Which factors place the client at risk for a hematologic health problem? SATA

family hx of bleeding problems

excessive alcohol consumption

diet high in Vitamin K

A hospitalized client has a platelet count of 58,000/mm3. What action by the nurse is most appropriate?

Place the client on safety precautions

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client would the nurse assess first?

Client who reports shortness of breath

A nurse is caring for four clients. After reviewing todays laboratory results, which client should the nurse see first

client with PT of 28 seconds

A nurse works in a gerontology clinic. What age-related changes cause the nurse to alter standard assessment techniques from those used for younger adults? SATA

Nail beds become thickened or discolored

Progressive loss of hair occurs

Skin becomes dry as the client ages

What age-related changes related to the hematologic system will the nurse expect during health assessment? SATA

nail beds become thickened and discolored

Progressive thinning of hair/ hair loss

A nurse is caring for a client with leukemia. The student asks why the client is still at risk for infection when the WBCs are high. What response by the registered nurse is best

Those WBCS are abnormal and don’t provide protection

The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met?

Doing activities of ADLs using rest periods

The family of a neutropenic client reports the client is not acting right. What action by the nurse is the priority?

Assess the client for infection

A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition?

I usually put ice on bumps for bruises

A nurse is teaching a client with a cerebellar function impairment which statement would the nurse include in this client's discharge teaching?

Ask a friend to drive you to your follow-up appointments

The nurse is performing an assessment of cranial nerve III which testing is appropriate

Pupil constriction

During a lumbar puncture which position should the patient be i

Pt should be on the left side knees to chest( fetal position)

An 84 year old client who is usually alert and oriented experiences an acute cognitive decline which of the following factors would the nurse anticipate as contributing to this neurologic change(SATA)

Infection

Drug toxicity

Hypoxia

The nurse is teaching the daughter of a client who has middle stage alzheimer disease the daughter asks will the sertraline my mother is taking improver her dementia how would the nurse respond about the purpose of the drug

It will not improve her dementia but can help control emotional responses

A client with early-stage alzheimer disease is admitted to the hospital with chest pain which nursing action is most appropriate to manage this clients dementia

Ensure a structured and consistent environment

The nurse observes a client with late-stage alzheimer disease eat breakfast afterward the client states I am hungry and want breakfast what is the nurse's best response

I see you are still hungry I will get you some toast

The nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed alzheimer disease which statement by the caregiver indicates a need for further teaching

I will avoid communicating with the client to prevent agitation

The nurse teaches assistive personnel (AP) about how to care for a client with early-stage alzheimer disease which statement would the nurse include

Reorient the client to the day time and environment with each contact

After teaching the wife of a client who has Parkinson disease the nurse assesses the wife's understanding which statement by the client's wife indicates that she correctly understands changes with this disease

He may have trouble chewing so I will offer bite sized portions

The nurse plans care for a client with parkinson disease which intervention would the nurse include in this client's plan of care

Keep the head of the bed at 30 degrees or greater

A nurse teaches assistive personnel(AP) about how to care for a client with parkinson disease which statement would the nurse include as part of this teaching

Allow the client to be as independent as possible with activities

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis which question would the nurse ask

Do you live in a crowded residence

The nurse plans care for a client with epilepsy who is admitted to the hospital which interventions would the nurse include in this client's plan of care (SATA)

Have suction equipment with an airway at the bedside

Have oxygen administration set at the bedside

Ensure that the client has IV access

The nurse assesses a client who has parkinson disease which signs and symptoms would the nurse recognize as a key feature of this disease(SATA)

Flexed trunk

Slow movements

Uncontrolled drooling

The nurse initiates care for a client with a cervical spine cord injury who arrives via emergency medical services what action would the nurse take first

Evaluate respiratory status

A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury what other assessment finding will the nurse anticipate for this client

Flaccid bowel

The nurse is performing a focused assessment of left posterior temporal lobe functions will assess the patient for

Ability to understand written and oral language

Which problem can the nurse expect for a patient who has a positive romberg test result

Falls

A nurse assesses a client who is recovering from anterior cervical discectomy and fusion which complications should alert the nurse to urgently communicate with the healthcare provider

Auscultated stridor

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program the client states I don't understand the need for rehabilitation the paralysis will not go away and it will not get better how would the nurse respond

"The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability."

