ALL QUESTIONS ASSOCIATED WITH ATI

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created 1 year ago by roneshac93
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STARTED THIS AT THE BEGINING OF NURSING SCHOOL ! I HAVE PASSED MY EXIT EXAM USING THESE CARD ! HOPE THIS HELPS ANYONE IN NEED
updated 6 weeks ago by roneshac93
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A NURSE IS CARING FOR A CLIENT WHO HAS BEEN APPLYING SILVER SULFADIAZINE CREAM TO A DEEP PARTIAL THICKNESS ARM BURN FOR THE PAST 2 WEEKS. THE NURSE SHOULD MONITOR THE CLIENT FOR WHICH OF THE FOLLOWING ADVERSE EFFECTS?

LEUKOPENIA

AN ADVERSE EFFECT OF SILVER SULFA. THE NURSE SHOULD MONITOR THE CLIENTS ALLERGIC REACTION CAUSING A DECREASE IN THE CLIENTS WBC COUNT

2

A NURSE IS CONTRIBUTING TO THE PLAN OF CARE FOR A CLIENT WHO HAS BEEN ADMITTED FOR TREATMENT OF A MALIGNANT MELANOMA OF THE UPPER LEG WITHOUT METASTASIS. THE NURSE SHOULD EXPECT THE PROVIDER TO PERFORM WHICH OF THE FOLLOWING PROCEDURES?

SURGICAL EXCISION

THE TREATMENT OF CHOICE FOR SMALL, SUPERFICIAL LESIONS. DEEPER LESIONS REQUIRE WIDE LOCAL EXCISION, FOLLOWED BY SKIN GRAFTING

3

A NURSE IS CARING FOR A CLIENT WHOSE WOUNDS ARE COVERED WITH A HETEROGRAFT DRESSING. IN RESPONSE TO THE CLIENT'S QUESTIONS ABOUT THE DRESSING, THE NURSE EXPLAINS THAT IT IS OBTAINED FROM WHICH OF THE FOLLOWING SOURCES?

PIG SKIN

HETEROGRAFTS ARE OBTAINED FROM AN ANIMAL, USUALLY A PIG

4

A NURSE IS CARING FOR A CLIENT WHO HAS A LESION ON THE BACK OF HIS RIGHT HAND. THE CLIENT ASKS THE NURSE WHICH TYPE OF SKIN CANCER IS THE MOST SERIOUS. WHICH OF THE FOLLOWING RESPONSES SHOULD THE NURSE MAKE ?

MELANOMAS.

MALIGNANT NEOPLASMS WITH ATYPICAL MELANOCYTES IN BOTH THE EPIDERMIS, THE DERMIS, AND SOMETIMES THE SUBQ CELLS. IT IS THE MOST LETHAL TYPE OF SKIN CANCER. OFTEN CAUSING METASTASES IN THE BONE, LIVER, LUNGS, SPLEEN , CNS AND THE LYMPH NODES.

5

A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO HAS BURN INJURIES TO HIS TRUNK ABOUT WHAT TO EXPECT FROM THE PRESCRIBED HYDROTHERAPY. WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT INDICATES AN UNDERSTANDING OF THE TEACHING?

" I WILL BE ON A SPECIAL SHOWER TABLE"

HYDROTHERAPY IS A SPECIAL SHOWER TABLE THAT FACILITATES THE EXAMINATION AND DEBRIDEMENT OF THE WOUND.

ADVANTAGES: THE WATER CAN BE KEPT AT A CONSTANT TEMPERATURE AND THERE IS A LOWER RISK OF WOUND INFECTION.

6

A NURSE IS ASSISTING WITH THE ADMISSION OF A CLIENT WHO IS BEDRIDDEN AND WAS ADMITTED FROM HOME. THE NURSE NOTES A SHALLOW CRATER IN THE EPIDERMIS OF THE CLIENTS SACRAL AREA. THE NURSE SHOULD DOCUMENT THAT THE CLIENT HAS A PRESSURE ULCER AT WHAT OF THE FOLLOWING STAGES?

STAGE 2

- PARTIAL THICKNESS SKIN LOSS

- VISIBLE AND SUPERFICIAL

- CAN APPEAR AS A BLISTER, ABRASION, OR SHALLOW CRATER

- EDEMA PERSISTS AND THE ULCER CAN BECOME INFECTED.

- MIGHT REPORT PAIN AND DRAINAGE

7

A NURSE IS ASSISTING WITH THE CARE OF A CLIENT WHO IS IN THE RESUSCITATION PHASE FOLLOWING A MAJOR BURN. WHICH OF THE FOLLOWING LABORATORY FINDINGS SHOULD THE NURSE EXPECT.

SODIUM 132 MEq/L

SHOULD ANTICIPATE CLIENT TO HAVE A LOW SODIUM LEVEL BECAUSE SODIUM IS TRAPPED IN INTERSTITIAL SPACE

8

A NURSE IS COLLECTING DATA FROM A CLIENT WHO SUSTAINED SUPERFICIAL PARTIAL THICKNESS AND DEEP PARTIAL THICKNESS BURNS 72 HOURS AGO. WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE REPORT TO THE PROVIDER?

TEMPERATURE OF 39.1 (102.4)

- ELEVATED TEMP INDICATES INFECTION

- SEPSIS IS CRITICAL FINDING FOLLOWING A MAJOR BURN

9

A NURSE IS ASSISTING WITH THE DEVELOPMENT OF A PROGRAM TO EDUCATE CLIENTS ABOUT MEASURES TO REDUCE THE RISK OF SKIN CANCER. WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD THE NURSE INCLUDE.

AVOID EXPOSURE TO THE MIDDAY SUN

- AVOID CONTACT BETWEEN 1100 AND 1500 BECAUSE SUN RAYS ARE THE STRONGEST DURING THAT TIME

10

A NURSE IN A PROVIDERS OFFICE IS CARING FOR A CLIENT WHO HAS A NEW DIAGNOSIS OF HERPES ZOSTER. THE NURSE SHOULD ANTICIPATE A PRESCRIPTION FOR WHICH OF THE FOLLOWING MEDICATIONS?

ACYCLOVIR

- ANTIVIRAL MEDICATION

- INHIBITS REPLICATION OF THE VIRUS THAT CAUSES HERPES ZOSTER

11

A NURSE IS ASSISTING WITH THE DEVELOPMENT OF AN EDUCATION SESSION ABOUT MALIGNANT MELANOMA FOR A GROUP OF CLIENTS. THE NURSE SHOULD INCLUDE THAT WHICH OF THE FOLLOWING CLIENTS HAS AN INCREASED RISK FOR DEVELOPING MALIGNANT MELANOMA

A CLIENT WHO HAS A LIGHT COMPLEXION

- A LIGHT COMPLEXION HAS LESS PIGMENTATION

12

A NURSE IS COLLECTING DATA FROM A CLIENT WHO HAS AN ARM LESION. WHICH OF THE FOLLOWING CHARACTERISTICS IS A CLINICAL MANIFESTATION OF A MALIGNANT MELANOMA

IRREGULARLY SHAPED WITH BLUE TONES

- MALIGNANT MELANOMAS ARE IRREGULARLY SHAPED AND CAN BE BLUE, RED, OR WHITE IN TONE.

- OFTEN OCCUR ON UPPER BACK AND LOWER LEGS

13

A NURSE IS REINFORCING DISCHARGE TEACHING WITH A CLIENT WHO IS POSTOPERATIVE FOLLOWING A SURGICAL EXCISION OF A BASAL CELL CARCINOMA. WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE INCLUDE AS AN INDICATION OF MALIGNANCY OF A MOLE?

ULCERATION

- BLEEDING , EXUDATION ARE INDICATIONS OF A MOLES POTENTIAL MALIGNANCY

- INCREASING IN SIZE

- FOLLOW UPS AND PROPER TECHNIQUES FOR SELF EXAMINATION

14

A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO IS WHEELCHAIR BOUND AND HIS CAREGIVER ABOUT WAYS TO REDUCE THE RISK OF PRESSURE ULCER FORMATION. WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD THE NURSE INCLUDE?

SHIFT YOUR WEIGHT IN THE WHEELCHAIR EVERY 15 MINUTES

- THIS RESPONSE ADDRESSES THE SAFETY ISSUE OF PRESSURE ULCER RISK

- MOST LIKELY TO DEVELOP IF THE CLIENT DOES NOT SHIFT POSITION FREQUENTLY TO RELIEVE PRESSURE

15

A NURSE ON A SURGICAL UNIT IS CARING FOR FOUR CLIENTS WHO HAVE HEALING WOUNDS. WHICH OF THE FOLLOWING WOUNDS SHOULD THE NURSE EXPECT TO HEAL BY PRIMARY INTENTION?

SURGICAL INCISION

A WOUND THAT HEALS BY PRIMARY INTENTION

16

PRIMARY INTENTION

A CLEAN WOUND THAT IS CLOSED MECHANICALLY WITH WELL APPROXIMATED EDGES AND MINIMAL SCARRING

17

A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO HAS A LARGE WOUND HEALING BY SECONDARY INTENTION. THE NURSE SHOULD INSTRUCT THE CLIENT THAT WHICH OF THE FOLLOWING NUTRIENTS PROMOTES WOUND HEALING?

VITAMIN C

18

A NURSE IS CARING FOR AN ADOLESCENT CLIENT WHO HAS BURN WOUNDS ON HER FACE AND HANDS. WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT INDICATES THAT SHE HAS ADAPTED TO HER CHANGED BODY IMAGE?

" MAY I GO WITH MY FAMILY TO THE VISITORS LOUNGE?"

19

A NURSE IS OBSERVING THE SKIN OF A CLIENT WHO HAS FROSTBITE. THE CLIENT HAS A SMALL BLISTER THAT CONTAIN BLOOD AND THE SKIN OF THE AFFECTED AREA DOES NOT BLANCH. THE NURSE SHOULD CLASSIFY THIS INJURY AS WHICH OF THE FOLLOWING?

3 DEGREE FROSTBITE

  • AFFECTED SKIN HAS SMALL BLISTERS THAT ARE BLOOD FILLED AND THE SKIN DOES NOT BLANCH
20

A NURSE IN A PROVIDERS OFFICE IS COLLECTING DATA FROM A CLIENT WHO HAS SKIN LESIONS. THE NURSE NOTES THAT THE LESIONS ARE 0.5CM (0.20IN) IN SIZE, ELEVATED, AND SOLID, WITH VERY DISTINCT BORDERS. THE NURSE SHOULD DOCUMENT THE FINDINGS AS WHICH OF THE FOLLOWING SKIN LESIONS?

PAPULES

  • SMALL, SOLID, ELEVATED LESION WITH DISTINCT BORDERS
  • USALLY SMALLER THAN 10MM IN DIAMETERS
  • WARTS AND ELEVATED MOLES ARE EXAMPLES
21

A NURSE IN AN URGENT CARE CLINIC IS CARING FOR A CLIENT WHO HAS A SNAKEBITE ON HER ARM. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE?

IMMOBILIZE THE LIMB AT THE LEVEL OF THE HEART

  • LIMIT THE SPREAD OF THE VENOM
  • ANY CLOTHING OR JEWELRY SHOULD BE REMOVED BEFORE SWELLING WORSENS
22

THE HEALTH CARE PROVIDER HAS ORDERED ORAL GRISEOFULVIN OF TINEA CAPITIS. THE PATIENT'S MOTHER ASKS THE NURSE WHY AN ORAL MEDICATION IS USED RATHER THAN A CREAM. WHAT INFORMATION SHOULD BE PROVIDED BY THE NURSE?

TOPICAL CREAMS DO NOT REACH THE ROOT OF THE HAIR TO KILL FUNGUS

23

THE NURSE IS CARING FOR A PATIENT WITH AN OPEN SKIN LESION. WHAT IS THE PATIENT GOAL WITH HIGH PRIORITY?

THE PATIENT DOES NOT DEVELOP AN INFECTION OF THE LESION

24

WHAT ASSESSMENT SHOULD THE NURSE REPORT TO THE HEALTH CARE PROVIDER IMMEDIATELY FOR AN ADULT PATIENT WITH PARTIAL THICKNESS BURNS OVER 25% OF HIS BODY?

HOURLY URINARY OUTPUT OF 10 TO 15 ML

25

A PATIENT HAS A RASH ON HER BACK THAT BEGAN ABOUT 10 DAYS AGO WITH A RAISED, SCALY BORDER AND A PINK CENTER. NOW SHE HAS A SIMILAR ERUPTION ON BOTH SIDES OF HER BACK. WHAT CONDITION MIGHT SHE HAVE?

PITYRIASIS ROSEA

26

A PATIENT COMPLAINS OF A BURMNING PAIN ON HIS LOWER THORACIC AREA. ON INSPECTION, THE AREA IS FOUND TO BE ERYTHEMATOUS AND EDEMATOUS WITH A CLUSTER OF VESICLES. WHAT CONDITION IS MOST LIKELY TO BE DIAGNOSED?

HERPES ZOSTER

27

A PATIENT STATES THAT HE HAS BASAL CELL CARCINOMA AND IS GOING TO DIE. WHEN PLANNING THE BEST RESPONSE TO MAKE, THE NURSE SHOULD INCLUDE WHAT KNOWLEDGE?

BASAL CELL CARCINOMA IS RARELY TERMINAL

28

IT IS IMPORTANT TO TEACH A PATIENT THE WARNING SIGNS OF SKIN CANCER. WHICH CHARACTERITICS OF A NEVUS IS A WARNING SIGN OF SKIN CANCER?

  • BORDER IRREGULARITY
  • DELAYED OR PROLONGED LESIONAL HEALING
29

A PATIENT HAS AN INHALATION BURN INJURY. WHICH IS A MEDICAL EMERGENCY?

RESPIRATORY STRIDOR

30

WHAT METHOD OF ASSESSING BURN SIZE APPLIES ONLY TO ADULTS?

RULE OF NINES

31

THE NURSE JUST FINISHED AN ASSESSMENT FOR A PATIENT WITH SYSTEMIC LUPUS E. WHAT CLINICAL MANIFESTATION WOULD THE NURSE EXPECT TO FIND?

  • ORAL ULCERS
  • ERYTHEMATOUS RASH OVER THE NOSE AND CHEEKS
32

THE HEALTH CARE PROVIDER HAS SCHEDULED A DEBRIDEMENT FOR A PATIENT WHO HAS PARTIAL THICKNESS BURNS ON HIS CHEST AND RIGHT UPPER LEG. WHICH NURSING INTERVENTION IS MOST IMPORTANT?

ADMINISTER AN OPIOIOD ANALGESIC INTRAVENOUSLY BEFORE THE DEBRIDEMENT

33

A PATIENT IS ADMITTED WITH PARTIAL AND FULL THICKNESS BURNS ON HIS RIGHT LOWER EXTREMITY. WHAT IS LIKELY TO BE INCLUDED IN THE PLAN OF CARE INITIALLY?

CLOSED DRESSING CHANGE EVERY 3 HOURS

34

A PATIENT IS ADMITTED WITH PARTIAL THICKNESS BURNS ON HIS UPPER CHEST AND FACE. WHAT IS THE MOST IMPORTANT THING FOR THE NURSE TO MONITOR IN THE PATIENT ON ADMISSION?

RESPIRATORY PROBLEMS

35

WHAT SHOULD BE INCLUDED IN THE ASSESSMENT OF A PATIENT WITH AN ELECTRICAL BURN?

