determine if there is a problem with drainage. Administer PRN pain medication: Although pain management is important, it is essential to understand the cause of the pain before administering medication, as this could mask symptoms of a more serious issue. Reposition the client in bed: This may help relieve discomfort, but it is not the first priority. Assessing the urine output provides more information on the client's condition.

Question 38

A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon? WBC count 8,000/mm3 Hct 42% INR of 1.6 Platelets 95,000/mm3

Answer 38

**INR of 1.6** Rationale: INR (International Normalized Ratio) is a measure of blood coagulation. A normal INR is typically between 0.8 and 1.2. An INR of 1.6 indicates that the client is at increased risk for bleeding during surgery, and this should be addressed before proceeding with the surgical intervention. WBC count 8,000/mm³: This is within the normal range (approximately 4,500-11,000/mm³) and does not require reporting. Hct (Hematocrit) 42%: This is also within the normal range for most adults (approximately 38.3% to 48.6% for men and 35.5% to 44.9% for women), so it does not need to be reported. Platelets 95,000/mm³: This is below the normal range (normal is typically 150,000 to 450,000/mm³), indicating thrombocytopenia, which can increase the risk of bleeding. While this is concerning, the elevated INR is a more immediate concern regarding surgical risk.

Question 39

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? Fluticasone Valproic acid Metmorfin Metoprolol

Answer 39

**Metmorfin** Rationale: Metformin, which is commonly prescribed for type 2 diabetes, should be withheld before and after the use of IV contrast dye due to the risk of lactic acidosis, especially in patients with impaired kidney function. It is typically advised to hold metformin on the day of the procedure and for 48 hours afterward until kidney function is reassessed.

Question 40

A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects? Hypoglycemia Constipation Diarrhea Hyperglycemia

Answer 40

**hypoglycemia** Rationale: When TPN is administered, the body becomes reliant on this source of glucose for energy. Abruptly stopping TPN can lead to a rapid decrease in blood glucose levels, resulting in hypoglycemia. Gradually tapering the TPN allows the body time to adjust and start utilizing oral or enteral nutrition without significant drops in blood sugar. Constipation and diarrhea can occur due to various reasons, including changes in diet, but they are not direct consequences of stopping TPN. Hyperglycemia can be a concern with TPN administration due to the high glucose content, but it is not a risk associated with the discontinuation of TPN.

Question 41

A nurse is caring for a client who is 6 hr postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? Adjust the clamps on the fixator frame Palpate the dorsalis pedis pulse Maintain the affected extremity in a dependent position Wrap sterile gauze on the sharp point of the pins

Answer 41

**Palpate the dorsalis pedis pulse** Rationale: Palpating the dorsalis pedis pulse is essential for assessing perfusion and circulation to the foot and toes following surgery on the leg. It helps ensure that the blood flow is adequate and that there are no complications related to the external fixator, such as vascular compromise.

Question 42

A nurse is caring for a client who has anemia. Which of the following assessments findings should the nurse anticipate with the client's condition? Headache Bradycardia Flushed skin color Heat intolerance

Answer 42

**Headache** Rationale: Clients with anemia may experience headaches due to decreased oxygen delivery to the brain, resulting from low hemoglobin levels. Bradycardia: Anemia typically causes tachycardia (increased heart rate) as the body compensates for the reduced oxygen-carrying capacity of the blood. Bradycardia (slower heart rate) is not a common finding in anemia. Flushed skin color: Anemia usually presents with pallor (pale skin) rather than flushed skin. Flushed skin is more often associated with conditions like fever, inflammation, or other circulatory issues. Heat intolerance: Heat intolerance is not a typical symptom of anemia. It may be more related to hyperthyroidism or other endocrine disorders.

Question 43

Question 93 Identifying a gravity drain

Question 44

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? Wound tissue firm to palpation Dark red granulation tissue Light yellow exudate Dry brown eschar

Answer 44

**Dark red granulation tissue** Rationale: Dark red granulation tissue is a sign of healing and indicates the formation of new tissue that is rich in blood vessels. Granulation tissue is typically moist, red, and can bleed easily; its presence suggests that the wound is moving toward healing. Wound tissue firm to palpation: While some firmness can be normal as healing progresses, excessively firm or hard tissue can indicate scarring or potential complications, not necessarily a sign of healing. Light yellow exudate: This can indicate the presence of necrotic tissue or infection. While some exudate is normal, light yellow exudate is not typically associated with healthy healing. Dry brown eschar: Eschar is dead tissue that usually indicates a non-healing wound. If the eschar is dry and brown, it suggests that the wound is not healing effectively, as healthy wounds typically show signs of granulation and epithelialization rather than eschar formation.