After teaching a client with a high thoracic spinal cord injury the nurse assesses the client's understanding which statement by the client indicates a correct understanding of how to prevent respiratory problems at home

’ll use my incentive spirometer every 2 hours while i'm awake

A client is scheduled for a percutaneous endoscopic lumbar discectomy which statement by the client indicates a need for further teaching

I'll be in the hospital for 2 to 3 days

A nurse assess clients at a community center which client is at greatest risk for low back pain

A 45-year-old male with osteoarthritis

A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion which complications would the nurse report to the primary healthcare (SATA)

Incisional bulging

Clear drainage on the dressing

Sudden and severe headache

A nurse assess a client with paraplegia from a spinal cord injury and notes reddened areas over the clients hips and sacrum what actions would the nurse take (SATA)

Reposition the client off the reddened areas

Apply a pressure reducing mattress

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago which assessment findings would the nurse correlate with neurogenic shock (SATA)

Heart rate of 34 beats/min

Urine output less than 30 mL/hr

Decreased level of consciousness

A nurse assesses a client who is recovering from an open traditional anterior cervical fusion which assessment findings would alert the nurse to a complication from this procedure (SATA)

Difficulty swallowing

Hoarse voice

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide(Cytoxan) and methylprednisolone(Medrol)which statement should the nurse include in this clients discharge teaching

Avoid crowds and people with colds."

A nurse cares for a client who has been diagnosed with huntington gene but has no symptoms the client ask for options related to family planning what is the nurse's best response

Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider.

An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash which planned intervention by the healthcare provider should the nurse question

Prepare the patient for lumbar puncture

During the neurological assessment the patient is unable to respond verbally to the nurse but cooperates with the nurse's direction to move his hands and feet. What should the suspect be as a likely cause of these findings?

damage to the frontal lobe.

The nurse recognizes which pathophysiologic feature as a hallmark of guillain barre syndrome

The immune system destroys the myelin sheath.

A patient who has numbness and weakness of both feet is hospitalized with Guillain barre syndrome the nurse will anticipate that collaborative interventions at this time will include

IV infusion of immunoglobulin (Sandoglobulin).

The nurse advises a patient with myasthenia gravis (MG) to

Perform physically demanding activities early in the day

A patient who has amyotrophic lateral sclerosis(ALS) is hospitalized with pneumonia which nursing action will be included in the plan of care

Assist with active range of motion

A 40 year old patient is diagnosed with early huntington's disease(HD) when teaching the patient the spouse and adult children about this disorder the nurse will provide information about the

Option of genetic testing for the patients children to determine their own HD risk

When a 74 year old patient seen in the health clinic the new development of a stooped posture shuffling gait and pill rolling type tremor the nurse will anticipate teaching the patient about

Antiparkinsonism drugs

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit which equipment should the nurse have available in the patients assigned room(SATA)

Side rail pads

Suction tubing

Oxygen mask

A patient with parkinson's disease is admitted to the hospital for treatment of pneumonia which nursing interventions will be included in the plan of care(SATA)

Provide an elevated toilet seat

Cuts patients food into small pieces

Place an armchair at the patient's bedside

A patient with bell's palsy refuses to eat while others are present because of embarrassment about drooling the best response by the nurse is to

Respect the patient's feelings and arrange for privacy at mealtimes

A patient hospitalized with a new diagnosis of Guillain Barre syndrome has numbness and weakness of both feet the nurse will anticipate teaching the patient about

Infusion of immunoglobulin

A patient is hospitalized with a new onset of Guillain barre syndrome the most essential assessment for the nurse to complete is

Observing respiratory rate and effort

You suspect bell's palsy in which patient

Sudden onset one sided facial weakness with ear pain and vesicles

A nurse plans care for a 77 year old client who is experiencing age related peripheral sensory perception changes which intervention would the nurse include in the client's plan of care

Ensure that the path to the bathroom is free from clutter.

When admitting a patient with acute confusion to the hospital, the nurse will interview the patient about health problems and health history primarily to

assess the patient's baseline cognitive abilities

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include?

"You should call the doctor if pain or herpes lesions occur near the ear."

What action should the nurse incorporate when administering a mental status examination to a patient with delirium

Choose a place without distracting stimuli

A patient is diagnosed with moderate dementia after multiple strokes. What would the nurse expect to find during assessment of the patient? (

Loss of recent long and term memory

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

Time and observe and record the details of the seizure and postictal state

A nurse teaches a client who is recovering from an open traditional cervical spine fusion which statement would the nurse include in this clients post operative instructions

Wear your neck brace whenever you are out of bed

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care?