CARDIAC IRREGULARITIES

36

A PATIENT IS ADMITTED WITH HERPES ZOSTER. THE HEALTH CARE PROVIDER ORDERS AN ANTIVIRUL MEDICATION TO SLOW THE PROGRESSION OF THE VIRUS. WHICH MEDICATION WITH THE NURSE ADMINISTER?

ACYCLOVIR (ZOVIRAX)

37

A PATIENT HAS BEEN DIAGNOSED WITH SCABIES. WHAT WILL THE NURSE ANTICIPATE TO ASSESS WITH THIS PATIENT?

  • WAVY BROWN LINES ON THE SKIN
  • NOCTURNAL PRITUS (ITCHING THAT IS MORE SEVERE AT NIGHT
38

AN ADOLESCENT PATIENT IS SEEN IN THE CLINIC WITH A MILD CASE OF ACNE. WHAT DOES THE NURSE EXPECT TO ASSESS?

THE PATIENT REPORTS A SENSE OF LOW SELF ESTEEM

39

A PATIENT WITH THERMAL BURNS OVER 30% OF HIS BODY HAS MAINTAINED A URINARY OUTPUT OF 250 ML FOR THE PAST 8 HOURS. WHAT CAN THE NURSE INFER FROM THIS INFORMATION?

STAGE OF HYPOVOLEMIC BURN SHOCK IS RESOLVING

40

A PATIENT TELLS THE NURSE SHE HAS NOT GONE OUT OF THE HOUSE FOR WEEKS BECAUSE SHE COULD NOT COVER LESIONS ON HER FACE WITH MAKEUP. WHAT WOULD BE AN APPROPRIATE PATIENT PROBLEM?

DISTORED BODY IMAGE, RELATED TO CHANGE IN PERSONAL APPEARANCE

41

WHEN TEACHING A PATIENT TO CARE FOR HERPES ZOSTER LESIONS AT HOME, WHAT IS THE MOST IMPORTANT INSTRUCTION FOR THE NURSE TO PROVIDE?

WHAT HANDS BEFORE AND AFTER APPLYING MEDICATION

42

THE NURSE IS REVIEWING THE HISTORY FOR A PATIENT WHO HAS BEEN ADMITTED WITH CELLUITIS. WHAT CONDITIONS WOULD PREDISPOSE THE PATIENT TO CELLULITIS?

  • MALNUTRITION
  • TREATMENT WITH CHEMOTHERAPY
  • VENUS INSUFFICIENCY OF THE LOWER LEGS
  • DIABETES MELLITUS
43

A PARENT TELLS THE DERMATOLOGISTS THAT HER DAUGHTER SEEMS TO BE LOOSING INTEREST IN SCHOOL/ WHICH MEDICATION COULD HAVE CAUSED THE PATIENTS CHANGE IN BEHAVIOR

ISOTRETINOIN

44

AN AFRICAN AMERICAN PATIENT IS SEEN WITH IMPENDING SHOCK AFTER AN ACCIDENT. HOW WOULD THE NURSE EXPECT THE SKIN TO APPEAR DURING THE ASSESSMENT OF THE PATIENT?

ASHEN, GRAY, OR DULL

45

THE NURSE PLANNING THE CARE FOR A PATIENT WHO HAS IMPETIGO EXPECTS TO ADMINISTER WHAT TOPICAL DRUG TO THE PATIENT ?

RETAPAMULIN

46

WHEN TEACHING HOME CARE TO A PATIENT WITH RECURRENT GENITAL HERPES INFECTION. IT IS IMPORTANT TO INCLUDE WHAT INFORMATION?

  • THE PATIENT WILL NEED TO USE PROTECTION EVEN WHEN NO LESIONS ARE EVIDENT
  • PRECAUTIONS FOR DELIVERY MUST BE MADE IN THE EVENT OF BECOMING PREGNANT
47

A NURSE IN A DEMATOLOGY CLINCIC IS USING THE ABCDE METHOD WHILE SCREENING SEVERAL OF A CLIENTS SKIN LESIONS FOR SKIN CANCER. WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE REPORT TO THE PROVIDER

COLOR VARIATION WITHIN A LESION

48

A NURSE IS ASSISTING WITH THE DEVELOPMENT OF A PROGRAM TO EDUCATE CLIENTS ABOUT MEASURES TO REDUCE RISK OF SKIN CANCER. WHAT INSTRUCTIONS SHOULD THE NURSE INCLUDE ?

AVOID EXPOSURE TO THE MIDDAY SUN

49

A NURSE IN A PROVIDER'S OFFICE IS COLLECTING DATA FROM A CLIENT WHO HAS SKIN LESIONS. THE NURSE NOTES THAT THE LESIONS ARE 0.5 (0.20 IN) IN SIZE, ELEVATED, AND SOLID WITH DISTINCT BORDERS. THE NURSE SHOULD DOCUMENT THESE FINDINGS AS WHICH OF THE FOLLOWING SKIN LESIONS ?

PAPULES

50

A NURSE IS SCREENING A CLIENT FOR SKIN CANCER. WHEN REINFORCING TEACHING WITH THE CLIENT ABOUT SKIN CANCER RISK, WHICH OF THE FOLLOWING RISK FACTORS SHOULD THE NURSE INCLUDE ?

EXCESSIVE EXPOSURE TO ULTRAVIOLET LIGHT

51

A NURSE IS REINFORCING TEACHING WITH A GROUP OF CLIENTS ABOUT SKIN CANCER. THE NURSE SHOULD EXPLAIN THAT BASAL CELL CARCINOMA ORIGINATES FROM WHICH OF THE FOLLOWING TISSUES?

EPIDERMIS

52

A NURSE IS CARING FOR AN ADOLESCENT CLIENT WHO HAS BURN WOUNDS ON HER FACE AND HANDS. WHAT STATEMENT BY THE CLIENT INDICATES THAT SHE HAS ADAPTED TO HER CHANGED BODY IMAGE?

MAY I GO WITH MY FAMILY TO THE VISITORS LOUNGE?

53

A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO HAS A LARGE WOUND HEALING BY SECONDARY INTENTION. THE NURSE SHOULD INSTRUCT THE CLIENT THAT WHICH OF THE FOLOOWING NUTRIENTS PROMOTES WOUND HEALING

VITAMIN C

54

A NURSE IS ASSISTING WITH THE ADMISSION OF A CLIENT WHO IS BEDRIDDEN AND WAS ADMITTED FROM HOME. THE NURSE NOTES A SHALLOW CRATER IN THE EPIDERMIS OF THE CLIENTS SACRAL AREA. THE NURSE SHOULD DOCUMENT THAT THE CLIENT HAS A PRESSURE ULCER AT WHICH OF THE FOLLOWING STAGES?

2

55

A NURSE IS CARING FOR A CLIENT WHO HAS BEEN APPLYING SILVER SULFADIZINE CREAM TO A DEEP PARTIAL THICKNESS ARM BURN FOR THE PAST 2 WEEKS. THE NURSE SHOULD MONITOR THE CLIENT FOR WHICH OF THE FOLLOWING ADVERSE EFFECTS

LEUKOPENIA

56

A NURS EIN A PROVIDERS OFFICE IS CARING FOR A CLIENT WHO HAS A NEW DIAGNOSIS OF HERPES ZOSTER. THE NURSE SHOULD ANTICIPATE A PRESCRIPTION FOR WHICH OF THE FOLLOWING MEDICATIONS

ACYCLOVIR

57

A NURSE IS CARING FOR A CLIENT WHO HAS A DEEP PARTIAL AND FULL THICKNESS BURN AND REQUIRES A TOPICAL ANTIMICROBIAL DRUG. THE GOAL OF THIS MEDICATION THERAPY IS TO REDUCE WHICH OF THE FOLLOWING OUTCOMES

BACTERICAL GROWTH

58

A NURSE IS CARING FOR A CLIENT WHO WOUNDS ARE COVERED WITH A HETEROGRAFT DRESSING. IN RESPONSE TO THE CLIENTS QUESTIONS ABOUT THE DRESSING THE NURSE EXPLAINS THAT IT IS OBTAINED FROM WHICH OF THE FOLLOWING SOURCES

PIG SKIN

59

A NURSE IS CONTRIBUTING TO THE PLAN OF CARE FOR A CLIENT WHO HAS BEEN ADMITTED FOR THE TREATMENT OF A MALIGNANT MELANOMA OF THE UPPER LEG WITHOUT MESTASIS. THE NURSE SHOULD EXPECT THE PROVIDER TO PERFORM WHICH OF THE FOLLOWING PROCEDURES ?

SURGICAL EXCISION

60

A NURSE IS ASSISTING WITH THE CARE OF A CLIENT WHO IS IN THE RESUSCITATION PHASE FOLLOWING A MAJOR BURN. WHICH OF THE FOLLOWING LAB FINDINGS SHOULD THE NURSE EXPECT

SODIUM 132 MeQ/l

61

A NURSE IS COLLECTING DATA FROM A CLIENT WHO IS 3 DAYS POST OP FOLLOWING ABDOMINAL SURGERY. THE CLIENTS INCISION I SLIGHTLY EDEMATOUS, APPEARS PINK WTH CRUSTING ON THE EDGES AND IS DRAINING SERISANGUINOUS FLUID. WHICH OF THE FOLLOWING STATEMENTS DESCRIBES THIS INCISION?

THE INCISION IS SHOWING SIGNS OF HEALING WITHOUT COMPLICATIONS

62

A NURSE IS ASSISTING WITH PLANNING CARE FOR A CLIENT WHO HAS DEEP PARTIAL THICKNESS AND FULL THICKNESS THERMAL BURNS OVER 40 PERCENT OF HIS TOTAL BODY SURFACE. THE FOLLOWING INTERVENTIONS SHOULD SHOULD THE NURSE INCLUDE IN THE PLAN

INITIATE RANGE OF MOTION EXERCISES

63

A NURSE IS CARING FOR A CLIENT WHO HAS SMOKE INHALATION AND FULL THICKNESS BURNS COVERING 63 PERCENT OF HER BODY. WHICH OF THE FOLLOWING NURSING ACTIONS IS THE NURSES PRIORITY ?

MONITOR RESPIRATORY STATUS

64

A NURSE IS COLLECTING DATA FROM A CLIENT WHO SUSTAINED SUPERFICIAL PARTIAL THICKNESS AND DEEP PARTIAL THICKNESS BURNS 72 HOURS AGO WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE REPORT TO THE PROVIDER

TEMP 39.1 (102.4)

65

A NURSE IN AN URGENT CARE CLINIC IS CARING FOR A CLIENT WHO HAS A SNAKEBITE ON HER ARM. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE?

IMMOBILIZE THE LIMB AT THE LEVEL OF THE HEART

66

A NURSE IS CARING FOR A CLIENT WHO HAS A LESION ON THE BACK OF HIS RIGHT HAND. THE CLIENT ASKS THE NURSE WHICH TYPE OF CANCER IS THE MOST SERIOUS. WHICH OF THE FOLLOWING RESPONSES SHOULD THE NURSE MAKE?

MELANOMAS

67

A NURSE IS REINFORCING DISCHARGE TEACHING WITH A CLIENT WHO IS POST OP FOLLOWING SURGICAL EXCISION OF A BASAL CELL CARCINOMA. WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE INCLUDE AS AN INDICATION OF MALIGNANCY OF A MOLE

ULCERATION

68

A NURSE IS COLLECTING DATA FROM A CLIENT WHO HAS AN ARM LESION. WHICH OF THE FOLLOWING CHARACTERISTICS IS A CLINICAL MANIFESTATION OF MALIGNANT MELANOMA

IRREGULARLY SHAPED BLUE TONES

69

A NURSE ON A SURGICAL UNIT IS CARING FOR 4 CLIENTS WHO HAVE WOUND HEALING WHICH OF THE FOLLOWING WOUNDS SHOULD THE NURSE EXPECT TO HEAL BY PRIMARY INTENTION

SURGICAL INCISION

70

A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO HAS BURN INJURIES TO HIS TRUNK ABOUT WHAT TO EXPECT FROM THE PRESCRIBED HYDRO THERAPY. WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT INDICATES UNDERSTAND OF THE TEACHING

I WILL BE ON A SPECIAL SHOWER CHAIR

71

A NURSE IS OBSERVING THE SKIN OF A CLIENT WHO HAS FROSTBITE. THE CLIENT HAS SMALL BLISTERS THAT CONTAIN BLOOD AND THE SKIN OF THE AFFECTED AREA DOES NOT BLANCH. THE NURSE SHOULD CLASSIFY THIS INJURY AS WHICH OF THE FOLLOWING

THIRD DEGREE FROSTBITE

72

A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO IS WHEELCHAIR BOUND AND HIS CAREGIVER ABOUT WAYS TO REDUCE THE RISK OF PRESSURE ULCER FORMATION. WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD THE NURSE INCLUDE ?

SHIFT YOUR WEIGHT IN THE WC EVERY 15 MINUTES

73

A NURSE IN AN URGENT CARE CLINIC IS COLLECTING DATA FROM A CLIENT WHO HAS EXTENSIVE BURNS, INCLUDING ON HER FACE . WHICH OF THE FOLLOWING DATA SHOULD THE NURSE COLLECT

RESPIRATORY RATE

74

A NURSE IS CARING FOR A CLIENT WHO HAS REGULAR OCCUPATIONAL EXPOSURE TO SUN LIGHT AND PRESENTS TO THE CLINIC FOR EVAL OF SEVERAL SKIN LESIONS WHICH OF THE FOLLOWING FINDINGS SHOULD ALERT THE NURSE TO THE FOLLOWING FINDINGS SHOULD ALRET THE NURSE TO THE POSSIBILITY OF MALIGNANT MELANOMA?

AN IRREGULARLY SHAPED BROWN LESION WITH LIGHT BLUE AREAS ON THE NECK

75

A COMMUNITY HEALTH NURSE IS TEACHING ABOUT MELANOMA WITH A GROUP OF CLIENTS. WHICH OF THE FOLLOWING CHARACTERISTICS OF LESIONS ASSOCIATED WITH MELANOMA SHOULD THE NURSE INCLUDE INT HE TEACHING?

IRREGULAR BORDER

76

A NURSE IS REINFORCING DISCHARGE TEACHING ABOUT FOOT CARE WITH A CLIENT WHO HAS DIABETES. WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD THE NURSE INCLUDE IN THE TEACHING ?

TEST WATER TEMP WITH THE WRIST

77

A NURSE IS ASSESSING A PATIENT'S INDWELLING URINARY CATHETER DRAINAGE AT THE END OF THE SHIFT AND NOTES THE OUTPUT IS CONSIDERABLY LESS THAN THE FLUID INTAKE. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE FIRST?

CHECK THE CATHETER FOR KINKS

78

A NURSE IS LIKELY TO RECIEVE AN ORDER FOR URINARY CATHETERIZATION OF A NEWLY ADMITTED PATIENT WHO

IS IN THE ICU FOR GASTROINTESTINAL BLEED

79

A NURSE IS PREPARING TO INSERT AN INDWELLING URINARY CATHETER FOR A FEMALE PATIENT. WHEN BEGINNNING THE INSERTION PROCEDURE, THE NURSE SHOULD INSTRUCT THE PATIENT TO

BEAR DOWN

80

WHEN PROVIDING PERINEAL CARE FOR A FEMALE PATIENT WHO HAS AN INDWELLING URINARY CATHETER. WHAT AREA SHOULD THE NURSE CLEAN LAST

THE ANUS

81

A NURSE IS PLANNING ON OBTAINING A URINARY SPECIMEN FROM A PATIENTS CLOSED URINARY SYSTEM. IDENTIFY THE SEQUENCE OF STEPS THE NURSE SHOULD TAKE

  • WIPE THE PORT WITH AN ALCOHOL SWAB
  • INSERT A 10 ML SYRINGE AND NEEDLE INTO THE PORT
  • WITHDRAW 5 ML OF URINE
  • TRANSFER THE URINE TO A STERILE SPECIMEN CONTAINER
  • TRANSPORT THE SPECIMEN TO THE LAB
82

A NURSE IS APPLYING A CONDOM CAT FOR AN OLDER ADULT PATIENT WHO IS UNCIRCUMCISED. WHAT IS AN APPROPRIATE STEP IN THE PROCEDURE ?