Question 45

A nurse is performing skin cancer screening on a group of clients. Which of the following findings should the nurse identify as an indication of melanoma? Raised lesion with a rolled border Scaly lesion with a crusted appearance Reddened lesion with dilated blood vessels Flat lesion with irregular borders

Answer 45

**Flat lesion with irregular borders** Rationale: Flat lesions with irregular borders can be characteristic of melanoma, which often presents as asymmetrical, with uneven edges, and can vary in color. Melanomas are often larger than moles and can change in size, shape, or color over time. Raised lesion with a rolled border: This description is more typical of basal cell carcinoma, which often appears as a pearly or raised lesion with a rolled edge. Scaly lesion with a crusted appearance: This could suggest squamous cell carcinoma or another skin condition, but it is not a typical presentation for melanoma. Reddened lesion with dilated blood vessels: This description might indicate other skin issues, such as vascular lesions or benign skin conditions, rather than melanoma.

Question 46

A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching? "I will eat a high-fiber diet" "I will expect my stools to be loose" "I will take a laxative when I'm constipated" "I will empty my bag when it is full"

Answer 46

**"I will expect my stools to be loose"** Rationale: After an ileostomy, the output from the stoma is typically liquid to semi-liquid. This is because the ileum (the last part of the small intestine) is responsible for absorbing fluids, and when it is bypassed, the stool consistency will remain loose. "I will eat a high-fiber diet.": This is incorrect. A high-fiber diet is not typically recommended immediately after ileostomy surgery because it can lead to blockages. The client should initially follow a low-fiber diet until they are fully healed and then gradually reintroduce fiber as tolerated. "I will take a laxative when I'm constipated.": This statement is inappropriate for a client with an ileostomy. Because the ileum is already bypassed, laxatives are generally not needed and could lead to complications. "I will empty my bag when it is full.": While this statement reflects good practice, it is more accurate to say that the client should empty the bag when it is about one-third to one-half full. Waiting until it is completely full could risk leakage or damage to the stoma.

Question 47

NGN A nurse is caring for a male client who has an exacerbation of heart failure. Which of the following prescriptions should the nurse expect to receive from the provider? Verapimil 80 mg PO TID Furosemide 40 mg IV bolus every 6 hr Adenosine 6 mg rapid IV bolus now Atropine 1 mg IV bolus every 5 min up to 3 mg

Answer 47

**Furosemide 40 mg IV bolus every 6 hr** Rationale: Furosemide is a loop diuretic commonly used to treat fluid overload in clients with heart failure. It helps reduce edema and relieve symptoms of congestion by promoting diuresis (increased urine production).

Question 48

A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first? Measure the client's blood pressure Initiate VI fluid therapy for the client Prepare the client for temporary pacing Administer atropine to the client

Answer 48

**Measure the cleint's blood pressure** Rationale: Assessing the client's blood pressure is crucial because it helps determine the severity of the bradycardia and whether the client is hemodynamically stable. If the client is hypotensive, that can indicate a need for immediate interventions, such as administering atropine or preparing for pacing. Initiate IV fluid therapy for the client: While this may be necessary depending on the client’s condition, it is important to first assess the client's blood pressure and overall stability. Prepare the client for temporary pacing: This is a potential intervention if the bradycardia is symptomatic and causing hemodynamic instability. However, it should be done after assessing the client's blood pressure and determining the need for pacing. Administer atropine to the client: Atropine is indicated for symptomatic bradycardia, but again, it should be administered based on the client's hemodynamic status, which starts with assessing their blood pressure.

Question 49

Question 99 Arrange options in order you perform them first A nurse in in an emergency department is caring for a client who is to receive tissue plasminogen activator (tPA) for the treatment of an ischemic stroke.

Answer 49

1. Check for the contraindications 2. Weigh the client 3. Administer the tPA 4. Transfer the client to the CCU.

Question 50

NGN Patient Receiving TPN Review

Question 51

A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? "I will limit my portions of meat to 8 ounces" "I will increases my intake of canned vegetables" "I will use canola oil when making salad dressing" "I will drink whole milk with my cereal"

Answer 51

**I will use canola oil when making salad dressing"** Rationale: Canola oil is low in saturated fat and contains healthy fats, such as monounsaturated and polyunsaturated fats, which are beneficial for heart health. It can help reduce cholesterol levels when used as a substitute for less healthy fats. "I will limit my portions of meat to 8 ounces": While portion control is important, 8 ounces is generally too high. For heart health, it's typically recommended to limit portions of lean meat, fish, or poultry to around 3-4 ounces per meal. "I will increase my intake of canned vegetables": Many canned vegetables contain added sodium, which can raise blood pressure. Fresh, frozen, or low-sodium canned vegetables are better choices. "I will drink whole milk with my cereal": Whole milk is high in saturated fat, which can raise cholesterol levels. Low-fat or fat-free milk is recommended for individuals with cardiovascular disease.