Instruct the patient how to self catheterize

While administering a mental status examination to a patient with delirium the nurse should

Choose a place without distracting environmental stimuli

The nurse is caring for a patient who is being evaluated for a possible metastatic spinal cord which of these data obtained when assessing the patient requires most immediate action by the nurse

the patient has new onset weakness in both legs

A patient with a history of a T2 spinal cord tells the nurse I feel awful today my head is throbbing and I feel sick to my stomach which actio n should the nurse take first

check the blood pressure

A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with a 1+ pedal pulse. What action would the nurse perform first?

Assess the neurovascular status of the right leg.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic intervention does the nurse recommend?

Ice packs

A client has a bone density score of -2.8. What intervention would the nurse anticipate based on this assessment?

Planning to teach about bisphosphonates

When administering alendronate (Fosamax) to a patient with osteoporosis, the nurse will

Assist the patient to sit up at the bedside

A client who had a partial gastrectomy 3 days ago begins experience vertigo sweating and tachycardia about 30 minutes after eating breakfast what postoperative complications would the nurse suspect

Dumping syndrome

After a patient has had a hemorrhoidectomy at an outpatient surgical center, which instructions will the nurse include in discharge teaching?

Take prescribed pain medications before you expect a bowel movement

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis?

Muscle twitching and finger numbness

The nurse is assessing a client who has hepatitis C what extrahepatic complications would the nurse anticipate (SATA)

Polyarthritis

Heart disease

Myalgia

Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis?

Palpable abdominal mass

A woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. Which intervention should the nurse anticipate?

Nystatin tablets

A patient with knee pain who is diagnosed with bursitis asks the nurse to explain just what bursitis is. The nurse will respond that bursitis is an inflammation of

a small, fluid-filled sac found at some joints

The nurse is caring for a client who has pain during circumduction of the shoulder when the nurse moves the arm behind the client. Which of the following questions should the nurse ask?

"Do you have difficulty putting on a jacket?"

The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to

administer IV fluids

A client had an open traditional Whipple procedure this morning. For what priority complication would the nurse assess?

Fluid and electrolyte imbalances

The nurse is performing an initial assessment and notes that the client weighs 186.4 Ib (84.7 kg). Six months ago, the client weighed 211.8 lb (96.2 kg). What action by the nurse is appropriate?

Ask the client if the weight loss was intentional

The nurse will be teaching self-management to patients after gastric bypass surgery. Which information will the nurse plan to include?

Drink fluids between meals but not with meals

Which assessment finding is of most concern for a patient with acute pancreatitis?

Palpable abdominal mass

The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis?

Hepatitis C

The nurse notes that the primary health care provider documented the presence of mucosal erythroplasia in a client. What does the nurse understand that this most likely means for this client ?

Early sign of oral cancer

Which daily behavior of a client with GI problems requires further nursing assessment? Select all that apply.

Smokes a pack of cigarettes

Uses Fleet enemas frequently to assist with bowel movements

Takes 325 mg of aspirin at night for arthritic pain

Travels extensively across the world

A 26-yr-old patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. The nurse will teach the patient to avoid

Smoked foods such as ham and bacon

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)?

Ranitidine decreases gastric acid secretion

The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which complication would the nurse monitor?

Upper gastrointestinal (GI) bleeding

A client has an open traditional hiatal hernia repair this morning. What is the nurse’s priority for client care at this time?

Preventing respiratory complications

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (SATA)

Decreased hydrochloric acid production

Diminished sensation that can lead to constipation

Fat not digested as well in older adults

Pancreatic vessels become calcified

The nurse will plan to monitor a patient with an obstructed common bile duct for

Steatorrhea

A nurse is learning about different surgical procedures and their classifications. Which examples below does this include? (Select all that apply.)

Liver biopsy: diagnostic

Arthroscopy: preventative. Ileostomy: palliative. Total shoulder replacement: reconstructive

Body contouring: cosmetic

A client is scheduled to have a total hip arthroplasty. What preoperative teaching by the nurse is most important?

Remind the client to have all dental procedures completed at least 2 weeks prior to surgery.

A client who had a fractured ankle open reduction internal fixation (ORIF) 4 weeks ago, reports burning pain and tingling in the affected foot. For which potential complication would the nurse anticipate?