LEAVING A SPACE BETWEEN THE PENIS AND THE CATHETERS TIP

83

A NURSE WHO IS PREPARING TO INSERT A STRAIGHT URINARY CAT FOR A MALE PATIENT SHOULD

APPLY LIGHT TRACTION TO THE PENIS

84

A NURSE IS CARING FOR A PATIENT WHO HAS A TRACH TUBE WITH AN INNER CANNULA IN PLACE. WHAT SUPPLIES SHOULD THE NURSE USE TO DY THE INNER CANNULA OF THE PATIENTS TRACH TUB AFTER CLEANING IT

FOLDED PIPE CLEANERS

85

A NURSE IS PREPARING TO SUCTION SECRETIONS FORM THE MOUTH OF A PATIENT WHO HAS DYSPHAGIA. WHAT IS THE APPROPRIATE SUCTION DEVICE OR METHOD FOR THE NURSE TO USE?

YANKAUER CATHETER

86

A NURSE IS CARING FOR A PATIENT WHO HAS A TRACHEOSTOMY TUBE IN PLACE. DURING TRACH CARE, WHAT SHOULD THE NURSE PLACE UNDERNEATH THE FLANGES OF THE OUTER CANNULA

COMMERCIALLY PREPARED FENESTRATED DRESSING

- DOES NOT UNRAVEL AND HAS FENESTRATION SLITS DESIGNED TO FIT AROUND THE TRACHOSTOMY TUBE UNDER THE FLANGES

87

A NURSE IS CARING FOR A PATIENT WHO HAS CUFFED ENDOTRACHEAL TUBE IN PLACE. WHAT IS AN APPROPRIATE COMPONENT OF ET TUBE CARE FOR THIS PATIENT

REPOSITIONING THE ET TUBE IN THE PATIENTS MOUTH EVERY 12 HOURS

88

A NURSE IS PREPARING TO PERFORM ENDOTRACHEAL TUBE CARE AND PLANS TO USE TAPE TO SECURE THE TUBE. WHAT IS AN APPROPRIATE PREP ACTION FOR THIS PROCEDURE ?

HAVE TINCTURE OF BENZOIN READY TO APPLY TO THE PATIENTS FACE

89

A NURSE IS SUCTIONING A PATIENTS AIRWAY USING IN LINE SUCTIONING. WHEN USING THIS METHOD IT IS APPROPRIATE FOR THE NURSE TO

REUSE THE CATHETER REPEATEDLY

90

A NURSE IS PERFORMING CHEST PHYSIOTHERAPY FOR A PATIENT WHO NEEDS HELP MOBILIZING AND EXPECTORATING THICK PULMONARY SECRETIONS. TO INCREASE THE TURBULENCE OF THE AIR THE PATIENT EXHALES THE NURSE SHOULD USE WHICH TECHNIQUE

VIBRATION

USED DURING OR AFTER PERCUSSION TO INCREASE THE TURBULENCE OF EXHALED AIR AND LOOSEN SECRETIONS

91

A NURSE IS CARING FOR A PATIENT WHO SUSTAINED TRAUMA TO HIS HEAD AND NECK AND WILL REQUIRE LONG TERM AIRWAY SUPPORT. WHAT DEVICE WILL BE REQUIRED FOR HOME HEALTH CARE FOR THIS PATIENT?

TRACHEOSTOMY TUBE

92

STANDARD PRECAUTIONS MANDATE

DISINFECTING HANDS IMMEDIATELY AFTER REMOVING GLOVES

93

AFTER COMPLETING A PROCEDURE THAT REQUIRED DONNING PERSONAL PROTECTIVE EQUIPMENT CONSISTING OF A GOWN, N95, A FACE SHIELD AND GLOVES. WHAT SHOULD THE NURSE REMOVE FIRST WHEN REMOVING PPE SEPARATELY

GLOVES

94

YOU ARE ABOUT TO IRRIGATE A PATIENTS OPEN WOUND. BESIDES GLOVES, WHICH OTHER ITEM OF PPE MUST YOU WEAR?

FACE SHIELD

95

WHICH PRODUCT CAN AFFECT THE PERMEABILITY OF GLOVES

PETROLEUM BASED HAND LOTION

96

A CLIENT HAS A HEALTHCARE ASSOCIATED INFECTION (HAI). WHAT BEST DESCRIBES HAI?

ACQUIRING THE INFECTION WHILE HOSPITALIZED

97

YOU ARE CARING FOR A PATIENT DIAGNOSED WITH MYCOPLASMAL PNEUMONIA. DROPLET PRECAUTIONS HAVE BEEN INSTITUTED SO YOU MUST

PROTECT YOUR EYES

98

CONTACT PRECAUTIONS WOULD BE MANDATED FOR A HOSPITALIZED ADULT PATIENT DIAGNOSED WITH

INFECTIOUS DIARRHEA

99

you are washing your hands with non antimicrobial soap and water prior to repositioning a patient in a bed. during the handwashing procedure it is important to?

continue for at least 15 seconds

100

to decontaminate your hands with an alcohol based gel, you rub them together until all of the gel has evaporated and your hands are dry. the primary reason you do this is that

drying provides the full antiseptic effect

101

which of the following is an advantage of using alcohol based gel?

it use takes less time than washing with soap and water does

102

after assisting a newly admitted patient in removing his shoes and outerwear you notice what appears to be soil or grime on your hands you

wash your hands with soap and water

103

WHERE DOES HEMATOPOIESIS TAKE PLACE?

RED BONE MARROW

104

THE NURSE IS REPOSITIONING A PATIENT. DURING THE MOVEMENT THE EXTREMITY IS PLACED IN A POSITION AWAY FROM THE MIDLINE OF THE BODY. TO DOCUMENT THIS POSITION, WHAT TERM IS MOST APPROPRIATE

ABDUCTION

105

A PATIENT IS SUSPECTED OF HAVING RHEUMATOID ARTHRITIS. WHAT DIAGNOSTIC TESTS MAY BE USED TO SUPPORT THE DIAGNOSIS?

  • CBC
  • ESR
  • C REACTIVE PROTEIN
106

THE NURSE IS REVIEWING THE ASSESSMENT FINDINGS AND MEDICAL HISTORY OF A PATIENT SUSPECTED OF HAVING GOUTY ARTHRITIS. WHAT FINDINGS SUPPORT THE DIAGNOSIS?

TOPHI

107

A 55 YEAR OLD PATIENT MENTIONS THAT SHE IS POSTMENOPAUSAL AND IS NOT TAKING ESTROGEN SUPPLEMENTS. A REVIEW OF HER NORMAL DIETARY INTAKE INDICATES HIGH CONSUMPTION OF CAFFINE LIMITED DIETARY INGESTION OF CALCIUM. BASED ON HER HISTORY, SHE FACES AN INCREASED RISK FOR WHAT CONDITION?

OSTEOPOROSIS

108

WHAT ARE APPROPRIATE NURSING INTERVENTION FOR A PATIENT SUFFERING FROM A FRACTURED HIP WITH A BIPOLAR HIP REPAIR?

  • MAINTAIN ABDUCTION OF THE AFFECTED EXTREMITY
  • ENSURE THE HEAD OF THE BED IS NOT ELEVATED MORE THAN 45 DEGREES
109

A PATIENT IS BEING DISCHARGED AFTER A PROSTHETIC HIP IMPLANT. SHE ASKS WHEN SHE CAN BEGIN TO BEAR WEIGHT ON THE AFFECTED LEG. WHAT WOULD THE NURSE RESPONSE BE?

" YOU WILL MOST LIKELY REQUIRE SOME DEGREE OF NON WEIGHT BEARING FOR 6 WEEKS TO 3 MONTHS "

110

A PATIENT HAS BEEN SEEING THE HEALTH CARE PROVIDER FOR COMPLAINTS OF OSTEOARTHRITIS. TODAY THE PATIENT IS DISCUSSING CONCERNS ABOUT THEIR CONDITION AND ASKS WHAT HAS CAUSE THE OSTEOARTHRITIS. WHAT WOULD BE THE NURSES RESPONSE?

" WEAR AND TEAR OVER THE YEARS HAVE MOST LIKELY CAUSED THE JOINTS TO BEGIN TO DEGENERATE"

111

WHEN PROVIDING CARE TO A PATIENT IN SKELETAL TRACTION WHAT ACTION WOULD BE INCLUDED IN THE NURSE'S PLAN OF CARE?

CLEANSE PIN SITES AND OBSERVE FOR SIGNS OF INFECTION

112

AFTER A FRACTURE OF THE FOREARM OR TIBIA, COMPLAINTS OF SHARP, DEEP, UNRELENTING PAIN IN THE HAND OR FOOT UNRELIEVED BY ANALGESICS OR ELEVATION OF THE EXTREMITY INDICATE WHAT TYPE OF INFECTION?

COMPARTMENT SYNDROME

113

A PATIENT SUFFERED A KNEE INJURY WHILE PLAYING FOOTBALL. THE PATIENT IS SCHEDULED FOR AN ARTHROSCOPIC EXAM AND ASKS THE NURSE TO EXPLAIN THE PROCEDURE. WHAT INFORMATION WILL BE GIVEN TO THIS PATIENT ?

" YOUR HEALTH CARE PROVIDER WILL INSERT A SMALL SCOPE INTO YOUR KNEE JOINT TO VISUALIZE THE JOINT FOR DAMAGED TISSUE

114

A PATIENT WITH RA ASKS IF THERE IS A CURE. WHAT WOULD BE THE MOST APPROPRIATE RESPONSE BY THE NURSE ?

" NO, BUT NEW DRUGS CAN INTERFERE WITH THE BODYS REACTION TO INFLAMMATION AND BETTER CONTROL THE DISEASE PROCESS"

115

A PATIENT IS SCHEDULED FOR ENDOSCOPIC SPINAL MICRO SURGERY TO CORRECT A HERNIATED DISK. WHAT IS THE MOST ACCURATE STATEMENT CONCERNING THIS TYPE OF SURGERY

" SPECIAL SCOPES ARE PLACED THROUGH SMALL INCISIONS CAUSEING MINIMAL DAMAGE TO SURROUNDING TISSUE"

116

A PATIENT HAS OSTEOARTHRITIS OF THE KNNEE AND IS SEEKING INFORMATION ABOUT GLUCOSAMINE SUPPLEMENTS. WHAT WOULD BE AN APROPRIATE RESPONSE FROM THE NURSE ?

" STUDIES SUGGEST THAT GLUCOSAMINE SUPPLEMENTS MAY HAVE BE HELPFUL IN MAINTAING HEALTHY JOINT FUNCTION

117

WHAT IS THE MOST APPROPRIATE NURSING ASSESSMENT FOR THE PATIENT PROBLEM OF INEFFECTIVE TISSUE PERFUSION, SECONDARY TO FRACTURED HIP?

ASSESS FOR DISTAL PULSES

118

A PATIENT HAS JUST UNDERGONE TOTAL HIP REPLACEMENT. THE PATIENT ASKS WHY SHE CANNOT CROSS HER LEGS WHEN SITTING BUT MUST DO STRAIGHT LEG RAISING EXERCISES. WHAT IS THE MOST CORRECT RESPONSE?

" THE EXERCISES HELP STRENGTHEN THE LEG MUSCLES, CROSSING YOUR LEGS PUTS PRESSURE ON THE JOINTS AND COULD DAMAGE THE HIP PROSTHESIS

119

WHICH OBJECTIVE SIGNS WILL THE NURSE FIND DURING THE ASSESSMENT OF A PATIENT WITH COMPARTMENT SYNDROME IN THE LOWER LEG?

  • ABSENCE OF PULSATION IN THE AFFECTED EXTREMITY
  • PAIN THAT IS UNRELEASED BY MEDICATION OR ELEVATION OF THE EXTREMITY
120

A PATIENT HAD A COMPOUND FRACTURE OF HIS RIGHT FEMUR 2 YEARS BEFORE THE PRESENT ADMISSION. HIS HCP SUSPECTS OSTEOPMYELITIS AND HAS INFORMED THE PATIENT THAT TESTS ARE NEEDED TO CONFIRM THE DIAGNOSIS. THE PATIENT WANTS TO KNOW WHAT TESTS CAN BE ORDERED TO DETERMINE OSTEOMYELITIS. AN APPROPRIATE RESPONSE WOULD BE ?

  • BONE SCAN
  • BONE BIOPSY
  • ESR
121

A CONSTRUCTION WORKER SUFFERED A FRACTURE OF THE FEMUR 48 HOURS AGO. THE NURSE NOTICES THAT HE HAS PETECHIAE ON THE CONJUNCTIVA, CHEST , NECK AND AXILLAE. PETECHIAE IN THESE LOCATIONS ARE CONSISTENT WITH WHICH CONDITION?

FAT EMBOLISM

122

A NURSE IS COLLECTING DATA FROM A CLIENT WHO IS 24 HR POST OP FOLLOWING AN ABOVE THE ELBOW AMPUTATION. WHAT SHOULD THE NURSE IDENTIFY AS PRIORITY?

REPORT OF MUSCLE SPASMS

123

A NURSE IS CARING FOR A CLIENT WHO HAD A BELOW THE KNEE AMPUTATION FOR GANGRENE OF THE RIGHT FOOT. THE CLIENT REPORTS SENSATIONS OF BURNING, AND CRUSHING PAIN IN THE TOES OF THE RIGHT FOOT. WHAT STATEMENT SHOULD THE NURSE MAKE ?

AN ANTICONVULSANT MEDICATION CAN BE HELPFUL IN RELIEVING THIS TYPE OF PAIN.

124

A nurses is caring for a client who is 4hr post-op following a laparoscopic cholecystectomy. which of the following findings should the nurse expect?

right shoulder pain

125

nurse is assessing client who is experiencing perforation of a peptic ulcer. which of the following manifestations should the nurse expect?

border like abdomen

126

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred?

rigid abdomen

127

A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray?

wheat toast

128

A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding?

clear liquids

129

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings?

Diaphoreisis

130

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first?

place the client in semi followers position

131

A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching?

"A hepatitis B immunization is given to infants and children."

132

A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client?

liver transplant

133

a nurse is collecting data from a client who is in the early stages of hep a. which of the following manifestions should the nurse expect?

anorexia

134

A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention by the nurse?

the head of the bed elevated 20 degrees

135

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is used to do which of the following?

to detect ulcerations in the stomach

136

a nurse is reinforcing teaching with a client who has diverticulitis about preventing acute attacks. what type foods should the nurse recommend?

foods high in fiber

137

a nurse is assisting a client who has esophageal varices. the nurse might anticipate a prescription for what medication?

vasopressin

138

A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching?

"This procedure can determine how well the lower part of your esophagus works."