Question 52

A nurse is caring for a client who has COPD. Click to highlight the findings below that require immediate follow-up?

Answer 52

Neurological: Client is restless Pulmonary: Tachypneic, cough is productive, and mucous is yellow in color Cardiovascular: Pulse 110/min, +2 pulses in all extremities Chronic bronchitis: Involves inflammation of the lining of the bronchial tubes, leading to excessive mucus production, coughing, and difficulty breathing. Emphysema: Involves damage to the alveoli (air sacs) in the lungs, which reduces the surface area for gas exchange, making breathing difficult.

Question 53

A nurse is caring for a client who is experiencing an exacerbation of heart failure. The nurse is assessing the client 24 hr later. How should the nurse interpret the findings related to the diagnosis of heart failure?

Answer 53

Unrelated to the diagnosis: Temp & WBC count Improvement: Clear lung sounds Worsening Condition: Creatinine 1.8 mg/dL Weight 113 kg Shortness of breath

Question 54

A nurse is caring for a client who has heart failure. What is the client at risk for developing? Drag words from the choices below to fill in each blank in the following sentence. Dysrhythmias Respiratory alkalosis Acute kidney injury fluid volume deficit

Answer 54

The client is at risk for developing ___ and ___. **Dysrhythmias and acute kidney injury** Rationale: Yes, at risk. Heart failure affects the heart's ability to pump blood efficiently, which can lead to electrical disturbances in the heart. Structural changes like ventricular hypertrophy and electrolyte imbalances (from diuretics) can predispose the client to dysrhythmias, such as atrial fibrillation, ventricular tachycardia, and other arrhythmias. Dysrhythmias are a common complication in heart failure and can worsen the condition. Yes, at risk. Clients with heart failure are at significant risk for acute kidney injury (AKI). This occurs due to reduced cardiac output, which impairs kidney perfusion and leads to decreased glomerular filtration. Diuretics, commonly used in heart failure management to reduce fluid overload, can also contribute to dehydration and worsen kidney function, increasing the risk of AKI.

Question 55

A nurse is providing teaching for a client who has diabetes mellitus about the self administration of insulin. The client has prescriptions for regular and NPH insulins. Which of the following statements by the client indicates an understanding of the teaching? "I will draw up the regular insulin into the syringe first" "I will shake the NPH vial vigorously before drawing up the insulin" "I will store prefilled syringes int he refrigerator with the needle pointed downward." "I will insert the needle at a 15-degree angle"

Answer 55

**"I will draw up the regular insulin into the syringe first."** Rationale: Order of drawing insulin: Always draw up clear (regular) insulin before cloudy (NPH) insulin. Mixing NPH insulin: Roll the vial gently; do not shake. Storage: Keep unopened insulin in the refrigerator and opened vials at room temperature, avoiding extreme temperatures.

Question 56

A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement? Move the client to a double room Use chemical restraints at bedtime Use a bed alarm Encourage participation in activities that provide excessive stimulation

Answer 56

**Use a bed alarm** Rationale: A bed alarm is a safety device that alerts staff when a client is attempting to get out of bed. For clients with dementia who have a history of wandering, this is an appropriate intervention to prevent falls or wandering out of the room. It allows for early intervention without the use of restraints and promotes client safety. "Move the client to a double room": Incorrect: Moving the client to a double room might increase confusion and agitation. Clients with dementia often do better in a calm, quiet environment with minimal distractions, which may be harder to achieve in a shared room. "Use chemical restraints at bedtime": Incorrect: The use of chemical restraints (such as sedative medications) should be avoided unless absolutely necessary and prescribed for a specific medical indication. Chemical restraints can have adverse effects, especially in clients with dementia, including increased confusion, falls, and further cognitive decline. "Encourage participation in activities that provide excessive stimulation": Incorrect: Activities with excessive stimulation (loud noise, complex tasks, busy environments) can increase agitation and confusion in clients with dementia. It's better to provide activities that are calming, structured, and appropriate for the client’s cognitive level.

