Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Isolate the client from other clients, family, and health care workers not wearing proper PPE.

A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?

Return for periodic liver function studies.

A client asked the nurse for information about how to reduce risk factors for

benign prostatic hyperplasia (BPH). which information should the nurse provide?

Increase physical activity.

The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?

Encourage frequent mouth care.

After teaching a client newly diagnosed with cholecystitis about recommended

diet changes, the nurse evaluates the client’s learning. Which food choices

eliminated by the client indicate to the nurse that teaching has been successful?

Whole milk and daily servings of ice cream

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty

wearing the continuous positive air pressure (CPAP) mask because it is

uncomfortable. The client asked the nurse for an alternative way to manage sleep

apnea. Which recommendation should the nurse provide?v

Begin a weight loss program.

A client is admitted to the hospital with symptoms consistent with a right

hemisphere stroke. Which neurovascular assessment requires immediate

intervention by the nurse?

Pupillary changes to ipsilateral dilation.

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

Washes the radiation site with antibacterial soap and water.

The nurse is preparing an older client for a magnetic resonance imaging (MRI)

with contrast. Which laboratory value should the nurse report to the health care

provider before the scan is performed?

Reference Range:

Glycosylated hemoglobin (A1C) [4% to 5.9%]

Creatinine [ 0.5 to 1.1 mg/dL (44 to 97 mmol/L

Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L

Blood Urea Nitrogen (BUN [ 10 to 20 mg/dL (3.6 to 7.1 mmol/L)

Serum creatinine of 1.9 mg/dL (169 mmol/L)

A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain?

Reference range:

Sodium [ 136 to 145 mEq/L (136 to 150 mmol/L

Urine Specific Gravity (1.005 to 1.03)

Weight gain of 2 pounds (0.91 kg) in one day.

Which intervention should the nurse include in the teaching plan for a client with pruritus?

Instruct the client to keep fingernails trimmed short.

On the 3rd postoperative day, a client who has had a hip replacement surgery

becomes anxious and diaphoretic, and begins to experience auditory hallucinations.

The client denies having any pain. The client's vital signs are pulse rate is 125

beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88

mm Hg. Which nursing intervention(s) should the nurse implement? Select all that

apply.

Administer and as needed (PRN) dose of lorazepam.

Reorient to day and time frequently

present a calm, supportive demeanor.

An older adult client with symptoms of osteoarthritis asks the nurse which form

of exercise would be most beneficial. Which is the best response by the nurse?

Swimming is an excellent exercise for you.

The nurse is providing dietary instructions for a client who is being discharged

after passing a calcium oxalate renal stone. Which food should the nurse instruct

the client to avoid?

Spinach salad

In assessing a client with ulcers on the lower extremity, which findings indicate

that the ulcers are likely to be a venous, rather than arterial, origin?

Irregular ulcer shapes and severe edema

A client who received 6 units of packed red blood cells 3 days ago for a lower

gastrointestinal bleed is now displaying of shortness of breath with occasional

stridor and is reporting muscle cramping. Which serum laboratory value should the

nurse immediately report to the health care provider?

Reference range:

Potassium (3.5 to 5 mEq/L

Magnesium (Adult 1.3 to 2.1 mEq/L)

Calcium (9 to 10.5 mg/dL

Sodium (136 to 145 mEq/L

Calcium 6.5 mg/dL

After initializing a steroid nebulizer treatment for a client with asthma and

respiratory distress, which intervention is most important for the nurse to

implement?

Teach proper use of a rescue inhaler.

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

Washes the radiation site with antibacterial soap and water.

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

high pitched sound hearing upon inspiration

A client experiences residual effects following and acute attack Meniere’s

disease and receives a new prescription for antihistamine. Which assessment

finding indicates that the medication is effective?

Ambulates easily without Vertigo

The nurse prepares a teaching plan for an adult client with metabolic syndrome.