139

A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis?

night sweats

140

A nurse is caring for an older client who has chronic obstructive pulmonary disease with pneumonia. The nurse should monitor the client for Which of the following acid-base imbalances?

respiratory acidosis

141

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions?

the nurse ascultates coarse crackles in the lung field

142

A nurse is providing teaching to a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation?

total lung capacity

143

A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care?

tape all connections between the chest tube and drainage system.

144

A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax?

dry cough

145

A nurse on a medical unit is assisting with the care of a client who has a possible closed pneumothorax and significant bruising of the left chest following a motor vehicle crash. The client reports severe left chest pain on inspiration. The nurse should hear which of the following findings when auscultating the clients lung sounds?

absence of breath sounds

146

A nurse in a clinic is reinforcing teaching with a client who is to have a tuberculin skin test. Which of the following information should the nurse include?

You must return to the clinic to have the test read in 2 or 3 days

147

A nurse is assisting with discharge teaching for a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include?

Lie on you back with you head elevated 30 degrees when resting

148

A nurse is reinforcing teaching with a client who has cystic fibrosis and a prescription for daily chest physiotherapy. The nurse should instruct the client that which of the following is the purpose of these treatments?

To mobilize secretions in the airways

149

A nurse is reinforcing preoperative teaching with a client who is to undergo a pneumonectomy. The client states I am afraid it will hurt to cough after the surgery. Which of the following statements should the nurse make?

I will show you how to splint your incision while coughing

150

A nurse is collecting data from a client who has a prescription for cisplatin IV to treat lung cancer. Which of the following client findings is an adverse effect of this medication?

tinnitus

151

A nurse is reinforcing teaching about pursed lip breathing for a client who has COPD and emphysema. The nurse should explain that this breathing does which of the following?

Keeps the airways open on exhalation

152

A nurse is assisting the provider to prepare a client for a thoracentesis. The nurse should instruct the client that which of the following positions will be used for this procedure?

Sitting while leaning forward over the bedside table

153

A nurse is assisting with the development of a teaching plan about how to prevent an acute asthma attack for a young adult client. Which of the following points should the nurse plan to discuss first?

Determine the clients perception of the disease process and what might have triggered the current attack

154

A nurse on a medical unit is assisting with the care of a client who aspirated gastric contents prior to admission. The provider prescribed 100% oxygen by nonrebreather mask after the client reported severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome?

PaO2 50 mmHg

155

A nurse is assisting with the plan of care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?

eat high calorie food first

156

A nurse on a medical surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. The nurse collects additional data from the client. Which of the following findings is an indication of pulmonary embolism?

sudden onset of dyspnea

157

a nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. what actions should the nurse take to assist the client with smoking cessation?

Discuss ways the client can reduce the number of cigaretters smoked per day

158

A nurse is caring for a client who has pneumonia and is experiencing thick oral secretions. what actions should the nurse take first?

encourage deep breathing and coughing

159

a nurse is reinforcing preop teaching with a client who will undergo a total laryngectomy. what statements should the nurse identify as an indication that the client understands the impact of the surgery?

" I understand that I will have a permanent tracheostomy after the surgery "

160

A nurse on a medical surgical unit is caring for 4 clients. what client should then urse monitor for crepitus?

a client who has a chest tube following a pneumothorax

161

a nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. what actions should the nurse take first?

evaluate the client for stridor

162

a nurse is reinforcing teaching about pursed lip breathing with a client who has COPD and emphysema. The nurse should explain that this breathing technique does which of the following

keeps the airways open on exhalation

163

a nurse is caring for an older adult client who has COPD and pneumonia. the nurse should monitor the client for which of the following acid base imbalances?

respiratory acidosis

164

a nurse is assisting with the plan of care for a client who is post op following a hip arthroplasty/ in the clients medical record, the nurse notes a history of COPD. What oxygen delivery methods should the nurse recommend to use for this client

nasal cannula

165

a nurse is caring for a client is scheduled to have his chest tube removed. what action should the nurse take ?

auscultate the lungs after removal

166

a nurse is reinforcing teaching with a client who has cystic fibrosis and a prescription for daily chest physiotherapy. what is the purpose of this treatment.

to mobile secretions in the airways

167

a nurse is reinforcing discharge teaching with a client who had a pulmonary embolism. what statement should the nurse identify as an indication that the client understands the information?

I'll call the doctor if I see any blood in my urine or stool

168

A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. what information should the nurse include in the teaching.

use pursed- lip breathing during periods of dyspnea (shortness of breath)

169

a nurse is collecting data about the respiratory status of a client who has COPD. what manifestations should the nurse identify as an indication of the early onset of respiratory failure.

Tachycardia

170

a nurse is collecting data from a client who has a positive TB skin test. which of the following findings should the nurse identify as an indication the the client has active TB ?

night sweats

171

a nurse is helping the provider prepare a client for thoracentesis. the nurse should instruct the client that which of the following positions will be used for this procedure.

sitting while leaning forward over the bedside table

172

a nurse is assisting with the care of a client who had a chest tube inserted 12 hours ago. the nurse notes a crackling sensation upon palpation of the skin on the right side of the clients chest. the nurse should notify the charge nurse that the client is demonstrating a clinical manifestation of which of the following complications?

Crepitus

173

a nurse is preparing to assist a provider in withdrawing arterial blood from a clients radial artery for ABG measurement. what actions should the nurse plan to take?

check the circulation in the clients ulnar artery prior to obtaining the specimen

174

a nurse is assisting with planning postop education for a client who will undergo radial neck dissection for cancer of the larynx. the nurse should suggest which of the following topics?

  • npo status
  • alternative methods of communication
  • changes in body image
  • swallowing exercises
175

a nurse is caring for a client who is post op following a rhinoplasty. what findings should be reported to the surgeon

frequent swallowing

- can indicate posterior nasal bleeding and possibly hemorrhage

176

a nurse is reinforcing teaching about breathing techniques with a client who has emphysema. which of the following statements should the nurse identify as an indication that the client understands the mechanics behind pursed lip breathing?

" when I breathe out through pursed lips, my airways don't collapse between breaths"

- slows exhalation

- maintains inflation of the distal airways

- enhances respirations

177

a nurse is reinforcing discharge instructions with a client who has a new laryngectomy. the nurse should tell the client to be careful while bathing to prevent what complication?

aspiration of water

178

a nurse is reinforcing preop teaching with a client who has lung cancer and will undergo a pneumonectomy. which of the following pieces of information should the nurse include?

  • you will have a chest tube placed after surgery
  • we'll help you turn, cough, and breathe deeply after surgery
  • we'll give you oxygen to support your breathing if you need it
179

a nurse on a med surg unit is caring for a client who is post op following a hip replacement. the client reports feeling apprehensive and restless. the nurse collects additional data from the client. what finding is an indication of pulmonary embolism.

sudden onset of dyspnea

- rapid onset

- dyspnea due to reduced blood flow to the lungs

180

a nurse is caring for a client who has a chest tube. the nurse notes that the chest tube has become disconnected from the chest drainage system. what actions should the nurse take?

immerse the end of the chest tube in a bottle of sterile water

181

a nurse in a providers office is collecting data from a client who reports recent exposure to TB. which of the following findings is a clinical manifestation of pulmonary TB ?

night sweats

- fevers also clinical manifestation

182

a nurse is caring for a client who had a left lowerr lobectomy to treat lung cancer. what factor has a significant impact on the plan of care for this client?

Lung cancer usually has metastasized before the client has symptoms

183

a nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. which of the following findings is an indication of the prodromal stage of inhalation anthrax?

dry cough

184

a nurse on a medical unit is assisting with the care of a client who has a possible closed pneumothorax and significant bruising of the left chest following a motor vehicle crash. the client reports sever left chest pain on inspiration. the nurse should hear what findings when auscultating the client's lung sounds

absence of breath sounds

185

a nurse is reviewing the lab results of a client who has metabolic alkalosis. which of the following labs values should the nurse expect?

pH 7.49

HCO3 32 mEq/L

PACO2 40 mmHG

186

a nurse is reinforcing teaching with a client about pulmonary function tests. which of the following tests measures the volume of air the lungs can hold a the end of max inhalation ?

total lung capacity

187

a nurse in a clinic is reinforcing teaching with a client who is scheduled to have a TB skin test. which of the following pieces of info should the nurse include?

"you must return to the clinic to have the test read in 2 or 3 days"

188

a nurse is reinforcing discharge teaching with a client who has emphysema. which of the following instructions should the nurse take?

try to drink at least 2-3 liters of fluid per day .........

.....

189

a nurse is caring for a client who is experiencing acute opioid toxicity. which of the following actions should the nurse identify as priorty.

ensure an adequate airway

190

a nurse is caring for a client following a right pleural thoracentesis. the nurse measures a total of 35 mL of purulent drainage. what findings indicate a tension pneumothorax?

- tracheal deviation to the left

- absent breath sounds on the right side

- neck vein distention

191

a nurse on a med surg unit is collecting data from a client who recently transferred from the ICU following endotracheal extubation. which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the charge nurse

increased coughing

192

a nurse is collecting data from a client who has pharyngitis. what finding is the nurses priority to report to the provider

inspiratory stridor

193

a nurse is caring for a client who is extremely anxious and is hyperventilating. the clients ABG results are pH 7.50, PaCO2 27 mmHg and HCO3 - 25 mEq/L. the nurse should identify that the client has which of the following acid base imbalances.

respiratory alkalosis

194

a nurse is reinforcing teaching with a client who has a chronic cough and is scheduled for a bronchoscopy. what statement indicates an understanding of the teaching?

" a tissue sample might be obtained during the procedure "

195

a nurse is assisting with the plan of care for a client who has COPD and is malnourished. which of the following recommendations to promote nutritional intake should the nurse include in the plan of care.

Eat high calorie foods first

196

a nurse is assisting a provider with a comprehensive physcial examination of a client. when the provider uses transillumination the nurse should explain to the client that this technique helps evaluate which of the following structures?

maxillary sinuses

197

a nurse is collecting data from a client who has a precription for cisplatin IV to treat lung cancer. what is an adverse effect of this medication?

tinnitus

198

a nurse is contributing to the plan of care for a client who is recieving mechanical ventaliation. which of the following recommendations should the nurse make?

maintain the head of the bed at 30 degrees

199

a nurse on a medical unit is assisting with the care of a client who aspirated gastric contents prior to admission. the provider prescribed 100 percent oxygen by norebreather mask after the client reported severe dyspnea. what findings is a clinical manifestation of acute respiratory distress syndrome?

PaO2 50 mmHg

200

a nurse is caring for a client who has a 20 year history of COPD and is recieving oxygen at 2 L/min via nasal cannula/ the client is shortness of breath and has O2 sat via pulse ox of 85%. what actions should the nurse take.

Increase the oxygen flow and request and ABG

201

a nurse in a medical surgical unit is assessing a client . the nurse should identify that which of the following findings is a manifestation of pulmonary embolism.

stabbing chest pain

202

a nurse is reinforcing preop teaching with a client who is scheduled to undergo pneumonectomy. the client states " I am afraid that coughing will hurt after the surgery" what response should the nurse make

" i will show you how to splint your incision while coughing

203

a nurse is assisting with the plan of care for a client following placement of a chest tube 1 hour ago/ what action should the nurse include in the plan of care.

tape all connections between the chest tube and draingage system

204

a nurse is assisting with discharge teaching for a client who is post op following a rhinoplasty. which of the following instructions should the nurse include?

lie on your back with your head elevated 30 degrees when resting

205

a nurse is assisting with the care of a client who has a chest tube in place following a thoractomy. which of the following actions should the nurse take?

- place the drainage unit below the clients chest level

206

a nurse is preparing a client for discharge following a bronchoscopy. what assesment is the nurses priority.

- confirming the gag reflex

207

a nurse is caring for a client who has a tracheostomy with an inflated cuff in place. which of the following findings indicates that the nurse should suction the clients airway secretions?

the client has coarse crackles in the lung fields

208

a nurse is assiting with preparing a client for a bronchoscopy. which actions should the nurse take?

- explain the client will recieve sedation and will not remember the procedure

- verify that the client understands the purpose and nature of the procdure

209

a nurse is caring for a client who is post op following a thoracic lobectomy. the client has 2 chest tubes in place. 1 in the lower portion of the thorax and the other higher up on the chest wall. when the family asks the nurse why the client has 2 chest tubes, which of the following responses should the nurse make?

the lower tube will drain blood, an the higher tube will remove air

210

a nurse in the PACU is collecting data from a newly admitted client and observes intercoastal retractions and high pitched inspiratory sound. the nurse should identify that these findings are manifestations of which of the following complications?

respiratory obstruction

211

a nurse is auscultating the lungs of a client who is having an acute asthma attack. which of the following sounds should the nurse expect to hear.

noisy wheezing

212

a charge nurse recieves notification of the admission of a client who is coughing frequenly and whose sputum is pink, frothy, and copious . the client has a history of night sweats, anorexia, and weight loss. which of the following actions should the nurse take?

- assign the client to a private room with negative - pressure airflow

- wear an respirator when entering the clients room

213

a nurse is caring for a client who has COPD and is experiencing shortness of breath. what action should the nurse take first?

place the client in an upright position

214

the nurse notes blanching, coolness, and edema at the peripheral IV site. on the basis of these findings, the nurse should implement which actin?

1. remove the iv

2. apply a warm compress

3. check for a blood return

4. measure the area for infiltration

remove the iv

rationale: because infiltration can be damaging to the surrounding tissue, the appropriate action would be to remove the iv to prevent any further damage.

215

the nurse has recieved the client assignment for the day. which client should the nurse attend to first?

1. the client who has a nasogastric tube attached to intermitten suction

2. the client who needs to receive subq insulin before breakfast

3. the client who is 2 days post op and is complaining of incisional pain

4. the client who has a blood glucose level of 50 mg/dL (2.85 mmol/L and complains of blurred vision

the client who has a blood glucose level of 50 mg/dL (2.85 mmol/L) and complains of blurred vision

rationale: client is showing symptoms of hypoglycemia, treatment should be implemented first.

216

the nurse preps to care for a client on contact precautions who has a hospital acquired infection caused by methicillin resistant staphylococcus aurues. the client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. the nurse should assemble which neccessary protective items before entering the clients room?

1. gloves and gown

2. gloves mask goggles

3. gloves mask gown goggles

4. gloves gown and shoe protectors

gloves mask gown goggles

217

a nurse at an opthalmology clinic is collecting data from a client referred by the provider for a potential cataract. which of the following client reports should the nurse recognize is consistent with cataracts?

  1. halos when looking at lights
  2. loss of peripheral vision
  3. bright flashes of light and floaters
  4. eyestrain and headache with close work

halos when looking at lights

218

a nurse is collecting data from an older client who states he is homeless. which of the following findings should the nurse document as comorbidities for the client ?

  1. inadequate shelter clothing for the weather
  2. malnutrition and poverty
  3. dementia and tuberculosis
  4. lack of preventive health care and immunizations

dementia and tuberculosis

219

a nurse is reinforcing teaching about calcium supplements with an older adult female client who has osteoporosis and a recent pair of a fracture in her right hip. what should the nurse include in the instructions?

you should take your calcium supplements with a large glass of water

220

a nurse is reinforcing teaching with a group of healthy older adult clients about health screenings after age 50 years. what health screening should the nurse recommend that the clients complete annually?

visual acuity

221

a nurse is participating on a committee that is developing age appropriate care standards for older adult clients. which of the following of erikson's developmental tasks should the nurse recommend as the focus?

integrity

222

a nurse is reinforcing dietary teaching with an older adult who is on bedrest following development of DVT about methods to increase peristalsis. which of the following high fiber food choices should the nurse recommend?