Question 57

A nurse is caring for a client receiving TPN. Which of the following actions should the nurse take? For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicate for the client? Request a prescription for insulin Request an antibiotic to be administered Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula Have 3 nurses verify the TPN solution prescription Notify provider to increase TPN rate/hr Obtain client weight twice daily

Answer 57

Anticipated: Request a prescription for insulin. Nonessential: Request an antibiotic to be administered. Have 2 nurses (not 3) verify the TPN solution. Obtain client weight (once daily is sufficient). Contraindicated: Decrease the client's oxygen to 1.5 L/min. Notify the provider to increase the TPN rate without proper clinical indication. 1. Request a prescription for insulin: Anticipated: Clients receiving TPN may experience elevated blood glucose levels due to the high glucose content in the solution. It is common to request an insulin prescription to manage hyperglycemia during TPN therapy, even for clients who are not diabetic. 2. Request an antibiotic to be administered: Nonessential: This intervention is nonessential unless there is a specific reason (e.g., infection) for the client to receive antibiotics. TPN itself does not necessitate antibiotic therapy, but the nurse should monitor for signs of infection at the central line site or systemic infection. 3. Decrease the client's oxygen to 1.5 L/min via nasal cannula: Contraindicated: Decreasing oxygen levels should be done only based on an assessment of the client's oxygenation status (e.g., SpO2, blood gases). TPN administration does not typically affect oxygen needs, and reducing oxygen could be harmful without proper evaluation. The nurse should assess oxygen needs before adjusting flow rates. 4. Have 3 nurses verify the TPN solution prescription: Nonessential: Standard practice for TPN verification typically involves two nurses checking the prescription, contents, and infusion rate to prevent errors. Having three nurses verify the TPN is excessive and not a standard protocol unless it is a local policy or in particularly complex cases. 5. Notify provider to increase TPN rate/hr: Contraindicated: TPN should generally be titrated carefully and not increased abruptly without a clear medical indication. Rapid increases in the TPN rate can cause complications such as fluid overload, hyperglycemia, or electrolyte imbalances. The rate is typically started low and gradually increased according to the provider’s order. 6. Obtain client weight twice daily: Nonessential: Weighing the client daily is anticipated to monitor for fluid balance and nutritional status, but twice daily is usually nonessential unless the client has severe fluid balance issues (e.g., severe edema, heart failure). Once-daily weights are generally sufficient for clients receiving TPN.

Question 58

A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first? Measure blood pressure Administer aspirin Administer nitroglycerin Initiate IV access

Answer 58

**Administer nitroglycerin** Rationale: Administer nitroglycerin: This should be the priority because nitroglycerin helps to dilate the coronary arteries, improving blood flow to the heart and relieving the chest pain (angina) quickly. Relieving chest pain in acute angina is critical to prevent further myocardial damage. Measure blood pressure: While important, it should be done after administering nitroglycerin since nitroglycerin can cause a drop in blood pressure, and you need to monitor for this effect after the medication. Administer aspirin: Aspirin is also important, as it reduces platelet aggregation and helps prevent clot formation. However, it is typically given after nitroglycerin when treating angina. Initiate IV access: While important for medication administration and potential emergency interventions, it can be done after addressing the immediate need to relieve chest pain with nitroglycerin.

Question 59

A nurse in the emergency departmnet is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment? Run a tongue blade on the outside of the clien't sole and note any flaring of the toes Tap the client's facial nerve and note any facial twitching Gently elevate the cleint's head and note any nuchal rigidity Strike the client's patellar tendon witha percussion hammer and note any increase in response.

Answer 59

**Nuchal rigidity** Rationale: Nuchal rigidity (stiffness of the neck) is a common and significant finding in meningitis. It indicates irritation of the meninges (the protective membranes covering the brain and spinal cord) and can help confirm the suspicion of meningitis.

Question 60

A nurse is planning care for a client who is postoperative following insertion of an arteriovenous graft in their left forearm. Which of the following actions should the nurse include in the plan of care? Splint theleft forearm to prevent damage to the graft Collect blood specimens from the graft Check the pulse distal to the graft Keep the left forearm below the level of the heart

Answer 60

**Check the pulse distal to the graft** Rationale: Check the pulse distal to the graft: It is crucial to assess circulation in the limb to ensure adequate blood flow beyond the graft. A weak or absent pulse could indicate compromised blood flow or a complication, such as a clot or blockage in the graft. Splint the left forearm to prevent damage to the graft: This is unnecessary and could restrict movement and blood flow, potentially leading to complications. Collect blood specimens from the graft: Blood should not be drawn from the arteriovenous graft to avoid damaging the graft and causing complications like infection or clotting. Keep the left forearm below the level of the heart: Keeping the forearm below the heart could increase swelling and compromise blood flow. Elevation of the limb (slightly above heart level) is typically recommended to reduce swelling and promote circulation.