Which finding(s) should the nurse address to help the client reduce the risk for

diabetes mellitus and vascular disease? Select all that apply

Blood pressure of 150/96 mm Hg

Increased triglyceride levels

Abdominal obesity

Hyperglycemia

A client presents with the onset of severe headache, fever, nuchal rigidity, and

petechial rash on arms and legs. The nurse recognizes the client is exhibiting

symptoms of which condition?

Meningococcal meningitis.

Following a motor vehicle accident, a client with chest trauma receives a chest

tube to relieve a hemothorax. Two hours following the chest tube insertion, the

nurse observes the water level in the water seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?

Continue to monitor the drainage system.

A male client who had abdominal surgery 5 days ago, and hospitalized because

of a surgical wound infection, tells the nurse that he feels like his insides just

spilled out when he coughed. Which action should the nurse take first?

Visualize the abdominal incision.

A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is

admitted with severe dehydration. Which assessment finding warrants immediate

intervention by the nurse?

Gastroccult positive emesis.

After performing a head-to-toe assessment for a client with Addison's disease, the nurse reports findings to the healthcare provider. The findings include moist mucous membranes, strong palpable peripheral pulses, and blood pressure 132/88 mm Hg. The client verbalizes understanding of the illness and importance of taking medications every day. Which action should the nurse implement?

Begin preparing the client for discharge home.

The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

The client will record episodes of angina and self-management for one week

A client is admitted with a history of hypertension and an acute myocardial

infraction 2 years ago. The client reports,

“I am feeling weak and tired, so I cannot

exercise at all. I feel out of breath when I walk even a short distance. Since I

cannot exercise, I am gaining weight. My shoes are even getting tight” the cardiac

monitor displays sinus tachycardia. Which cue should lead the nurse to further

assess the client for other symptoms of right sided heart failure?

Report of tight shoes

Client with acute renal injury (AKI) wait 110.3 lbs (50 kg) and has potassium

level of 6.7 mEq/L is admitted to the hospital. Which prescribed medication should the nurse administer first?

Reference Range:

Potassium 3.5 to 5 mEq/L

Sodium polystyrene sulfonate 15 grams by mouth.

A client with type 1 diabetes mellitus, hypertension, and chronic kidney disease

is to begin hemodialysis treatment. Which statement should the nurse include in

client education?

Expect the insulin dose to be reduced.

Five months following treatment for Herpes zoster (shingles), an older client

tells the home health nurse of continuing to experience pain where the rash

occurred. Which action should the nurse implement?

Complete an assessment of the clients pain

During a routine assessment at an outpatient clinic, the nurse notes that a client

has abdominal obesity and a high waist hip ratio with the body mass index of 32

kg/m2. Which action(s) should the nurse take in response to these findings? Select

all that apply.

Discuss the importance of a regular exercise program.

Measure the clients blood pressure in both arms.

Screen for family history for diabetes mellitus.

A client has an absolute neutrophil count (ANC) of 500/mm³ (0.5 x 10⁹/L) after completing chemotherapy. Which intervention is most important for the nurse to implement?
Reference Range:
Neutrophils (ANC) [2500 to 5800/mm³ (2.5 to 5.8 x 10⁹/L)]

Place the client in protective isolation.

The health care provider prescribes one liter of 0.9% sodium chloride, USP

intravenously (IV) to be infused over 10 hours for a client. How many mL/hrshould the nurse program the infusion pump to deliver ( Enter numerical value

only)

100ml/hr

The healthcare provider prescribes regular insulin 6 units/hr intravenously (IV)

. The IV solution contains 100 units of regular insulin and not 100 mL oh 0.9%

normal saline. How many mL/hr should the nurse program the infusion pump?

(Enter numerical value only)

6ml/hr

While completing a health assessment for young adult female with the cute

appendicitis, the client informs the nurse that there is a chance that she may be

pregnant. The operating team is preparing to take the client to surgery. Which

intervention should the nurse implement immediately?