  1. navy bean soup
  2. canned fruit juice
  3. white rice pudding
  4. soy milk

navy bean soup

223

a nurs eat an assisted living center is conducting an orientation session for a group of newly hired AP. what instruction should the nurse include regarding clients who are hearing impaired?

maintain eye contact with the clients

224

a nurse is assisting with planning care for an older adult client following abdominal surgery for a bowel obstruction. what information about pain management should the nurse include in the plan of care?

older adult clients are sensitive to the analgesic effect of opiates

225

a nurse at a long term care facilitiy is assisting with planning care for a group of older adults. when planning care, the nurse should consider that older adult clients are most likely to exhibit a decrease in which of the following?

  1. short term memory
  2. creative ability
  3. decision making skills
  4. cognitive capacity

short term memory

226

a nurse in a long term care facility is promoting reminiscence among older adult clients. which of the following actions should the nurse take?

institute a daily storytelling hour

227

a nurse is reinforcing teaching with a newly hired assistive personnel about her role in helping older clients witch adls. the nurse should explain that which of the following is the most common factor that affects a clients ability to perform ADLS?

  1. social withdrawal
  2. chronic physcial disability
  3. emotional impairment
  4. cognitive dysfunction

chronic physical disability

228

a nurse is assisting with the admission of an older adult client who fell at home 3 days ago. the client has fractured hip, malnutrition, and dehydration. which of the following laboratory values, noted n admission, should indicate to the nurse prolonged manlnutrition?

  1. increased sodium
  2. decreased albumin
  3. increased BUN
  4. decreased blood glucose

decreased albumin

229

a nurse is caring for an older adult client who has a new onset of type 2 diabetes mellitus. which of the following physciologic changes contribute to the development of type 2 diabetes?

  1. increased production of insulin by the pancreas
  2. decreased sensitivity to the circulating insulin
  3. increased rate of glucose metabolism
  4. decreased release of gylcogen by the liver

decrease sensitivity to the circulating insulin

230

a nurse is caring for an older adult client who has pneumonia. which of the following physiologic changes associated with aging places the client at a greater risk for pneumonia?

  1. decreased anterior posterior diameter
  2. increased diameter of the small airways
  3. decreased number of cilia
  4. increased alveolar surface

decreased number of cilia

231

a nurse is caring fora client who has alzheimers disease and refuses to take her morning antihypertensive med. the client is oriented to name and place and is able to perform adls' with minimal supervision. which of the following actions should the nurse take?

  1. crush the pills and feed them to the client in applesauce
  2. insist the client comply by informing her of the possible implications of a missing dose
  3. notify the provider of the need for further evaluation of the clients level of competence
  4. ask the client to express her reasons for refusing the medications and document the event

ask the client to express her reasons for refusing the medication and document the event

232

a nurse is collecting data from an older adult client for signs of dehydration. which of the following findings should the nurse consider an expected pat of the aging process?

  1. elevation of urine specific gravity
  2. decreased creatinine clearance
  3. dry oral mucous membranes
  4. poor skin turgor over the sternum

decreased creatinine clearance

233

an older adult client tells a nurse at a health fair " I am always forgetting things. I cannot even remember where I parked my car ! Do you think I have alzheimer's disease?" what would be the therapeutic response by the nurse ?

" that must be very upsetting. can you tell me about your forgetfulness?"

234

a nurse is reinforcing teaching with a group of older adult female clients who are postmenopausal about dietary requirments. what statement should the nurse make about folic acid?

" adequate folic acid intake is associated with a reduced risk for heart disease"

235

a nurse is reinforcing teaching with an older adult client who has osteoarthritis of the right hip and lower lumber vertebrae. which of the following statements by the client indicates an understanding of the teaching?

  • " I should avoid the use of a heating pad on my back"
  • " to relieve the pressure on my hip, I can use a cane while ambulating"
  • " I have steriod injections to my joints as the first medication of choice to treat my pain"
  • I will exercise if it causes pain"

to relieve the pressure on my hip I can use a cane while ambulating

236

a nurse is collecting data from an older adult client during an annual physical. which of the following findings should the nurse report to the provider ?

  1. BP 118/76 mm Hg
  2. fasting blood glucose level of 160mg/dL
  3. report of waking to void two to three times per night
  4. report of a bowel movement every other day

fasting blood glucose level 160 mg/dL

237

a nurse is reviewing the medical record of a client who is postmenopausal and has osteoporosis. the client has a new prescription for alendronate sodium. which of the following findings in the clients history should the nurse recognize is a contraindication to this medication?

  1. glaucoma
  2. pagets disease
  3. esophageal stricture
  4. long term corticosteriod use

esophageal stricture

238

a nurse is collecting data from an older adult client. which of the following actions should the nurse take to collect subjective data?

  1. leave the client a writen questionaire to fill out in private
  2. allow sufficient time for the client to respond to the questions
  3. talk to family members to obtain the clients health history
  4. obtain the health history from the clients medical record

allow sufficient time for the client to respond to the questions

239

a nurse in the clinic is assessing an older adult client for the second time this week. the client reports a decreased energy level, insomnia, and anorexia. Diagnositic tests are withing the expected reference ranges. For which of the following conditions should the nurse screen the client?

  1. sarcopenia
  2. dementia
  3. depression
  4. diabetes

depression

240

a nurse is contributing to the plan of care for a client who had a stroke. which of the following goals should the nruse identify as the priority for this client?

  1. the clients skin will remain intact during hospitalization
  2. the client will verbalize one new word each week
  3. the client will begin to help turn himself in bed, indicating improved mobilitiy
  4. the clients aireway will remain clear, as evidenced by clear breath sounds.

the client's airway will remain clear, as evidenced by clear breath sounds.

241

a nurse is planning to administer diphenydramine hydrochloride to an older adult client. which of the following actions should the nurse plan to take prior to administration

  1. review the medical record for a client history of glaucoma
  2. plan to administer med 30 min prior to a meal
  3. explain to the client that he will need to restrict fluid intake once he takes the medicaiton.
  4. remind the client that his appetite might increase when starting this medication

review the medical record for a client history of glaucoma

242

a nurse is assisting with the care of an older adult client who has dementia. the client becomes agitated and confused at night and wanders into the hallway. what action should the nurse take?

place the clients mattress on the floor

243

a nurse is contributing to the plan of care for a client who had a recent stroke and a history of GERD. for which of the following disorders should the nurse plan to monitor this client.

  1. duodenal ulcer disease
  2. aspiration pneumonia
  3. viral pneumonia
  4. esophageal varices

aspiration pneumonia

244

a nurse is caring for an older adult client who has gout and refuses to eat. the client's provider has approved the family to bring food from home. what foods should the nurse recommend that the client not eat?

lentil soup

245

a nurse is caring for an older adult client. which of the following physiologic changes associated with aging can affect medication dosage in this client?

  1. increased glomerular filtration rate
  2. decreased body fat
  3. decreased gastric motility
  4. decreased gastric pH

decreased gastric motility

246

a nurse is reinforcing teaching with an older adult client who has anemia. which of the following foods should the nurse recommend to increase the clients iron intake?

  1. greek yogur
  2. bran muffin
  3. peanut butter sandwhich
  4. dried fruit

dried fruit

247

a nurse is reviewing the medication list of an older adult client upon admission and notes that he is taking fluoxetine for depression. the nurse should identify that fluoxetine can increase the effects of which of the following medications that is also on the clients list

  1. levothyroxine
  2. gabapentin
  3. warfarin
  4. nadolol

warfarin

248

a nurse is assisting with the admission of an older adult client who is scheduled for surgery. the nurse is completing a medication reconciliation with the clients new admission medication prescriptions. for which of the following situations should the nurse plan to repeat the medication reconcililation process?

  1. the provider obtains informed consent from the client for surgery
  2. they client returns to the unit from the surgical suite
  3. the pharmacy delivers the clients medications to the unit
  4. the nurse is preparing to provide change of shift report

the client returns to the unit from the surgical suite

249

a nurse is reviewing the medication list of an older adult client and notes that the client is taking simvastatin for hypercholesterolemia as we as multiple herbal supplements. which of the following supplements indicated on the clients medication list can decrease the effect of this medication?

  1. garlic
  2. ginkgo biloba
  3. glucosamine
  4. st johns wort

st. johns wort

250

a nurse is reinforcing discharge teaching with an older adult client who is taking multiple medications. which of the following information should the nurse include in the teaching?

  1. " you should keep a medication list that includes only your prescribed medications"
  2. " you should compare your medication dose with others taking the same medications "
  3. " you should not experience adverse effects unless you begin taking a new medication "
  4. "you should consult your provider before taking an herbal supplement "

" you should consult with your doctor before taking any herbal supplements"

251

A nurse is reviewing the laboratory results of an older adult client who is taking multiple medications. which of the following findings could impact the clients ability to distribute medication throughout his system ?

  1. hgb 15 g/dL
  2. albumin 3.0 g/dL
  3. potassium 3.7 mEq/L
  4. total cholesterol 188 mg/dL

albumin 3.0

252

a nurse is caring for a client who is using a continuous passive motion device following a right total knee replacement. which of the actions should the nurse take when using the CPM device?

line up the frame joints of the COM device with the clients knee.

rationale: to avoid damage to the operative knee

253

a nurse is reinforcing teaching with an older adult client who is healthy and has chronic constipation about establishing bowel retraining program. which of the following statements should the nurse include in the teaching?

increase the fiber content of your diet

rationale: purpose is to manipulate factors within the clients control to produce the elimination of a soft formed stool at regular intervals.

254

a nurse is reviewing the medical record of an older adult client. for which of the following medications should the nurse request a hearing assessment of the client?

furosemide

rationale: can cause ototoxicity. decrease medication metabolism in the kidneys. teach client s/s of ototoxicity: tinitus and difficulty hearing

255

A nurse is reinforcing teaching with an older adult client who is to start taking warfarin. which of the following statements indicates the client understands the teaching?

I can continue to eat green salads

256

a nurse is collecting data from an 85 year old client. which of the following findings should the nurse report to the provider?

difference in pulse strength between lower extremities

rationale: difference can indicate vascular complication, assessment of the peripheral vascular system should also include temp, color, sensation, edema, skin integrity of bother the upper and lower extremities. identify any differences in symmetry of the findings and report them.

257

a nurse at a long term care facility is reinforcing teaching with an older adult client about ambulating with a quad cane. which of the following statements should the nurse include in the teaching?

hold the cane in the hand on the stronger side of your body

rationale: this actions allows for a more normal gait, with the ipsliateral arm and weaker leg moving at the same time

258

a nurse is collecting data from an older adult female client. which of the following findings should the nurse identify as a priority ?

rales heard in the bases of the lungs

259

a nurse is collecting data from an older adult client who reports feeling anxious about financial concerns and having difficulty sleeping for several months. which of the following actions should the nurse take?

determine the clients usual sleep habits

260

a nurse is assisting in the care of a client who is in hypovolemic shock. while waiting for a unit of blood, the nurse should plan to administer which of the following IV solutions?

0.9% sodium chloride

261

a nurse is caring for a client who has advanced heart failure. which of the following actions should the nurse take?

enforce fluid restrictions

rationale: helps reduce fluid retention in the lungs and lower extremities

262

a nurse is collecting data from a client who has an abdominal aortic aneurysm

what manifestations should the nurse expect?

lower back discomfort

rationale : back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots causing pain

263

a nurse is contributing to the plan of care for a client who has pernicious anemia. which of the following interventions should the nurse recommend?

initiate weekly injections of vitamin B12

rationale: lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract

264

a nurse is reiforcing discharge teaching with a client who has a new permanent pace maker. which of the following information should the nurse include in the teaching?

avoid lifting both arms above your head when dressing

rationale : dislodgement of the pacer leads can occur

265

a nurse is reinforcing teaching with a client who has anemia and a new prescription for epoetin alfa. what information should the nurse include in the teaching.

hypertension is a common adverse effect to this medication

rationale: rise in the prodction of erythrocytes

266

a nurse is caring for a client who is post op following a vein ligation and stripping for varicose veins. which of the following actions should the nurse take ?

position the client supine with his legs elevated when in bed?

rationale: promotes venous return to the heart

267

a nurse is assisting in the care of a client who has abdominal aortic aneurysm and is scheduled for surgery. the clients vital signs are BP 160/98, HR 102/min, RR 22/min and SPO2 95% which of the following actions should the nurse take?

administer antihypertensive medication for blood pressure

268

a nurse is collecting data from a client who has a history of peripheral arterial disease. which of the following findings on the clients lower extremities should the nurse expect?

cool, pale skin with minimal body hair

269

a nurse is collecting data from a client who has a manifestation of aplastic anemia. what findings should the nurse expect?

petechiae and eccymosiss

270

a nurse is administering a loop diuretic to a client who has a 3+ pitting edema in the lower extremities. what action should the nurse take?

monitor the client for ototoxicity

271

a nurse is assiting the plan of care for an older adult client who is to recieve a unit of packed RBC. what action should the nurse recommend?

verify the information on the packed RBCś with another nurse

272

a nurse is caring for a client who has a late stage heart failure and is experiencing fluid volume overload. what findings should the nurse expect?

weight gain of 1 kg (2.2 lbs) in 1 day

273

a nurse is assisting in the preparation of a unit of packed red blood cells for a client who has anemia. which of the following actions should the nurse take first?

witness the informed consent

274

a nurse is collecting data from a client who has a fluid volume overload resulting from a cardiovascular disorder. which of the following manifestations should the nurse expect?

jugular vein distension

moist crackles

postural hypotension

275

a nurse is evaluating a clients repeat laborartory results 4 hours after administering fresh frozen plasma. what labs should the nurse review?

prothrombin time

276

a nurse is caring for a client who has hemophilia. the client reports pain and swelling in a joint following an injury,

prepare for replacement of the missing clotting factor

277

a nurse is assisting in collecting data from a client who has a history of unstable angina. what should the nurse expect?

the client reports chest pain when at rest

278

a nurse is reinforcing teaching about lifestyle changes with a client who had a myocardial infarction and has a new prescription for a beta blocker. what statement indicates the client understand the teaching?

before taking my medication, i will check my blood pressure and radial pulse rate

279

a nurse is collecting data from a client who has RS HF. what finding should the nurse expect?

dependent edema

280

a nurse is caring for a client who has heart failure and is lethargic with muscle weakness. the clients telemetry displays dyrhythmias. which of the following lab results should the nurse anticipate?

potassium 2.8 mEq/L

281

a nurse is checking lab values for an adult who has sickle cell anemia and is in crisis. which complication should the nurse monitor?

elevated bilirubin

rationale: hemolysis of the abnormal red blood cells occurs

282

a nurse is assisting in the plan of care for a client who is percutaneous transluminal coronary angioplasty with stent placement. what actions should the nurse anticipate in the postop plan of care?

initiate an aspirin regimen

283

a nurse is collecting data from a client who reports using fish oil as a dietary supp. which of the following substances in fish oil should the nurse recognize as a health benefit to the client?

omega 3 fatty acids

284

a nurse is monitoring a client who is recieving a unit of packed red blood cells following surgery. the client reports itching and has hives 30 minutes after the infusin begins. what action should the nurse take first ?