Question 61

A nurse in a clinic is assessing a client who has type 1 diabetes mellitus. The client is diaphoretic, has a heart rate of 92/min, and reports palpitations. The client states, "I went for my morning run and feel exhausted." Which of the following repsonses should the nurse make? "Did you decrease your insulin intake before you exercise" "It is normal to feel this way after a morning run." "It becomes easier when exercise is a routine" "Were you careful to not have carbodhyrates after the run"

Answer 61

**"Did you decrease your insulin intake before you exercised?"** Rationale: Clients with type 1 diabetes who exercise without adjusting their insulin dosage or carbohydrate intake are at risk of hypoglycemia. Symptoms like diaphoresis, palpitations, and fatigue can indicate low blood sugar. Insulin requirements may decrease during exercise, and failing to adjust can lead to hypoglycemia, especially after physical activity like a morning run.

Question 62

A nurse is teaching about food choices to a lcient who has chronic kidney disease and must limit potassium intake. Which of the following choices should the nurse recommend as containing the least potassium? 1 cup of whie rice 1 medium baked potato skin 2 tbsp peanut butter 1/2 cup of non fat yogurt

Answer 62

**1 cup of white rice** Rationale: 1 cup of white rice: White rice is low in potassium and is a good choice for clients with chronic kidney disease who need to limit their potassium intake. 1 medium baked potato (with skin): Potatoes are very high in potassium, especially with the skin on. 2 tbsp peanut butter: Peanut butter contains moderate potassium, so it should be limited. 1/2 cup of non-fat yogurt: Dairy products, including yogurt, contain potassium, so they are also not ideal for a low-potassium diet.

Question 63

A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following insructions should the nurse include? "Brush your teeth for 60 seconds twice daily" "Wear your dentures only during meals" "Floss your teeth gently fllowing each meal" Rins your mouth with hydrogen peroxide"

Answer 63

**Floss your teeth gently following each meal** Rationale: Gentle flossing helps maintain oral hygiene without causing further irritation to the delicate mucous membranes. It's important to remove food particles and reduce the risk of infection, which is critical for clients undergoing chemotherapy. "Brush your teeth for 60 seconds twice daily": While oral hygiene is important, brushing for this long might be too harsh on sensitive, inflamed mucosa. The client should use a soft-bristled brush and brush gently. "Wear your dentures only during meals": Wearing dentures with mucositis can irritate the already sore and inflamed tissues, even during meals. It may be better to avoid dentures until healing improves. "Rinse your mouth with hydrogen peroxide": Hydrogen peroxide can be irritating and too harsh for mucositis. A mild saline or baking soda solution is typically recommended for rinsing the mouth to promote healing and reduce irritation.

Question 64

A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should the indicate to the nurse that the client needs a referral for occupational therapy? I've been having problems with bladder control I would rather be in a wheelchair than use a walker to get around I have a hard time with brushing my hair I have difficulty swallowing food

Answer 64

**I have a hard time with brushing my hair** Rationale: Occupational therapy helps clients improve their ability to perform daily activities (ADLs) such as grooming, bathing, and dressing. Difficulty with tasks like brushing hair is a key indication that the client could benefit from occupational therapy to develop strategies or use adaptive devices to maintain independence. "I've been having problems with bladder control": This would more likely require a referral to a urologist or physical therapy for pelvic floor exercises. "I would rather be in a wheelchair than use a walker to get around": This could involve a referral to physical therapy to assess mobility needs and ensure the client is using appropriate assistive devices. "I have difficulty swallowing food": This indicates dysphagia, which would require a referral to a speech therapist to address swallowing difficulties and reduce the risk of aspiration.

Question 65

A nurse is caring for a client in the ICU. The client's ECG monitor tracing reveals sinus bradycardia and ST segment elevation. The client reports shortness of breath and feeling dizzy and faint. Which of the following medications should the nurse administer? Atropine Lidocaine Satalol Digoxin

Answer 65

**Atropine** Rationale: Atropine is an anticholinergic medication used to increase heart rate in cases of bradycardia. Given the client is experiencing sinus bradycardia (a slow heart rate) along with ST segment elevation, which may suggest myocardial ischemia or infarction, atropine would be the appropriate choice to help increase the heart rate and improve cardiac output. Lidocaine: This is an antiarrhythmic primarily used for ventricular arrhythmias and is not effective for bradycardia. Sotalol: This is also an antiarrhythmic medication that is used to treat certain types of tachyarrhythmias and is not indicated for bradycardia. Digoxin: This medication is used to increase the force of cardiac contraction and control heart rate in certain arrhythmias, but it is not typically used to treat bradycardia, especially in the setting of acute symptoms like dizziness and fainting.