Complex regional pain syndrome

A nurse plans care for a client who is recovering from open reduction and internal fixation(ORIF) surgery for a right hip fracture. Which interventions would the nurse include in this plan of care? (Select all that apply.)

Elevate heels off the bed with a pillow.

Ambulate the client on the first postoperative day.

Reposition the client every 2 hours.

A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures would the nurse share with the client? (Select all that apply.)

It leads to minimal blood loss.

It allows for early ambulation.

It promotes healing.

A nurse cares for a client with a recently fractured tibia. Which assessment would alert the nurse to take immediate action?

Numbness and tingling in the extremity………….Report to the doctor immediately.

A nurse cares for a client who had a bronchoscopy/post endoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next?

Assess the gag reflex before giving any food or water.

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is appropriate?

Assess the gag reflex.

A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions should the nurse include in the plan of care?(Select all that apply.)

Administer pain medications as prescribed.

Palpate the abdomen for distention.

Assess for sudden changes in mental status.

Evaluate stools for occult blood.

Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer?

Red, velvety, patches on the buccal mucosa

Which statement to the nurse from a patient with jaundice indicates a need for teaching?

“I use acetaminophen (Tylenol) every 4 hours for back pain.”

What action(s) by the nurse is (are) appropriate to promote nutrition in a client who had a partial gastrectomy? (SATA)

Administer vitamin B12 injections

Ask the primary health care provider about folic acid replacement

Provide iron supplements for the client

When caring for a patient with a history of a total gastrectomy, the nurse will monitor for

cobalamin (vitamin B12) deficiency

A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities would the nurse include in the health teaching? (SATA)

Frequently assesses the ergonomics of the equipment being used.”\

Take breaks to stretch fingers and wrists during working hours.”

Adjust chair height to allow for good posture.”

When assessing for Tinel’s sign in a patient with possible right carpal tunnel syndrome, the nurse will ask the patient about

Tingling in the right thumb and index finger

The nurse who notes that a 59-yr-old female patient has lost 1 inch in height over the past 2 years will plan to teach the patient about

dual-energy x-ray absorptiometry (DEXA)

Which information in a 67-yr-old woman’s health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system?

The patient’s mother became shorter with aging

The nurse reviews a list of drugs that can cause secondary osteoporosis. Which drugs are most commonly associated with this health problem? (SATA)

Barbiturates

Corticosteroids

Loop Diuretics

Which medication information will the nurse identify as a potential risk to a patient’s musculoskeletal system?

The patient has severe asthma requiring frequent therapy with oral corticosteroids.

A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder?

Elevated international normalized ratio (INR)

Elevated serum ammonia

Elevated prothrombin time (PT)

The nurse is reviewing the laboratory profile for a client who has muscular dystrophy. Which laboratory value(s) would the nurse expect to be elevated? (SATA)

Creatine Kinase (CK)

Lactic dehydrogenase (LDH)

Aspartate aminotransferase (AST)

lase (ALD)

The nurse is caring for several clients with osteoporosis. For which client would bisphosphonates not be a good option?

Client with a spinal cord injury who cannot tolerate sitting up.

What abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider?

Petechiae on the chest and abdomen

Pt post op teaching of gastric bypass

Teach hydration

Pain in back or shoulders abdomen flank pain call dr

Small frequent meals

A nurse is caring for a client who has been diagnosed with a small bowel obstruction which assessment findings will the nurse correlate with this diagnosis SATA

Serum potassium 2.8

Abdominal pain in upper quadrants

Serum sodium of 121

High pitched bowel sounds

A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report?

Severe boring abdominal pain

A client is receiving adefovir for management of hepatitis B. What health teaching will the nurse provide for the client about this drug? Select all that apply.

Avoid places with crowds and individuals who have infection."

"Get your lab work done regularly because the drug can affect your kidneys."

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?

Ask the patient to extend both arms forward

The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?

The patients hands flap back and forth when the arms are extended

A patient with acute pancreatitis is NPO and has a nasogastric tube (NG) to suction. Which information obtained by the nurse indicates that these therapies have been effective?

Abdominal pain is decreased

A patient has been admitted with acute liver failure. Which data are most important for the nurse to communicate to the health care provider?

Asterixis and lethargy

Which part of the HIV infection process is disrupted by the antiretroviral

drug class of protease inhibitors?