stop the infusion of blood

285

a nurse is assisting in monitoring a client who had a myocardial infarction. what complication should the nurse monitor the first 24 ?

ventricular dysrhythmias

286

a nurse is checking for cardiac tamponade on a client who has pericarditis. which of the following actions should the nurse take?

auscultate bp for pulsus paradoxus

287

a nurse is collecting data from a client who has pericaditis. what should the nurse expect?

dyspnea

288

a nurse caring for a patient who has gastric cancer is initiating an infusion of parenteral nutrition via the patients implanted port. which of the following is an appropriate action for the nurse ?

cover the device and the needle with a sterile tranparent dressing

289

A nurse is caring for a patient who has a central venous catheter. when flushing the catheter, the nurse uses a 10 mL syringe to prevent what complication is associated with central vascular access devices

catheter rupture

290

a nurse is caring for a patient who has a central venous access device in place. what routine measure should the nurse use specifically to prevent lumen occlusion?

clamping the extension tubing while removing a syringe from the injection cap

291

an older adult patient who adheres to a regular cardio rehab schedule that includes water aerobics and swimming requires long term central venous access. what cva device is the best choice for allowing him to continue his aquatic program?

an implanted port

292

a nurse is preparing to obtain a blood sample from a patient who has a triple lumen central catheter in place for multiple therapies. what would be an appropriate action for the nurse to take?

turn off the distal infusions for 1 to 5 minutes before obtaining the blood sample

293

a nurse is caring for a patient who has a central venous catheter and suddenly develops dyspnea, tachycardia and dizziness. the nurse suspects air embolism and clamps the catheter immediately. what position should the patient be placed in?

on his left side in trendelenburg position

294

a patient who sustained trauma from a motor vehicle crash is transported to an emergency department. the provider determines the need for immediate central venous access for fluid and blood replacement and prophyactic antibiotic therapy. what is the appropriate cva device for this patient?

nontunneled percutaneous central catheter

295

a nurse is preparing to flush a patients peripherally inserted central catheter (PICC) because the patients catheter has a valved tip, the nurse . . .

use non heparinized saline solution for the flush

296

a nurse finds a patients iv inserting site red, wam and slightly edamtous, which of the following actions should the nurse perform first

discontinue the IV line

297

a nurse has just initiated a new peripheral IV infusion with 5% dextrose in water continuous infusion. how often should the nurse plan to replace the primary tubing?

every 96 hours

298

a nurse who has just initiated an IV infusion explains to the patient that complications are possible and that she will monitor the infusion regularly. the nurse should teach the patient that which of the following findings is an indication of early infiltration?

coolness

299

a nurse is initiating a peripheral iv infusion punctures the skin and selected vein and observes blood return in the flashback chamber of the IV catheter. what action should the nurse perform next?

lower the catheter until it is almost flush with the skin

300

which of the following is an important nursing action when converting an IV infusion to a saline lock?

flush the IV cat to confirm patency

301

a nurse has just inserted a peripheral IV catheter for a continuous infusion. To secure the cat. the nurse should ?

leave the connection between the hub and the tubing uncovered

302

a patient in early stage renal failure is prescribed an infusion of 0.45% sodium chloride. This type of solution is appropriate because it . . .

dilutes extracellular fluid and rehydrates the cells

303

a nurse is removing an IV cat from a patient who IV infusion has been discontinued. what action is appropriate?

pull the cat straight back from the insertion site

304

a nurse is discontinuing an iv infusion. for which of the following reasons is it important to verify and document the integrity and condition of the IV cat?

a broken off cath. tip indicates the risk for an embolus.

305

a nurse is caring for a client who has a new prescription for verapamil to treat atrial fibrillation. the nurse should instruct the client to avoid drinking grapefruit juice while taking verapamil because it can cause the client to experience which of the following conditions?

hypotension

306

a nurse is providing teaching to a client who has a new prescription for losartan to treat hypertension. the nurse should instruct the client that which of the following findings could indicate an adverse to the drug and needs to be reported

facial edema

307

a nurse is caring for a client who is taking a diuretic. the nurse should instruct the client to include which of the following foods in their diet to increase potassium intake?

raisins

308

a nurse is teaching a client who has a new prescription for nitroglycerin. the nurse should instruct the client that which of the manifestations is a potential adverse effect of this drug?

headache

309

a nurse is caring for a client who has a new prescription for dobutamine. the nurse should clarify the prescription with the provider if the client receiving which of the following types of drugs ?

MAOI

general anesthetic

tricyclic antidepressant

beta blocker

310

a nurse is caring for a client who has a new prescription for propranolol to treat tachydysrhthmia. the nurse should instruct the client to avoid taking which of the following types of OTC drugs while taking propranolol

NSAIDS

311

a nurse is teaching a client who has a new prescription for quinidine. which of the following statements should the nurse include.

monitor your pulse rate and report changes

312

a nurse is assessing a client who is taking a loop diuretic and is experiencing a thready, irregular pulse, orthostatic hypotension and confusion. the nurse should identify that these manifestations indicate which of the following adverse effects ?

hypokalemia

313

a nurse is caring for a client who will begin using transdermal NTG to treat angina pectoris. when speaking to the client about the drug, which of the following instructions should the nurse include?

  • apply the patch to a hairless area and rotate sites
  • apply a new patch when you start your day
  • remove patches for 10 to 12 hours each day
314

a nurse should recognice that milrinone is contraindicated for a client who has which of the following conditions?

acute myocardial infarction

315

a nurse is teaching a client who has a new prescription for gemfibrozil. which of the following instructions should the nurse include?

  • report any new intolerance to fired foods
  • report muscle tenderness
  • expect periodic liver function testing
316

a nurse is caring for a client who has glomerular filtration rate of 10 mL/min and a reduced urine output. the nurse should clarify a prescription for hydrocholorthiazide for this client because of which of the following characteristics of the drug?

the drug does not promote diuresis for clients who have renal insufficiency

317

a nurse is caring for a client who is taking atorvastatin and has a new prescription for gemfibrozil. the nurse should recognize that this drug combo places the client at an increased risk for which of the following adverse effects.

myopathy

318

a nurse is reviewing new prescriptions with a client who has heart disease . the nurse should instruct the client that which of the following drug is prescribed to treat hypercholesterolemia?

simvastatin

319

a nurse is caring for a client who is taking amiodarone to treat a fib. which of the following should the nurse instruct the client to avoid while taking this drug?

grape fruit juice

320

a nurse is caring for a client who is about to begin captopril therapy. which of the following adverse effects should the nurse instruct the client to report because it can indicate a need to discontinue drug therapy?

  • rash
  • distorted taste
  • swelling of the tongue
  • dry cough
321

a nurs eis caring for a client who is taking spironolactone to treat hypertension. the nurse should recognize that which of the following client lab values requires immediate intervention

potassium 5.2 mEq/L

322

a nurse is administering hydrochlorothiazide to a client who has gouty arthritis. the nurse should monitor the client for which of the following findings that indicates an adverse effect of this drug?

hyperuricemia

323

a nurse is caring for a client who has a new prescripition for aliskiren to treat hypertension. the nurse should monitor the client for which of the following findings as an adverse effect of the drug

  • hyperkalemia
  • throat swelling
  • cough
324

a nurse is caring for a client who is taking carvedilol and has a prescription for an oral antidiabetic drug to manage their new diagnosis of type 2 diabetes mellitus. By taking both drugs concurrently, the nurse should identify that the client is at an increased risk for which of the following conditions ?

hypoglycemia

325

a nurse is caring for a client who has a new prescription for verapamil. the nurse should clarify the prescription with the provider if the client has a history of which of the following conditions?

second degree av block

326

a nurse should identify that which of the following drugs is used only for the short term treatment of cardiac dysrhthmia because of the serious adverse effects associated with long term use?

procainamide

327

a nurse is caring for a client who is taking digoxin and develops changes on their ECG tracing and other manifestations that indicate the client has severe digoxin toxcity. which of the following drugs should the nurse expect to administer to treat this complication

antigen binding fragments

328

a nurse is providing teaching to a client who is taking simvastatin. the nurse should instruct the client to report which of the following manifestations as an indication of a serious adverse reaction that could require discontinuing drug therapy?

muscle pain

329

the provider talks with the client about clomiphene therapy. what instruction should the provider include?

begin 5 days after menstruation begins and take it every day for next 5 days

330

what adverse effects does clomiphene cause ?

- blurred vision

- hot flashes

breast engorgement

- nausea

331

recognizing the adverse effects of terbutaline, the nurse should monitor the client for what?

tachycardia

332

what drug should the nurse have available to reverse the adverse effects of terbutaline?

propanolol

333

the health care provider instructs the client to monitor for what when a taking conjugated estrogen and medroxyprogesterone acetate to treat postmenopausal vasomotor symptoms?

- swelling or pain in calf

334

combination oral contraceptives such as ethinyl estradiol and drospirenone, should be used with caution when a patient has what disorder?

diabetes

335

a client is prescribed testosterone to treat testicular failure. the nurse instructs the client to monitor and report what symptom?

weight gain

336

a client is prescribed finasteride to treat bph. when providing instruction about finasteride, the nurse should include which of the following information?

allow 6 to 12 months to see improvement

337

what medication should a health care provider question the use of when using sildenafil to treat erectile dysfunction?

nitroglycerin as needed for chest pain

338

a client is prescribed clomiphen for infertility. the hcp instructs the client to monitor for what?

pelvic pain

339

for rapid relief of urinary obstruction due to prostatic enlargment, the hcp should choose what drug?

tamsulosin

340

the hcp administers oxytocin for induction of labor. the hcp should monitor what order to assess for an adverse effect to oxytocin

- urine output

- bp

duration of contractions

- fetal heart rate

341

a nurse is caring for a male client who has hyperthyroidism and is not responding to treatment. the nurse should identify that hyperthyroidism is a contraindication of what drug?

Bethanechol

342

a nurse is caring for a client who missed a dose for her oral contraceptive. what instruction should the nurse give?

take missed dose as soon as possible

343

a nurse is caring for a client who is taking a combo oral contaceptive ehtinyl estradiol and drospirenone and is about to begin taking rifampin to treat TB . what instruction should the nurse give the client do to possible drug interactions ?

use additional birth control methods

344

a provider has prescribed a dinoprostone vaginal insert to promote cervical ripening in a client who is 40 weeks gestation. when administering dinoprostone, what actions should the nurse take

- urinate prior to insertion

- remove the pouch when active labor begins

- moniter for uterine hyperstimulation

- monitor the patients temperature

345

after administering terbutaline to a client to inhibit preterm labor, the nurse should asses what?

Heart Rate

346

a nurse is providing teaching to a client about using leuprolide to treat endometriosis. what instruction should the nurse include?

perform weight bearing activities

347

a nurse is assessing a client who has a new prescription for the combo oral contraceptive ethinyl estradiol and drospirenone. what findings should the nurse identify as a contraindication to use of this medication?

client smokes half a pack of cigarettes a day

348

a nurse is caring for a client who is about to begin taking cabergoline to treat infertility. the nurse should explain that the client needs to monitor which of the following labs ?

prolactin level

349

a nurse is caring for a client who received human menopausal gonadotropin what should the nurse expect to find?

follicular maturation

350

a nurse is providing safety education to a client who is scheduled to begin treatment for BPH. what instructions should the nurse include in the teaching?

change positions slowly

351

a nurse is providing teaching to a client about sildenafil to treat erectile dysfunction. what instruction should the nurse include?

do not take the drug with high fat foods

352

a nurse is caring for a client who has a new prescripition for transdermal conjugated estrogen and medroxyprogesterone to treat postmenopausal symptoms. what therapeutic effects should the nurse explain to the client

- reduces the risk of ovarian cancer

- relieves hot flashes

- prevents osteoporosis

353

a nurse is caring for aclient who has a new prescription for conjugated equine estrogen. the nurse should instruct the client to report which indication of a serious adverse reaction?

vaginal bleeding

354

a nurse is preparing to administer finasteride to a client who has bph. what precaution should the nurse plan to take when administering this drug?

wear gloves when handling the table

355

a nurse is assessing a client who has a new prescription to oxybutynin to treat neurogenic bladd. what assessment finding should the nurse identify as an adverset effect?

- dilated pupils

- dizziness

- distended bladder

- fever

356

a nurse is caring for a client who is about to begin cloiphene therapy to treat infertility. the nurse should monitor the client for which of the following adverse effects ?

ovarian hyperstimulation syndrome

357

a nurse should question the use of conjugated equine estrogen by a client who has a history of what?

blood clots

358

a nurse is providing teaching to a client who is taking bethanechol for urinary retention. what instructions should the nurse include

- avoid driving and activities that require alertness

- increase fluid intake

- stay close to a bathroom after taking the drug

359

a nurse is teaching a client about conjugated estrogen and medroxyprogesterone. what instructions should the nurse include?

have blood pressure checked regularly

360

a nurse is teaching a client who has a prescription for a testosterone transdermal patch. what statement indicates the client understand the teaching ?

i should apply the medications to a different site each time

361

the nurs eis caring for a client who is about to begin taking finasteride to treat BPH the nurse should explain to the client that monitoring which lab is important?

prostate specific angtigen

362

a nurse is teaching a client about receiving leuprolide to treat endometriosis. the nurse should instruct the client to expect what side effect?

vaginal dryness

363

a nurse is caring for a client who has BPH and is taking tamsulosin. the nurse should question the use of the drug if the client also has

erectile dysfunction for which he takes sildenafil

364

a nurse should question the use of estadiol and drospirenone by a client who has a renal disease due to increased risk of what?

hyperkalemia

365

a nurse is reinforcing teaching for a client who has angina pectoris and a new prescription to apply a nitroglycerin transdermal patch daily at home. what instruction should the nurse give the client?

fold used patch with medication area to the inside and discard in a closed receptacle

366

a nurse is talking with a client who is about to start taking NTG oral, sustained release capsuls. what should the instructions include?

swallow the capsules whole

367

a nurse is caring for a client who has a prescription for metoprolol. the nurse measures the clients vital signs and notes that the apical hr is 49/min the nurse should prepare to administer which of the following ?

atropine

368

a nurse is caring for a client who has heart failure notices that the client did not receive his scheduled dose of furosemide. when filling out an incident report about the occurrence, which oft he followig information should the nurse include?

- clients breath sounds clear bilaterally

- the nurse documents the clients status as a result of the occurrence

- the clients statement about the occurrence

369

a nurse is reinforcing teaching a client who has a new prescription for transfermal NTG to treat angina. the nurse should include what instructions?

apply patch to a hairless area

apply a new patch each morning

remove patch for 10 to 12 hours daily

370

a nurse is reinforcing discharge teaching with a client prescribed verapamil to treat angina what should be the nursing instructions

monitor for increased heart rate while taking this medication

371

a nurse at a providers office is assessing a client who has been taking hydrocortisone for adrenal insufficiency. the client reports fatigue and feeling overwhelmed by personal responsibilities. which of the following findings should the nurse identify as an indication the provider might need to increase the clients dosage?

hypotension

372

a nurse is providing teaching to a client who is about to begin exenatide therapy to treat type 2 diabetes mellitus. which of the following instructions should the nurse include?