Question 66

A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnosis, which of the following clients requires a private room? A client who has diabetes mellitus and is presenting witha acute ketoacidosis A client who has compound fracture of the right femur An older adult client who was admittied with aspiration pneumonia A client who reports having fever, night sweats, and cough for 2 days

Answer 66

**A client who reports having fever, night sweats, and cough for 2 days.** Rationale: This client’s symptoms could suggest a communicable disease, such as tuberculosis or another infectious process that could be transmitted to other clients. Therefore, isolating this client in a private room is essential to prevent the potential spread of infection. A client who has diabetes mellitus and is presenting with acute ketoacidosis: This client does not require isolation and can share a room with others. A client who has a compound fracture of the right femur: This client also does not need a private room, as there is no indication of infection or contagious disease. An older adult client who was admitted with aspiration pneumonia: While this client may be at risk for infection, aspiration pneumonia itself is not typically contagious. This client can also share a room with others who do not have similar infections.

Question 66

A nurse is caring for a client immediately following a cardiac catherization through the right femoral artery. Which of the following actions should the nurse take? Elevate the head of the client's bed to a 45 degree angle Instruct the client not to bend the affected leg Monitor the client's vital signs once every hour Restrict the clien's fluid intake

Answer 66

**Instruct the client not to bend the affected leg** Rationale: Instruct the client not to bend the affected leg: After a cardiac catheterization through the femoral artery, it is critical to keep the leg straight to prevent bleeding or hematoma formation at the puncture site. Bending the leg could increase the risk of complications such as bleeding or damage to the artery. Elevate the head of the client's bed to a 45-degree angle: After a femoral artery catheterization, the head of the bed should be kept low (typically no more than 30 degrees) to reduce pressure on the femoral artery and prevent bleeding. Monitor the client's vital signs once every hour: Initially, vital signs should be monitored more frequently, often every 15 minutes for the first hour, then gradually decreasing based on the client's stability. Restrict the client's fluid intake: Fluids should not be restricted. In fact, increasing fluid intake is often encouraged to help flush out the contrast dye used during the procedure and reduce the risk of kidney damage.

Question 66

A nurse is caring for a client who is using a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take? Increase the range of motion rapidly when the CPM machine is used intermittently Check settings of the CPM machine every 12 hr Turn the CPM machine off while the client is eating Store the CPM machin on the floor when not in use

Answer 66

**Turn the CPM machine off while the client is eating** Rationale: Turn the CPM machine off while the client is eating: This ensures the client can sit comfortably and focus on eating without the distraction or discomfort of the machine moving their knee. It also promotes better safety and positioning during meals. Increase the range of motion rapidly when the CPM machine is used intermittently: Range of motion should be increased gradually, according to the provider's orders. Rapid increases could cause pain or injury. Check settings of the CPM machine every 12 hours: The settings should be checked more frequently, such as every shift or whenever the machine is applied, to ensure it is functioning correctly and set to the prescribed range of motion. Store the CPM machine on the floor when not in use: The CPM machine should be stored in a clean and safe place, not on the floor, to prevent contamination or damage to the equipment.

Question 67

A nurse is teaching a group of young adult clients about risk fators for hearing loss. Which of the following factors should the nurse include in the teaching? SATA Chronic infecions of the middle ear Frequent exposure to low-volume noise Perforation of the eardrum Use of loop diuretics Born with high birth weight

Answer 67

**Chronic infections of the middle ear: Recurrent middle ear infections (otitis media) can lead to hearing loss over time due to damage to the structures of the middle ear.** **Perforation of the eardrum: A perforated eardrum can result in conductive hearing loss, as it disrupts the transmission of sound waves through the ear.** **Use of loop diuretics: Loop diuretics, such as furosemide, can be ototoxic, meaning they can damage the structures of the inner ear and cause hearing loss, especially when used in high doses.**

Question 68

A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make? Your provider wouldn't prescribe this medication if i weren't necessary I will tell your provider that you do not want to take this medication If you dont take this medication, you will feel worse Most clients feel better after taking the antibiotic

Answer 68

**Your provider wouldn't prescribe this medication if i weren't necessary ** Rationale: This response acknowledges the client's concerns while emphasizing that the medication was prescribed because it is necessary for their treatment. It provides reassurance that the provider has carefully considered the need for the antibiotic and encourages the client to understand the importance of taking the medication. "I will tell your provider that you do not want to take this medication": This may come across as dismissive of the client's concerns without addressing the importance of the medication. "If you don’t take this medication, you will feel worse": While this may be true, it could come across as threatening or coercive and may not encourage collaboration in care. "Most clients feel better after taking the antibiotic": This generalizes the experience of other clients and does not directly address the client’s individual concerns about why the medication is needed.