Clipping the newly generated viral proteins into smaller functional Pieces

Which statement made by the client with stage HIV-III disease (AIDS) whose CD4+ T-cell count has increased from 125 cells/mm3 (0.2 × 109/L) to 400 cells/mm3 (0.2 × 109/L) indicates to the nurse that more teaching is needed?

Although I am still HIV positive, at least I no longer have AIDS.”

The client on combination antiretroviral therapy calls the nurse to report that he is on vacation and the bag with his drugs was accidentally left on the airplane, so he missed all of yesterday’s dosages. What action does the the nurse recommend?

• Take today’s dosages as normally prescribed and continue to

follow your therapy program.”

Take today’s dosages as normally prescribed and continue to follow your therapy program.”

What is the most important question for the nurse to ask before giving the first dose of fosamprenavir to a client newly prescribed this drug?

“Are you allergic to sulfa drugs?”

Which activities can the nurse postpone or eliminate for the client who Has extreme fatigue today? Select all that apply.

Ambulating in the hall

Providing a complete bed bath

Teaching about nutrition therapy

Which dietary change does the nurse suggest for the client who has esophageal candidiasis?

“Eat soft, cool food such as pudding and smoothies.”

Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors?

Binding of the virus to the CD4+ receptor and either of the two coreceptors

Which food, drink, or herbal supplement does the nurse teach the client taking tipranavir to avoid?

St John's wort

A client who is HIV positive and receiving combination antiretroviral therapy tells the nurse she is now pregnant. Which drug does the nurse expect to be suspended during this patient’s pregnancy?

Abacavir

A client with known HIV 2 is admitted to the hospital with fever night sweats and severe cough laboratory results include CD4+ cell count of 180/mm3 and a negative tuberculosis(TB) skin test 4 days ago. What action would the nurse take first?

Place the client under airborne precautions

A student nurse is learning about human immunodeficiency virus(HIV) infection which statements about HIV infection are correct SATA

• CD4+ cells begin to create new HIV virus particles
• Antibodies produced are incomplete and do not function well
• Macrophages stop functioning properly
• Opportunistic infections and cancer are leading causes of death

A client with human immunodeficiency virus (HIV) has had a sudden decline in status with a large increase in viral load what action should the nurse take first

Assess the client for adherence to the drug regimen

The nurse is caring for a client diagnosed with human immune deficiency virus the clients CD4+ cell count is 399/mm3 what action by the nurse is best

Counsel the client on safer sex practices/ abstinence

The nurse is caring for a patient who is HIV positive and has a previous history of drug and alcohol abuse the patient is being treated with combination therapies including didanosine (videx) which laboratory findings would most concern the nurse

• Increased serum amylase and triglycerides and decreased serum calcium

Increased serum amylase and triglycerides and decreased serum calcium

Which statement(s) regarding type III hypersensitivity reactions is/are true? Select all that apply.

Type III responses are usually directed against self cells and tissues

Rheumatoid arthritis is an example of a health problem caused by this type of hypersensitivity

Which new-onset condition or symptom in a client who has systemic lupus erythematosus (SLE) now taking hydroxychloroquine does the nurse deem to have the highest priority for immediate reporting to prevent harm

Failure to see letters in the middle of a word

Which statement(s) regarding type I hypersensitivity reactions is/are true? Select all that apply.

The response is characterized by the five cardinal symptoms of inflammation

Type 1 responses are usually directed against non-self but the response is excessive

The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema

Which action will the nurse perform first for a client in anaphylaxis to prevent harm?

Injecting epinephrine

Which specific information will the nurse teach to the client with

systemic lupus erythematosus newly prescribed belimumab therapy?

The drug can only be given by a healthcare professional.

Which statements by assistive personnel indicate understanding regarding infection control measures needed to care for a client who has possible Clostridium ^difficile infection? Select all that apply.

• “I’ll wear an isolation gown when providing direct care.”
• . “I’ll wear gloves when providing direct care.”
• “I’ll use a hand sanitizer when I can’t wash my hands.”

The nurse takes a history for a client administered to the hospital. Which factors in the nursing history indicate that the client is at risk for infection? Select all that apply.

• Diabetes mellitus type 2 for 20 years
• 52-pack year history of cigarette smoking
• Admitted from a long-term care facility
• Has a history of multiple urinary tract infections
• Is 84 years of age

A client is diagnosed with C. difficile infection. What nursing action is the

priority for the client?.

Place the client on Contact Precautions.

When obtaining a health history and physical assessment from a 68-year old male client who has a history of an enlarged prostate, which finding does the nurse consider it significant? Select all that apply.