  • inject the drug subq
  • expect the peak effect in 2 hours
  • use the drug as a supplement to an oral hypoglycemic
373

a nurse caring for a client who is about to begin taking pioglitazone to treat type 2 diabetes mellitus. the nurse should explain to the client about the need to monitor which of the follow laboratory values

ALT

LDL

374

a nurse is caring for a client who is about to begin taking Propulthiouracil PTU to treat hyperthyroidism. the nurse should instruct the instruct the client to report which of the following adverse effects

sore throat

joint pain

bradycardia

rash

375

a nurse is teaching a client about self administering regular insulin. the nurse should instruct the client to rotate injection sites to prevent which of the following

lipohypertrophy

376

a nurse is caring for a client who is taking metformin and is scheduled to undergo angiography using iodine containing contrast dye. the nurse should identify that an interaction between metformin and the IV contrast dye increases the clients risk for which of the following conditions?

acute renal failure

377

a nurse is providing teaching to a client about taking fludrocoritsone to treat adrenocortical insufficiency. which of the following instructions should the nurse include?

  • obtain weight measurements daily
  • report weakness or palpitations
  • have blood pressure checked regularly
378

a nurse should recognize that a provider will prescribe a lower dose of sitagliptin for a client who has type 2 diabetes and who also has what?

renal impairment

379

a nurse is teaching a client who is about to begin levothyroxine therapy to treat hypothyroidism. which of the following instructions should the nurse include?

expect life long therapy with the drug

380

a nurse is caring for a client taking PTU and reports weight gain, drowsiness and depression. the nurse should identify that the client is experiencing which of the following adverse reactions

hypothyroidism

381

a nurse is speaking with a client who is taking glipizide to treat type 2 diabetes mellitus and has called to report feeling shaky, hungry, and fatigued. which of the actions should the nurse instruct the client to take?

perform a fingerstick blood glucose check

382

a nurse is assessing a client who has a new prescription for levothyroxine the nurse should identify which of the following findings as a contraindication

recent MI

383

a nurse is educaton the parent of a child who has Prader willi syndrome and has been prescribed somatropin. which of the following statements by a parent indicates understanding of the teaching?

we will use a different spot for injection each time we give the medication

384

a nurse is teaching a client who has a prescription for glipizide what instruction should the nurse include

avoid alcohol

385

a nurse is teaching a client about acarbose to treat 2 diabetes. which of the following instructions should the nurse include?

eat more iron rich foods

386

a nurse is caring for a client who is about to begin insulin glargine therapy. the nurse should identify the need for additional precautions because the client also takes which drugs ?

beta blockers

387

a nurse is caring for a client who is begin taking somatropin. the nurse should explain the need to monitor which of the following lab values?

urine calcium

blood glucose

388

a nurse is caring for a client who takes repaglinide 15 to 30 minutes before each meal to treat type 2 DM. the client asks if i skip a meal what should i do? which of the following responsese should the nurse make?

skip the dose

389

a nurse is teaching a client who has a prescripiton for pramlinitide therapy to treat type 1 DM. which of the following instructions should the nurse include?

administer before meals

390

which of the following drugs should a nurse have available for a client who is experiencing insulin toxicity?

glucagon

391

a nurse is caring for a client who is taking metformin to treat type 2 dm and reports muscle pain. which of the following adverse reactions should the nurse suspect?

lactic acidosis

392

a nurse is caring for a client who is taking desmopressin. the nurse should make whihc of the following assessments to evaluate the drugs effectiveness?

urine output

393

when considering replacement therapy options for a client who has chronic adrenocoritcal insufficiency, a nurse should recognize the provider will choose which drug?

hydrocortisone

394

a nurse administers pramlintide at 0800 to a client who has type 1 DM. at which of the following times should nurse expect the drug to exert its peak ?

0820

395

a nurse is caring for a client who is taking pioglitazone to treat type 2 dm. the nurse should monitor for which of the following findiings ?

weight gain

396

a nurse is caring for a male client who has an upper urinary tract infection. the nurse should identify that the infection is in which of the following portions of the urinary tract

kidney

397

a nurse is reinforcing teaching with a client who has a urinary tract infection and a prescription for cipro. which of the following instructions should the nurse include?

¨ you should not take an antacid within 2 hours of taking cipro "

398

a nurse is assisting with the development of plan of care for a client who has cystitis. which of the following interventions should the nurse include in the plan of care?

provide the client with a warm sitz baths

399

a nurse is reviewing the medical record of an older adult male client. the nurse should identify that which of the following findings place the client at risk for developing a uti?

the client has prostate disease

400

a nurse is collecting data from a client who has urosepsis. which of the following findings should the nurse expect?

decreased urinary output

401

a nurse is caring for a client who has a new prescription for maraviroc therapy. the nurse should instruct the client to report which of the following adverse effects?

Paresthesia
Cough
Jaundice
Fever

402

a nurse should recognize that realtegravir is used to treat clients who have which of the following conditions?

Resistant HIV disease

403

a nurse is caring for a client who has a prescription for cisplatin to treat testicular cancer. the nurse should instruct the client to report which of the following adverse effects?

Paresthesias
Sore throat
Flank pain
Tinnitus

404

a nurse is teaching a client about recommended immunizations. which of the following immunizations should the nurse recommend the client receive starting 50 years of age?

herpes zoster

405

a nurse is assessing a client following a trastuzumab infusion to treat metastatic breast cancer. which of the following findings should the nurse recognize as an indication that the client is experiencing an adverse reaction to the drug?

wheezing

dysrhythmias

hypotension

fever

406

a nurse is teaching a client about maraviroc. which of the following instructions should the nurse include?

"it is important to report any noticeable rash immediately as it might indicate an issue with your liver"

407

a nurse is teaching a guardian of a child about the recommended age range to recieve the hpv vaccine which of the following age ranges should the nurse include?

11 to 12

408

A nurse is teaching a client who has a new prescription for mercaptopurine to treat leukemia. Which of the following instructions should the nurse include?

Use contraception if pregnancy is a risk
Perform oral hygiene frequently
Perform hand hygiene frequently
Avoid activities that can cause injury

409

A nurse is instructing a client how to self- administer enfuvirtide. Which of the following instructions should the nurse include?

Allow the vial to sit until the solution is completely clear and without particulates

410

a nurse is teaching about immunizations . which of the following information should the nurse include in the teaching?

you should receive a tetanus booster every 10 years

411

a nurse is teaching a client who has a new prescription imatinib to treat chronic myeloid leukemia. which of the following instructions should the nurse include?

clean fruits and veggies thoroughly

weigh yourself daily

perform hand hygiene

avoid grapefruit and grapefruit juice

412

a nurse should recognize that enfuvirtide can be prescribed to clients who have which of the following conditons?

advanced HIV

413

a nurse is caring for a client who has a new prescription for ritonavir and zidovudine is prescribed with ritonavir for which of the following reasons?

to prevent drug resistance

414

a nurse is preparing to administer enfuvirtide to a client. which of the following actions should the nurse plan to perform?

-Administer the drug subcutaneously.
-Roll the vial gently to reconstitute the solution.
-Inject the solution at room temperature.

415

a nurse is caring for a client who has a new prescription for delavirdine therapy to treat HIV 1. the nurse should instruct the client to report which oft he following adverse reactions to the drug?

rash

416

A nurse is preparing to administer paclitaxel IV to a client who has ovarian cancer. Which of the following actions should the nurse take. (Select all that apply).

-Give the patient an antihistamine.
-Administer the drug through non-PVC tubing.
-Use an in-line filter.

417

A nurse is teaching the guardian of a 4- month- old infant about recommended immunizations for the infant. Which of the following immunizations should the nurse include?

Haemophilus influenza type B vaccine (Hib)

418

A nurse is caring for a client who has a new prescription for intrathecal cytarabine therapy to treat meningeal leukemia. The nurse should inform the client that they will also receive which of the following drugs to reduce the risk of neurotoxicity?

Dexamethasone

419

A nurse is caring for a client who is receiving vincristine to treat lung cancer. The nurse should monitor the client and recognize which of the following manifestations as an indication that the client is experiencing an adverse reaction to the drug.

Weak hand grasps.

420

A nurse is caring for a client who is prescribed zidovudine. Which of the following laboratory values should the nurse report to the provider?

hemoglobin 7.1

421

A nurse is preparing to administer the measles, mumps, and rubella (MMR) vaccine to a child. The nurse should recognize that the MMR vaccine provides which of the following types of immunity?

Artificial active immunity

422

A nurse is teaching a client who has a new diagnosis of breast cancer about the drug tamoxifen. The nurse should tell the client that which of the following conditions is a contraindication for taking tamoxifen?

Deep-vein thrombosis

423

A nurse is caring for a client who has a new prescription for topotecan therapy to treat resistant, small-cell lung cancer. The nurse should advise the client against taking which of the following types of over-the-counter drugs while receiving the therapy?

ibuprofen

424

A nurse should recognize that maraviroc is used in the treatment of which of the following conditions?

Chemokine receptor 5 (CCR5)-tropic HIV-1

425

A nurse is considering drug therapy options for a client who has metastatic breast cancer that is positive for human epidermal growth factor receptor 2 (HER2). Which of the following drugs should the nurse expect the provider to prescribe?

Trastuzumab

426

THE LPN IS OBSERVING THE CLIENTS CARDIAC RHYTHM ON THE MONITOR SCREEN AND NOTES THAT THERE IS AN ADDITIONAL PROMINENT WAVE FOLLOWING EACH T WAVE AND SUSPECTS THE PRESCENCE OF U WAVES. WHAT ACTIONS SHOULD THE LPN TAKE?

...

427

what are some causes of Fluid Volume Deficit ?

Vomiting

  • Diarrhea
  • Gi irritation
  • Gi suctioning
  • Ileostomy or colostomy grainage
  • Draining wounds, burns, or fistulas
  • Increased urine output from the use of diuretics
428

suspected data for a client with fluid volume deficit?

  • thirst
  • poor skin turgor
  • dry mucous membranes
  • increased hr
  • thready pulse
  • dyspnea
  • postural HYPOtension
  • weight loss
  • flat neck or hand veins
  • dizziness
  • weakness
  • increased specific gravity of the urine
  • confusion
  • increased hematocrit
  • decrease in urine volume and dark concentrated urine
429

interventions for fluid volume deficit?

  • Cause is treated
    • Replace fluids
      • IV solutions
      • Oral rehydration
  • Monitor vitals, respiratory and neurological status
  • Administer O2
  • Check mucous membranes and skin turgor
  • Monitor weight daily
  • Monitor hematocrit & electrolytes
    • Prepare to treat electrolytes
430

a client with kidney damage or failure is at high risk for what?

fluid volume excess

431

possible causes of fluid volume excess ?

  • Overhydration with IV fluids
  • Kidney damage
  • Hf
  • Long term use of corticosteroids
  • Excessive sodium ingestion
  • Syndrome of inappropriate antidiuretic hormone secretion
  • Irrigation of wounds or body cavities with hypotonic fluids
432

Objective and Subjective data collection for a client who is experiencing fluid volume excess?

  • Cough
  • Dyspnea
  • Lung crackles
  • Increased respirations and heart rate
  • Increased blood pressure
  • Bounding pulse
  • Pitting edema
  • Weight gain
  • Neck and hand vein distention
  • Increased urine output
  • Confusion
  • Decreased hematocrit
433

interventions for a client who is experiencing fluid volume excess?

    • Monitor vitals, respiratory, neurological status
    • Position in semi-fowlers
    • Administer diuretics as prescribed
    • Monitor hematocrit and electrolyte levels
    • Restrict fluids
  • Low sodium diet

`

434

what type of diet should a person experiencing fluid volume excess be on?

low sodium

435

HYPOkalemia

potassium values less than 3.5mEq/L

life threatening

436

food sources for potassium

  • Avocados
  • Bananas
  • Cantaloupe
  • Oranges
  • Strawberries
  • Tomatoes
  • Carrots
  • Mushrooms
  • Spinach
  • Fish
  • Pork
  • Beef
  • Veal
  • Potatoes
  • Raisins
437

causes of hypokalemia

  • Potassium losing diuretics
  • Diarrhea
  • Vomiting
  • Gastric suction
  • Corticosteroids or laxative
  • Kidney disease
  • Parenteral nutrition
  • Uncontrolled diabetes
  • Alkalosis
438

s/s of HYPOkalemia

    • Leg cramps
    • Abdominal cramps
    • Lethargy
    • Weakness
    • Shallow respirations
    • Thready pulse
    • Confusion
    • Decreased reflexes
    • HYPOactive bowel sounds and ileus
    • Postural hypotension
  • Peaked P waves
  • Flat T waves
  • Depressed ST segment and U waves
439

a nurse is caring for a group of clients who have mobility issues. which of the following clients is at the greatest risk for a complication?

  1. a 3 year old client who has a burned foot
  2. an 80 year old client who has a fractured hip
  3. a 30 year old client who has a cast applied for a fractured ankle
  4. a 42 year old client who has an indwelling urinary catheter

an 80 year old client who has a fractured hip

440

a nurse manager has established staff nurse committees to address unit issues, instituted an open door policy for talking about concerns, and supported the professional development of all staff members. which of the following leadership is this nurse manager?

  1. Laissez- faire
  2. autocratic
  3. democratic
  4. transformational

democratic

441

an experienced nurse is serving as a mentor to a newly licensed nurse. which of the following actions should the mentor perform?

  1. establish a set of goals for the newly licensed nurse to achieve
  2. establish a set timeframe with the newly licensed nurse for the mentorship
  3. serve as a guide and teacher for the newly licensed nurse in an established relationship
  4. develop a program of study for for the newly licensed nurse to follow

serve as a guide and teacher for the newly licensed nurse in an established relationship

442

a nurse on a medical surgical unit is planning for a group of clients. which of the following clients should the nurse attend to first?

  1. a newly admitted client who is scheduled to have an indwelling urinary catheter inserted
  2. a client who has kidney stones and reports flank pain of 6 on a scale of 0 to 10
  3. a client diagnosed with early stage chronic kidney disease who has a serum creatinine level of 2.0 mg/dl
  4. a client who has a cast newly applied on the forearm and reports tingling of the fingers

a client who has a cast newly applied on the forearm and reports tingling of the fingers

rationale : use ABC's to collect data

443

a nurse is a member of a quality improvement committee seeking to reduce the risk of adverse events in a health care facility. when reviewing recently submitted incident reports, which of the following incidents should the nurse identify as a sentinel event? \

  1. paralysis of a clients lower extremeties occurred following epidural anesthesia
  2. a client fall during ambulation did not result in client injury
  3. a complaint that a nurse was culturally insensitive was made by a client's family member
  4. surgery to the wrong site was stopped prior to a procedure.

paralysis of the clients lower extremeties occurred following epidural anesthesia

444

a nurse in an urgent care facility is preparing to administer a stat dose of medication to a toddler who is accompanied by their parent. the child is not wearing an identification band. How should the nurse identify the client?

  1. ask the child to say their name
  2. say the childs name and ask them if that is correct
  3. ask the parent to identify the child by name
  4. hold the medication until the child receives an id band

ask the parent to identify the child by name

445

a nurse is reviewing a new prescription by a provider. the nurse should verify that which of the following components of a prescription are present? Select all that apply

  1. dat and time of prescription
  2. client's diagnosis
  3. dosage of medication
  4. route of administration
  5. generic name of medication
  6. providers signature

Date and time

dosage of medication

route of administration

generic name of medication

providers signature

446

A nurse receives a telephone prescription from a provider. The provider states " administer three-tenths of a milligram of nitroglycerin orally to the client." How should the nurse trasncribe "three-tenths of a milligram" on the MAR?