Question 69

A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the pirority for the nurse to report to the provider? Muscle twitching Client report of nausea Client report of incisional pain Serosanguineous drainage

Answer 69

**Musce twitching** Rationale: Muscle twitching is a potential sign of hypocalcemia, which can occur after a thyroidectomy due to accidental removal or damage to the parathyroid glands. The parathyroid glands regulate calcium levels, and a drop in calcium can lead to neuromuscular excitability, presenting as muscle twitching, tingling, or even more serious symptoms like tetany or seizures. Hypocalcemia is a priority because it can lead to life-threatening complications if not addressed promptly. Client report of nausea: This is a common postoperative symptom and, while uncomfortable, is not immediately life-threatening. Client report of incisional pain: Postoperative pain is expected and can be managed with analgesics. Serosanguineous drainage: This is typical following surgery and is generally not concerning unless the drainage becomes excessive or purulent, indicating infection or hemorrhage.

Question 70

A nurse is assessing a client who has heart failure and a new prescription for metoprolol. Which of the following findings should the nurse identify as an adverse effect of the medication? Blood pressure 138/76 mm Hg Respiratory rate 10/min Temperature 36.3 degrees celsius (97.3 F) Heart rate 48/min

Answer 70

**Hear rate 48/min** Rationale: Metoprolol is a beta-blocker used to manage heart failure, hypertension, and other cardiac conditions. One of its primary actions is to slow the heart rate by reducing the effects of adrenaline on the heart. A heart rate of 48 beats per minute indicates bradycardia, which is a common adverse effect of metoprolol. If the heart rate becomes too low, it can lead to dizziness, fainting, or inadequate perfusion of tissues, which could be dangerous. Blood pressure 138/76 mm Hg: This is within an acceptable range and not indicative of an adverse effect. Respiratory rate 10/min: While this is on the lower end of normal, metoprolol generally affects the heart rate more than the respiratory rate. This finding should be monitored but is not a typical adverse effect of metoprolol. Temperature 36.3°C (97.3°F): This is a normal body temperature and not an adverse effect of the medication.

Question 71

A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include? Keep the client's room dark at night to promote sleep Display a monthly calendar in the client's room Provide the client with structured activities to fill their time Provide plenty stimulation in the client's room

Answer 71

**Provide the client with structured activities to fill their time** Rationale: Structured activities: Clients with Alzheimer's disease benefit from a structured and predictable routine, which helps reduce confusion and agitation. Structured activities can provide mental stimulation while preventing boredom or frustration, but they should be simple and suited to the client’s cognitive level. "Keep the client's room dark at night to promote sleep": A completely dark room can increase confusion and agitation in individuals with Alzheimer's. A night light is often recommended to reduce disorientation if they wake up. "Display a monthly calendar in the client's room": A monthly calendar may be too complex for a client with Alzheimer's disease. A daily schedule or clock showing the current day might be more appropriate. "Provide plenty of stimulation in the client's room": Excessive stimulation, such as loud noises or bright lights, can increase confusion and anxiety in Alzheimer's patients. A calm, quiet environment is typically more beneficial.

Question 72

A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response? Arrythmia Laryngeal edema Fever Hypertension

Answer 72

**Laryngeal edema** Rationale: Laryngeal edema is a serious and life-threatening manifestation of anaphylaxis, characterized by swelling in the throat, which can lead to airway obstruction and difficulty breathing. This requires immediate medical intervention. Arrhythmia: While this can be a serious condition, it is not specifically associated with anaphylaxis but rather with other cardiac or electrolyte imbalances. Fever: This is not a sign of anaphylaxis; it may indicate an infection or other inflammatory processes. Hypertension: Anaphylaxis is more likely to cause hypotension (low blood pressure) rather than hypertension due to vasodilation and fluid leakage from blood vessels.

Question 73

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include? Assist the client with toileting at least once every 4 hr Place the client's bed at the lowest height Request a prescription for a nightly sedative Turn off all lights in the client's room at night

Answer 73

**Place the client's bed at the lowest height** Rationale: Placing the bed at the lowest height is a safety measure that helps prevent falls, which are a common risk for clients with dementia who may become confused or disoriented. Keeping the bed low reduces the risk of injury if the client tries to get out of bed unassisted. Assist the client with toileting at least once every 4 hours: Clients with dementia often need more frequent toileting assistance, as they may not be able to communicate or recognize their need to use the bathroom. Toileting every 2 hours is generally more appropriate to prevent incontinence and associated complications. Request a prescription for a nightly sedative: Sedatives can increase confusion and the risk of falls in clients with dementia. Non-pharmacological interventions for sleep disturbances should be explored first. Turn off all lights in the client's room at night: Completely darkening the room may cause increased confusion and agitation. A night light is typically recommended to prevent disorientation during the night.