• Distended bladder
• Frequency of urination
• Dribbling urine after voiding

A client is on a 24-hour urine collection. At midpoint during the collection, the client tells the nurse that some of the urine was discarded. What action will the nurse take? Select all that apply.

• Reinforce client education.
• Notify the laboratory staff.
• . Document the discarded urine.
• Notify the health care provider.

The nurse is administering  a client undergoing a CT scan with contrast. Which finding does the nurse report as a possible immediate hypersensitivity reaction? Select all that apply.

• Pruritus
• Urticaria
• Laryngeal stridor
• Flushing of the skin

Which assessment finding would require the nurse to take immediate

action in a client who is 1 hour post kidney biopsy? Select all that apply.

Pink-tinged urine

Which client being managed for dehydration does the nurse consider at

greatest risk for possible reduced kidney function?

An 80-year-old man who has benign prostatic hyperplasia

Which lab finding is indicative of renal function alterations and not dehydration? Select all that apply.

• Creatinine 2.3 mL/dL
• Cystatin-c 105 mg/mL
• Creatinine clearance 175 mL/min

Which symptom(s) in a client during the first 12 hours after a kidney biopsy indicates to the nurse a possible complication from the procedure?

The heart rate is 118, blood pressure is 108/50, and peripheral pulses are thready.

What is the appropriate nursing response when a 66-year-old healthy client asks how often a visit to the eye care provider is recommended?

“Every 3 to 5 years if you have no eye problems.

Which supplement will the nurse recommend to a client who wants to enhance eye health?

Lutein

Which client statement affirms that nurse teaching about instillation of multiple different eye drops has been effective? Select all that apply.

“A schedule will help me remember when to instill the eyedrops.”

“If I have trouble instilling the drops, there are devices that can be helpful.”

“I can label the eyedrops by color to help me easily distinguish which one is which.”

“I will not touch the droppers to my eyes as this can cause contamination and infection.”

What finding does the nurse anticipate when assessing a client with a new diagnosis of glaucoma?

Gradual loss of visual fields

Which patient does the nurse identify at highest risk for development of dry age-related macular degeneration (AMD)?

62-year-old client with hypothyroidism

Which symptom will the nurse teach the client who just had surgery to correct a retinal detachment to immediately report to the eye care provider? Select all that apply .

• Pain in the affected eye
• Pus in the affected eye
• Decreased visual acuity

Which assessment data do the nurse anticipate when a client presents to the emergency department reporting the sensation of a foreign body in the eye? Select all that apply.

• Pain
• Tearing
• Photophobia
• Blurred vision

For which client would the nurse expect to teach intermittent catheterization?

• 35-year-old woman who has multiple sclerosis and incontinence

The nurse is caring for an 80-year-old female client with recurrent cystitis.Which teaching will the nurse include in the plan of care? Select all that apply .

Encourage fluid intake of 2-3 L of fluid throughout the day.

Instruct her to always wipe the perineum from front to back after each toilet use.

Reinforce that she should complete the entire course of antibiotics as prescribed.

Instruct her to empty her bladder immediately before and after having intercourse

A client with diabetes has the following assessment changes after a percutaneous nephrolithotomy procedure. Which change requires immediate nursing intervention?

difficulty breathing and an oxygen saturation of 88% on 2 L of

oxygen by nasal cannula

A 68-year-old male client is seeing the primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer?

A 30-year occupation as a long-distance truck driver

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient’s assigned room (select all that apply)?

• Side rails pads
• Oxygen mask
• Suction tubing

The nurse plans care for a client with epilepsy who is admitted to the hospital which interventions would the nurse include in this client's plan of care (SATA)

Have suction equipment with an airway at the bedside

Have oxygen administration set at the bedside

Ensure that the client has IV access

The nurse assesses a patient with pernicious anemia which finding would the nurse expect

• Tender bleeding gums

The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement by the client indicates understanding about those changes?