Perform a bedside pregnancy test.

A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis

jirovecii pneumonia has a CD4+ T cell count of 200 cells/mm (20%) the client

asked the nurse why they have these reoccurring massive infections. Which

pathophysiologic mechanism should the nurse describe in response to the client’s questions?

Reference Range:

T-helper CD4 cells [600 to 1500 cells/mm (60 to 75%)

Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.

The nurse is caring for a client who had a cholecystectomy two days ago. The client is febrile, reporting upper abdominal pain radiating to the back and has had three episodes of vomiting in the last 8 hours. The nurse reviews the client's serum amylase and lipase level results which are twice the normal value. Based on these findings, the nurse should recognize the client is exhibiting symptoms of which condition?

Acute pancreatitis.

while completing a health assessment for a young adult female with acute appendicitis. the client informs the nurse that there is a chance that she may be pregnant. the operating team is preparing to take the client to surgery. which intervention should implement immediately ?

Perform a bedside pregnancy test.

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

Report when hematuria becomes pink-tinged.

The Nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse recommend the client to follow?

Restrict protein intake by including meats and other high protein foods

The nurse is caring for an older male client with impaired skin integrity to sheering forces and pressure that is manifested as a draining stage 3 sacral ulcer. Which intervention is most important for the nurse to implement?

Encourage a diet high in protein

While planning care for a client with carpal tunnel syndrome. The nurse identifies a collaborative problem of pain. What is the etiology of this problem?

Compression of a nerve

A young adult female visits the clinic for primary dysmenorrhea and tells the nurse that she started taking a calcium supplement to reduce her menstrual cramps. But I quit taking calcium because it caused constipation. The client to know what she does to relive her menstrual cramps. Which action should the nurse implement first to address the client's concern?

Ask her how much calcium she had been taking daily

A client with a medical diagnosis of a ruptured cerebral aneurysm exhibits these symptoms no eye opening, no sound vocalized, and flexion to pain (decorticate posturing). When calculating the Glasgow Coma Scale score, Which value should the nurse document for this client?

five

A client with acute myelogenic leukemia (AML) is admitted to chemotherapy (CT) using cytarabine and the antitumor daunorubion . Which measures are most important for the nurse to implement during the induction stage of chemotherapy?

Precautions to prevent infection and bleeding

To reduce pulmonary complications for a client with Amyotrophic Lateral sclerosis (ALS). Which intervention should the nurse implement? (Select all that apply)

Initiate passives engage of motion exercises

Encourage use of incentive spirometer

Teach the client breathing exercises

A client with polycystic Kidney is admitted because of an abrupt onset of massive polyuria. The client is pale, tachycardia and female. Which serum laboratory finding requires immediate intervention by the nurse?

Sodium 184 mEq/L

A client tells the nurse, “I just received good news about my tumor, I have a neoplasm, but it is benign.”. How should the nurse respond?

Ask the client if the diagnostic test indicates any secondary metastasis

The Nurse is assessing a client diagnosed with medical diagnosis of a Bartholin cyst. Which physical assessment technique should the nurse use to observe the cyst?

Place the client in lithotomy position to perform a pelvic examination

A client with renal calculus is complaining of severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

Acute pain related to renal calculus

Which Technique should the nurse use when assessing for early signs of rheumatoid arthritis?

Observe the clients' fingers

A client with cancer develops tumor lysis syndrome (TLS) following chemotherapy. Wich nursing action has the highest priority in responding to the symptoms of this syndrome?

Maintainintravenoustherapy

A client with Hepatitis A is complaining of weakness and chronic fatigue. Which intervention is most important for the nurse to implement?

Provide liberal fluids for hydration and excretion of metabolic waste products

A client who had a cast yesterday to the lower left arm comes to the clinic complaining of pain in the cast arm. Which assessment finding is most important for the nurse to identify?