  1. .3 mg
  2. 3/10's mg
  3. 0.30 mg
  4. 0.3 mg

0.3

447

a nurse is preparing to administer medication to the client. which of the following should the nurse use to identify the client? select all that apply

  1. client's telephone number
  2. client's place of birth
  3. client's hospital room number
  4. client's photograph
  5. client's assigned id number

telephone number

name

photograph

assigned id number

448

a nurse is asked to administer a medication to a client because a coworker must help with an emergency. the coworker gives the nurse a syringe labeled furosemide 20 mg. the label also includes the client's name and hospital id number. which of the following responses by the nurse is appropriate?

  1. "I'll go and give the medication to the client right away"
  2. "go with me to identify the client properly, and then i'll give the medication for you"
  3. "you should ask the charge nurse to administer the medication"
  4. I'll go help with the emergency situation while you administer the medication"

I'll go help with the emergency situation while you administer the medication

449

a nurse is administering medications to a client. which of the following actions should the nurse perform during the planning step of the nursing process?

  1. identify client allergies
  2. calculate the dose
  3. explain the purpose of the medication to the client
  4. observe the adverse effects of the medication
  5. verify the dose

calculate the dose

verify the dose

450

a charge nurse is explaining her understanding of quality improvement to a newly hired LVN. which of the following statements by the newly hired nurse requires further teaching?

  1. " the joint commission mandates that accredited agencies have quality improvement programs
  2. quality improvement measures the degree to which an agency has met a criterion
  3. nurses who provide direct care are an integral component of the quality process

quality improvement measures the degree to which an agency has met a criterion

rationale: quality improvement promotes quality care and focuses on prevention. quality assurance measures the degree to which an agency has met a criterion

451

magnet recognition program

healthcare organizations that participate in this program must collect data about nursing sensitive outcomes

452

which of the following is an iatrogenic risk factor that can increase a client's risk for falls ?

  1. decreased visual acuity
  2. urinary urgency or nocturia
  3. type and number of medications prescribed for the client

type and number of medications prescribed for the client

rational: prescription medications are iatrogenic risk factors, which are related to the treatment regimen

453

a charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. the client has a history of night sweats, anorexia, and weight loss. which ofthe following actions should the nurse take?

  1. assign the client to a private room with negative pressure airflow
  2. add contact precautions to the clients plan of care
  3. wear n95 respirator when entering the client's room
  4. ensure the clients enviornment provides 4 exchanges of fresh air per minute
  5. institute protective environment precautions as soon as the client arrives?

assign the client to a private room with negative pressure airflow

wear an n95 when entering the clients room

rationale: history and status suggests TB. communicable infection, airborne precautions

454

a nurse is assisting with the plan of care for a client who has cushings syndrome due to chronic corticosterioid use. which of the folllowing actions should the nurse include in the plan of care?

  1. check the clien'ts blood glucose for hypoglycemia
  2. check for hypertension
  3. weight the client weekly
  4. insert an indwelling catheter

check for hypertension

rationale: the nurse should check for hypertension which can indicate fluid volume overload

455

a nurse is collecting data from a client who has pericarditis. which of the following manifestations should the nurse expect?

  1. bradycardia
  2. relief of chest pain with deep inspiration
  3. dyspnea
  4. chest pain that increases when sitting upright

dyspnea

rationales: pericarditis clients will experience dyspnea, hiccups and nonproductive cough which may indicate heart failure

456

a nurse collecting data from a client who has a closed head injury and is receiving mannitol for manifestations of increase intracranial pressure. which of the following findings indicates the medication is having a therapeutic effect?

  1. the clients urine output is 250mL
  2. the clients pupils are dilated
  3. the clients heart rate is 56/min
  4. the client is restless

the clients urine output is 250 mL/hour

rationale: mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water from the brain tissue.

457

a nurse is reinforcing discharge teaching with a client who is postoperative following a right mastectomy for breast cancer. the client will be going home with 2 jackson pratt drains. which of the following peices of information should the nurse include in the teaching?

  1. cloudy drainage is normal
  2. showering is permitted before the drainage tubes are removed
  3. avoid wearing deodorant until the drains are removed and incision heals
  4. do not begin exercising the arm until the provider removes the drainage tubes.

avoid wearing deodorant until the drains are removed and the incision heals

rationale: avoid deodorant and talcum powder until healed

458

a nurse is caring for a client who has just returned from the surgical suite following a right nephrectomy. which of the following indicates that the client is meeting successful short term goal following this procedure ?

  1. the client requests pain medication upon arrival from surgery
  2. a chest x-ray shows consolidation in the right lower lobe
  3. urinary output is 35 to 50mL hr consistently
  4. the client has slight abdominal distention

urinary output is 35 to 50 mL/hr

rationale: less than 30 mL indicates inadequate blood flow to the remaining kidney

459

a nurse is collecting data from a client who is postop following ESWL. the nurse should identify that which of the following findings is the priority?

  1. report of palpitations
  2. pink-tinged urine
  3. bruising on the flank area
  4. stone fragements in the urine

report palpations

rationale: think of ABC's

460

a nurse is collecting data from a client who is admitted to the facility for observation following a closed head injury. which of the following data is the priority for the nurse to collect to detect a change in the client's neurological status?

  1. vital signs
  2. body posture
  3. level of consciousness
  4. examination of pupils

Level of consciousness

rationale : change in LOC can be first indication of a change in neurologic status

461

A nurse is reinforcing teaching about hypoglycemia with a client who has DM. which of the following manifestations should the nurse include?

  1. bradycardia
  2. diaphoresis
  3. deep, rapid respirations
  4. palpitations
  5. shakiness

diaphoresis, shakiness, palpitations

462

a nurse is caring for a client who has lung cancer that has metastasized. which of the following findings indicates the client is developing superior vena cava syndrome?

  1. irregular cardiac rhythm
  2. numbness in the hands
  3. muscle cramps
  4. facial edema

facial edema

rationale: svc is partial occlusion of the superior vena cava leading to decreased blood flow through the vein the earliest manifestation is facial and upper extremity edema

463

a nurse is caring for a client who has 20 year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. the client is dyspneic and has an oxygen sat via pulse ox of 85% which of the following actions should the nurse take ?

  1. place a nonrebreather mask on the client and increase the oxygen flow to 3L/min
  2. prep the client for possibility of endo intubation and mechanical ventilation
  3. increase the oxygen flow and request an arterial blood gas determination
  4. position the client supine and administer an antianxiety medication

increase the oxygen flow and request an arterial blood gas determination

rationale: increase the flow and evaluate its effectivness with ABG results

464

a nurse is preparing an automated external defib. for a client receiving CPR after a cardiac arrest. which of the following actions should the nurse perform first?

  1. press the analyze button on the machine
  2. stop CPR and move away from the client
  3. push the charge button to prepare to shock
  4. apply the defib pads to the clients chest

apply the defib pads to the clients chest

465

a nurse is reinforcing discharge teaching with a client who has aplastic anemia. which of the following statements should the nurse identify as an indication that the client understands instructions?

  1. I need to stay active to prevent blood clots in my legs
  2. if i have a bad headache I can take aspirin to get rid of it
  3. i should eliminate uncooked foods from my diet for now
  4. i should eat more iron fortified cereal to stregthen my blood

I should eliminate uncooked foods from my diet for now

rationale: eating thoroughly cooked foods can help prevent infections avoid raw fruits and veggies

466

a nurse names 3 objects for the client to remember, asks the client to repeat them, and tells the client he will have to repeat them again in a few minutes. after 5 minutes, the nurse asks the client to name the objects. the nurse is using this strategy to test which type of memory?

immediate

rationale: 3 object protocol involved

467

a nurse is reinforcing discharge teaching with the partner of a client who has AIDS. which of the following statements by the clients partner indicates further teaching?

  1. i will dispose of soiled tissues in a separate plastic bags
  2. I'll clean blood spills immediately with hot water
  3. I know that handwashing is an important preventive measure
  4. i will wash soiled clothes in hot water

I'll clean blood spills immediately with hot water

rationale: clean with bleach and wear gloves

468

during a neurological eval. a nurse asks how the client arrived at the appointment and with whom. which of the following types of memory is the nurse testing?

recall/ recent

469

a nurse is reinforcing teaching about dietary modifications for a client with newly diagnosed with cirrhosis. which of the following foods should the nurse recommend ?

  1. grilled chicken
  2. potato soup
  3. fish sticks
  4. baked ham

grilled chicken

470

A NURSE IS REINFORCING DISCHARGE TEACHING TO A CLIENT FOLLOWING OPEN RADICAL PROSTATECTOMY. THE CLIENT IS GOING HOME WITH AN INDWELLING URINARY CAT. WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT INDICATES UNDERSTANDING OF THE TEACHING ?

1. I WILL BE ABLE TO TAKE A TUB BATH IN 1 WEEK

2. i WILL TAKE ACETAMINOPHEN IF i HAVE ANY PAIN

3. i WILL USE SUPPOSITORIES TO PREVENT CONSTIPATION

4. i WILL REGAIN MY BLADDER CONTROL ONCE THE CATHETER IS REMOVED

TAKE ACETAMINOPHEN IF PAIN

471

A NURSE IS COLLECTING A HEALTH HISTORY FROM A CLIENT WHO HAS SKIN CANCER. WHICH OF THE FOLLOWING CLIENTS HISTORY AT THE HIGHEST RISK FACTOR FOR DEVELOPING SKIN CANCER

1. AGE OVER 60

2. GENETIC PREDISPOSITION

3. LIGHT SKINNED RACE

4. OVER EXPOSURE TO SUNLIGHT

OVER EXPOSURE TO SUNLIGHT

472

A NURSE IS CARING FOR A CLIENT WHO IS RECEIVING CHEMO TO TREAT CANCER. WHICH OF THE FOLLOWING EFFECTS SHOULD THE NURSE ANTICIPATE FROM THE CHEMO>

1. GINGIVAL HYPERPLASIA

2. HIRSUTISM

3. PANCYTOPENIA

4. WEIGHT GAIN

PANCYTOPENIA

- BONE MARROW SUPPRESSION

- DEFICIENCY OF WBCS, RBCS AND PLATELT COUNTS

- ADVERSE EFFECT OF CHEMO

473

A NURSE IS CARING FOR A CLIENT WHO HAS LUNG CANCER THAT HAS METASTASIZED. WHICH OF THE FOLLOWING INDICATES THE CLIENT IS DEVELOPING SUPERIOR VENA CAVA SYNDROME?

1. IRREGULAR CARDIAC RHYTHM

2. NUMBNESS IN THE HANDS

3. MUSCLE CRAMPS

4. FACIAL EDEMA

FACIAL EDEMA

474

A NURSE IS COLLECTING DATA FROM A CLIENT WHO HAS CANCER AND IS RECEIVING CHEMOTHERAPY BY PERIPHERAL IV INFUSION. THE CLIENT REPORTS PAIN AT THE INSERTION SITE AND THE NURSE NOTES FLUID LEAKING AROUND THE CATHETER. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE FIRST?

1. TAKE A PHOTOGRAPH OF THE PERIPHERAL IV SITE

2. OBTAIN AN RECORD THE CLIENTS VITAL SIGNS

3. STOP THE INFUSION

IDENTIFY ALL MEDICATIONS ADMINISTERED THROUGH THE IV SITE FOR THE PAST 24 HRS

STOP THE INFUSION

475

A NURSE IS CARING FOR A CLIENT WHO HAS TESTICULAR CANCER AND IS EXPERIENCING PERIPHERAL NEUORPATHY AS AN ADVERSE EFFECT OF CHEMO. WHICH OF THE FOLLOWING CLIENT MANIFESTATIOS IS AN EXPECTED FINDING OF PERIPHERAL NEUROPATHY?

1. THINNING OF THE SCALP HAIR

2. TINGLING OF THE HANDS AND FEET

3. REDUCED ABILITY TO CONCENTRATE

4. SORES IN THE MUCOUS MEMBRANES

TINGLING IN THE HANDS AND FEET

476

A NURSE IS COLLECTING DATA FROM A CLIENT. WHICH OF THE FOLLOWING FINDINGS IS THE HIGHEST RISK FACTOR FOR DEVELOPING BLADDER CANCER

1. THE CLIENT IS A HAIRDRESSER

2. THE CLIENT USES TOBACCO

3. THE CLIENT IS OVER 60 YEARS

4. THE CLIENT HAS FREQUENT UTIS

THE CLIENT USES TOBACCO

477

A nurse is planning care for client who has cancer and has developed thrombocytopenia following chemotherapy. Which of the following precautions should the nurse offer to minimize the adverse effects of thrombocytopenia?

1. MONITOR VISITORS FOR MANIFESTATIONS OF INFECTION

2. REMIND THE CLIENT TO USE AN ELECTRIC RAZOR

3. ENCOURAGE FREQUENT REST PERIODS

4. INSTRUCT THE CLIENT TO RINSE MOUTH DAILY WITH NORMAL SALINE

REMIND THE CLIENT TO USE AN ELECTRIC RAZOR

NEUTROPENIA PROHIBIT VISITORS, THROMBOCYTOPENIA DO NOT

478

A nurse is collecting a health history from a female client who is undergoing screening for breast cancer. Which of the following factors should the nurse identify for placing the client at the greatest risk for developing breast cancer?

1. OBESITY

2. ORAL CONTRACEPTIVE USE

3. ALCOHOL USE

4. OVER 50 YEARS OF AGE

OVER 50 YEARS OF AGE

479

A nurse is providing teaching to a client who has cancer and is receiving external radiation therapy. Which of the following statements by the client indicates an understanding of the teaching?

1. I NEED TO PROTECT THE AREA FROM SUNLIGHT

2. IM GOING TO APPLY SKIN LOTION TO THE AREA EVERY DAY

3. ILL MASSAGE THE AREA ONCE PER DAY

4. ILL WASH THE MARKINGS OFF AFTER EACH THERAPY TREATMENT

I NEED TO PROTECT THE AREA FROM SUNLIGHT

480

A nurse is providing postoperative discharge teaching to a client following a pan hysterectomy for uterine cancer. Which of the following information should the nurse include in the teaching?

1. YOU WILL NEED TO CONTINUE TO USE SOME FORM OF BIRTH CONTROL FOR 6 MONTHS

2. YOU MIGHT EXPERIENCE MANIFESTATIONS OF MENOPAUSE

3. DO NOT LIFT ANYTHING HEAVIER THAN 15 POUNTS

4. PAIN OR BURNING ON URINATION IS AN EXPECTED OUTCOME OF THIS SURGERY

YOU MIGHT EXPERIENCE MANIFESTATIONS OF MENOPAUSE

481

A nurse is admitting a client who has multiple myeloma and a white blood cell count of 2,200/mm3. Which of the following foods should the nurse prohibit the family members from bringing to the client?

1. FRIED CHICKEN FROM A FAST FOOD RESTURAUNT

2. A CASE OF CANNED NUTRITIONAL SUPPLEMENTS

3. A FACTORY SEALED BOX OF CHOCOLATES

4. A FRESH FRUIT BASKET

A FRESH FRUIT BASKET

482

A nurse is obtaining a health history from a client who has cancer of the cervix. Which of the following manifestations should the nurse expect?

VAGINAL BLEEDING

483

A nurse in an oncology clinic is assessing a client who has early stage Hodgkin's lymphoma. Which of the following findings should the nurse expect?

1. BONE AND JOINT PAIN

2. ENLARGED LYMPH NODES

3. INTERMITTENT HEMATURIA

4. PRODUCTIVE COUGH

ENLARGED LYMPH NODES