• Ill increase animal protein like fish and meat

The nurse assesses a client's oral cavity as seen in the photo below what actions by the nurse is most appropriate

• Teach the client about cobalamin therapy

Which patient statement to the nurse indicates that the patient understands self care for pernicious anemia

• I could choose nasal spray rather than injections of vitamin B12

The nurse is performing an assessment on a client with a diagnosis of pernicious anemia which finding would the nurse expect to note in this client

• Red tongue that is smooth and sore

Which condition or symptom does the nurse associate with a patient who has chronic gastritis

• Pernicious anemia

The registered nurse is precepting a new nurse who is caring for a client with pernicious anemia as a result of a gastrectomy which statement made by the new nurse indicates understanding of this diagnosis

• Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine

The nurse is caring for a client with a diagnosis of chronic gastritis the nurse monitors the client knowing that this client is at risk for which vitamin deficiency

• Vitamin B12

After undergoing Billroth 1 gastric surgery the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance on the basis of these symptoms the nurse suspects which postoperative complication

• Pernicious anemia

A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery the nurse instructs the client that in this disorder because the stomach lining produces a decreased amount of a substance known as the intrinsic factor the client will need which medication

Vitamin B12 injections

A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse's best response?

• The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor."

A patient with Parkinson’s disease has bradykinesia. Which action will the nurse include in the plan of care?

Suggest that the patient rock from side to side to initiate leg movement

A patient has been given a prescription for levodopa carbidopa (Sinemet) for her newly diagnosed parkinson's disease she asks the nurse why are two drugs in this pill the nurse's best response reflects which fact

Carbidopa prevents the breakdown of levodopa in the periphery

While a patient is receiving drug therapy for parkinson's disease the nurse monitors for dyskinesia which is manifested by which finding

Difficulty in performing voluntary movements

Which of the following laboratory tests would you order for an older diabetic man with the following complete blood count (CBC) results: hemoglobin = 11 g/dL, hematocrit = 38%, mean corpuscular volume (MCV) = 105 fL, and normal reticulocyte count?

• Serum folate acid and B12 level

A patient has an Hct of 30%, a hemoglobin of 8 g/dL, and an RBC count of 4.0 × 1012/L. What is the morphological classification of this anemia?

• Microcytic hypochromic

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

• Administer PRN acetaminophen (Tylenol).

The patient’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. (SATA)

• Incisional bulging
• Clear drainage on the dressing
• Sudden and severe headache

After change-of-shift report, which patient should the nurse assess first?

• Patient with myasthenia gravis who is reporting increased muscle weakness

A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important

• Avoid large crowds and people who are ill.

A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client problem has been met

• Weight gain of 3 pounds in 1 month

A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best

MG is an autoimmune problem in which nerves do not cause muscles to contract.

A patient is hospitalized with new onset of Guillain-Barré syndrome. The most essential assessment for the nurse to complete is

observing respiratory rate and effort.

A nurse assesses a client with a spinal cord injury at level T5. The client’s blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next?

• Palpate the bladder for distention

Which of these nursing actions for a patient with Guillain-Barré syndrome is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)?

• Passive range of motion to extremities q4hr

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell’s palsy. Which information should the nurse include in teaching the patient?

Call the doctor if you experience pain or develop herpes lesions near the ear.”

The primary health care provider prescribes daily celecoxib for a client experiencing persistent joint pain in both knees. Which health teaching will the nurse provide for the client regarding this drug for long-term pain control? Select all that apply.

• Report any sign of bleeding, including bloody or dark, tarry stool.”
• “Do not take other NSAIDs while on celecoxib.”
• “Report any major changes in the amount of urine you excrete each day.”

Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors?

Binding of the virus to the CD4+ receptor and either of the two co-receptors.

Which food, drink, or herbal supplement does the nurse teach the client taking tipranavir to avoid?

• St. John's wort

A client who is HIV positive and receiving combination antiretroviral therapy tells the nurse she is now pregnant. Which drug does the nurse expect to be suspended during this patient's pregnancy?

• Raltegravir

Which statement regarding type 1 hypersensitivity reaction is/are true?

• The response is characterized by the five cardinal symptoms of inflammation
• Type 1 responses are usually directed against non-self but the response is excessive.
• The second phase of the reaction with accumulation of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.

Which action will the nurse perform first for a client in anaphylaxis to prevent harm?

Injecting epinephrine

Which specific information will the nurse teach to the client with systemic lupus erythematosus newly prescribed belimumab therapy?

The drug can only be given by a healthcare professional.

How does a mutation in a suppressor gene, such as BRCA1, increase the risk for cancer development?

Removing the control over proto-oncogene expression

A client’s cancer is staged as T1,N2,M1 according to the TNM classification system. How does the nurse interpret this report?

The client has small primary tumor extension into two lymph nodes and one site of distant metastasis

Which statement made by a 62 year old client alerts the nurse to the possibility that he may be at increased genetic risk for cancer development?