Circulatory impairment distal to the cast

The nurse review lab values of a female client with metastatic breast cancer and notes that the client's serum calcium level is 14 mg/dL. The client is weak, fatigued, and depressed. New prescriptions include increasing the rate of intravenous fluids. Which action should the nurse take first?

Increase the intravenous fluids as prescribed.

A client with hypovolemic shock is admitted to the intensive care unit with an intraosseous (IO) vascular access device placed in the right proximal tibia. The client has received two liters of normal saline and one unit of packed red blood cells through the IO access device since admission. Which assessment finding warrants immediate intervention by the nurse?

IO Vascular access in lace greater than 24 hours

Clients' laboratory findings indicate elevations in thyroxine and triiodothyronine hormones. The nurse suspects that the client may have hyperthyroidism. Which symptom is most often associated with hyperthyroidism?

Increased pulse rate

Prior to initiating peritoneal dialysis, which nursing action is most important for the nurse to implement

Obtain and record the clients' vital signs

The nurse is preparing to insert an indwelling catheter for a male client who has diabetes and a semirigid penile implant. After placing the sterile drapes and prepping the meatus, the nurse notes that the client's penis is erect. Which action should the nurse implement?

Continuetoinsertthecatheter

The nurse is conducting discharge teaching for a male client with a prescription for magnesium hydroxide 15 mL one time per day. His home medication cup is ounces. How many ounces should he take each dose?

0.5 ounces

Following the administration of intravenous regular insulin to a client diagnosed with hyperkalemia, the nurse should expect which outcome to occur?

An improvement in the cardiac conduction abnormalities

An adult male who is insulin dependent diabetic. Is admitted to the hospital because of headaches. When the client stiffens and begins to seize. Which intervention is most important for the nurse to implement?

Give the client a rapid form of glucose supplement

A female client returns to the clinic after being treated for chlamydia with azithromycin IM and reports that she still has symptoms. The healthcare provider obtains a swab of the discharge from the cervix for testing chlamydia. The client reports maintaining a monogamous relationship when laboratory results are positive for sexually transmitted infection. Which information should the nurse obtain to evaluate the ineffective results of treatment?

Determine if the clients sexual partner received treatment for chlamydia

The nurse implements a change in the approach to the client care after gathering evidence of a new approach. What should the nurse do first?

Evaluate effectiveness of the change

The Home Health nurse is caring for a client with Parkinson's disease who is beginning to experience swallowing difficulties. Which intervention should the nurse include for this client?

Encourage the client and family to provide a semi-solid diet with thick liquids

A client with chronic cirrhosis has esophageal varices. it is most important for the nurse to monitor the client for?

Hematemesis

The intracranial pressure of a brain-injured client who is on a ventilator has increased from 15 mm Hg to 25 mm Hg within the last 30 minutes. The client is beginning to flex all extremities intermittently. Based on these findings, which immediate action should the nurse take?

Asses the patency of the client's artificial airway

A young male client has a diagnosis of epididymitis and a positive culture for Escherichia coli. Which information should the nurse include in the teaching plan?

Surgical intervention often indicated

A client has a prescription for a viscous compound containing lidocaine HCL and diphenhydramine to relieve the discomfort of mucositis caused by radiation therapy. Which instructions should the nurse provide the client about administration of this prescription?

Gently pat the solution on the sore areas, using cotton tipped applicators

A client admitted dehydration resulting from vomiting and diarrhea. The nurse knows that the client is at greatest risk of developing which condition?

Cardiac dysrhythmia

When the nurse begins discharge instructions for a client and her spouse, the client who had an above the knee amputation for complications associated with diabetes, tells the nurse that she is not ready to go home and wants to stay home in the hospital another day, which intervention is important for the nurse to implement?

Ask the client what frightens her about leaving the hospital and returning home

The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority when providing care for the client?

Obtain results of culture and sensitivity of CSF