Question 74

A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication? I'm going to include more cantaloupe in my diet I will try to limit foods that contain salt I'll check my blood pressure so it doesn't get too high I will check my pulse before I take the medication

Answer 74

**"I'm going to include more cantaloupe in my diet."** Rationale: Furosemide is a loop diuretic that causes the excretion of water and electrolytes, particularly potassium. Low potassium levels (hypokalemia) are a common adverse effect of furosemide. Cantaloupe is high in potassium, and increasing dietary intake of potassium-rich foods like cantaloupe can help counteract this potential adverse effect. "I will try to limit foods that contain salt": While reducing salt intake is important in managing heart failure, this statement does not address the potential adverse effects specific to furosemide, such as hypokalemia. "I'll check my blood pressure so it doesn't get too high": Furosemide can lower blood pressure, so the concern would be low blood pressure (hypotension), not high blood pressure. "I will check my pulse before I take the medication": Checking the pulse is more relevant for medications that directly affect heart rate, like beta-blockers or digoxin, but it is not typically a key concern for furosemide therapy.

Question 75

A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion? Cool, clammy skin Acetone breath Kussmaul respirations Increased urine output

Answer 75

**Cool, clammy skin** Rationale: Cool, clammy skin is a classic sign of hypoglycemia. When blood glucose levels drop, the body releases adrenaline (epinephrine), which can cause symptoms such as sweating, shakiness, and cool, clammy skin. Other common symptoms of hypoglycemia include dizziness, confusion, irritability, and increased heart rate. Acetone breath: This is associated with hyperglycemia and diabetic ketoacidosis (DKA), not hypoglycemia. The presence of acetone breath indicates a build-up of ketones due to insufficient insulin. Kussmaul respirations: These are deep, labored breaths typically seen in metabolic acidosis, particularly in DKA, which occurs in states of hyperglycemia. Increased urine output: This is often associated with hyperglycemia and can be a sign of osmotic diuresis due to elevated blood sugar levels.

Question 76

A charge nurse oon a neurological uni is making room assignmens for a group of clients. Which of the following clients should the nurse assign to the room closes to the nurse's station? A client who has experienced brain death and is awaiting organ procurement A client who has a headache following a grad 1 concussion A client wh ohas a score of 10 on GCS folowing a motor vehicle crash A client who has a socre of 0 on the NIH Stroke Scale following a transietn ischemic attack

Answer 76

**A client who has a score of 10 on the GCS following a motor vehicle crash.** Rationale: A Glasgow Coma Scale (GCS) score of 10 indicates that the client is in a moderate coma and may require close monitoring due to potential deterioration in their neurological status. Placing this client near the nurse's station allows for more frequent observation and quicker intervention if their condition worsens. A client who has experienced brain death and is awaiting organ procurement: This client is stable in terms of monitoring needs, as brain death means there is no neurological function or need for intensive observation. A client who has a headache following a grade 1 concussion: While they require care, this client is generally stable and does not need to be monitored as closely as one with a lower GCS score. A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack (TIA): A score of 0 indicates no neurological deficits, and this client is also stable and requires less frequent monitoring.

Question 77

A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take? Perform a Mantoux skin test on the client Assign the client to a negative-pressure airflow room Recommend that the client's family members receive antiviral therapy Wear a surgical mask when providing care to the client

Answer 77

**Wear a surgical mask when providing care to the client** Rationale: Pertussis (whooping cough) is highly contagious and is transmitted through respiratory droplets. Wearing a surgical mask helps to protect both the nurse and other patients from the spread of the infection while caring for the client. Perform a Mantoux skin test on the client: The Mantoux test is used for screening for tuberculosis (TB), not for pertussis. Pertussis is caused by the bacterium Bordetella pertussis, and TB screening would not be relevant in this situation. Assign the client to a negative-pressure airflow room: Negative-pressure rooms are used for airborne precautions (e.g., tuberculosis), while pertussis is primarily droplet-transmitted. The appropriate setting would be a private room, but not necessarily a negative-pressure room. Recommend that the client's family members receive antiviral therapy: Pertussis is treated with antibiotics, not antivirals. Family members who are exposed may need to receive prophylactic antibiotics, but this would not be described as antiviral therapy.

Question 78

A nurse is assessing a cliet who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take? Remove one of the weights Tie knotts in the ropes near the pulleys to shorten them Increase the elevation of the affected extremity Pull the client up in bed

Answer 78

**Remove one of the weights** Rationale: In skeletal traction, weights are used to create a pulling force to align the bones and reduce the fracture. If the weights are resting on the floor, it indicates that they are not providing the necessary traction. This can compromise the alignment of the fracture and delay healing. Removing one of the weights may help to adjust the system and ensure that proper traction is being applied. Tie knots in the ropes near the pulleys to shorten them: This is not a safe intervention, as it can alter the intended traction and lead to complications. Increase the elevation of the affected extremity: While elevation is important to reduce swelling, it does not address the issue of the weights not providing traction. Pull the client up in bed: This does not correct the problem of the weights resting on the floor and could further disturb the traction setup.