His sister died from cancer of the appendix

His brother is being treated for breast cancer

A client with chemotherapy-induced neutropenia is prescribed filgrastim. The client states, “ The bones in my legs are aching so bad.” What is the appropriate nursing response?

Bone pain in your legs is a side effect of filgrastim that improves with time.

The nurse is caring for a client with a sealed radiation implant for the treatment of cancer. Which nursing intervention is appropriate? SATA

Place a caution sign on the door of the client’s room

Do not allow children to visit the client for any length of time

Keep the door to the client’s room closed

The nurse is teaching a client who has been prescribed an oral chemotherapy agent. What teaching will the nurse include?

Do not crush, split,break, or chew the oral chemotherapy drug

A client who was bitten by a spider develops cellulitis of the left lower arm. What assessment findings will the nurse expect when caring for this client? SATA

Fever

Pain

Redness around the spider bite

Warmth in the affected arm.

Swelling of the affected arm

A client is diagnosed with C.difficile infection. What nursing action is the priority for the client?

Place the client on contact precaution.

Which statement regarding erythrocytes is true?

The lack of a nucleus in a mature erythrocyte increases its life span

Which response or health problem does the nurse expect to be present in a client who has a lifelong deficiency of antithrombin III?

Increased risk for clot formation and disruption of perfusion

Which precaution has the highest priority for prevention of harm when the nurse teaches the client about home care after a bone marrow aspiration?

Avoid taking any aspirin or aspirin-containing products

Which new symptoms in a client who is being managed for sickle cell crisis does the nurse report immediately to prevent harm? SATA

Decreased handgrip strength on one side

Fever of 102.2 F (39C)

Short of breath

Which intervention is a priority for the nurse to teach the client with polycythemia vera to prevent harm related to injury as a result of impaired platelet function?

Use a soft-bristle toothbrush

A client who is 5 weeks post-transplant after an allogeneic stem cell transplantation for acute lymphocytic leukemia comes to the clinic with a swollen belly and weight gain. Which additional assessment data support the nurse’s suspicion of possible sinusoidal obstructive syndrome (SOS)? SATA

Jaundiced skin and sclera

Pain in the upper right abdominal quadrant

The nurse is preparing to conduct a focused neurologic assessment for a client who had a traumatic brain injury. Which assessment finding is the concern of the nurse?

Decreased level of consciousness

The is caring for a client following a cerebral angiography. Which assessment finding will the nurse report immediately to the health care provider?

Bleeding from the injection site

The primary health care provider started a client with multiple sclerosis on mitoxantrone therapy. Which statement will the nurse include in teaching the client about this drug?

Avoid crowded places such as malls and large public gatherings.

A client is admitted with a suspected cervical spinal cord injury. What is the nurse’s priority action for this client?

Manage the client’s airway

Which statement by the client indicates a need for further teaching by the nurse about preventing back injuries?

Exercise is not going to help my back very much

The nurse is teaching a client who has osteopenia about alendronate. Which statement by the client indicates a need for further teaching?

I will take this drug at night to prevent nausea

the nurse is caring for a client who was admitted with a draining diabetic ulcer on the lower extremity. What personal protective equipment will the nurse teach the staff to use? SATA

Gown

Gloves

Immediately following a colonoscopy, which client behavior will the nurse report to the health care provider? SATA

Abdominal guarding

Change in mental status

Which teaching will the nurse include when educating a client who is scheduled to have an esophagogastroduodenoscopy (EGD)? SATA

Anesthesia will be used for sedation

The procedure takes about 20 to 30 minutes to complete.

A separate test will be required to obtain any needed biopsies

You will need to refrain from eating for at least 6 to 8 hours before the EGD.

A nurse is caring for a 34 year old client newly diagnosed with GERD. Which lifestyle change the nurse suggested? SATA

Lose weight if needed

Do not eat before bed

Avoid pants with a tight waistband or belt

The primary health care provider prescribes bismuth subsalicylate for a client as part of treating H. pylori infection. What health teaching will the nurse include for the client about this drug?

The drug may cause your tongue and stool to turn black

What health teaching will the nurse include to promote gastric health for an adult client? SATA

Stop smoking or using tobacco of any form

Do not drink excessive amount of alcohol

Avoid excessive amounts of pickled or smoked food

Avoid taking large amounts of NSAIDs

The nurse is caring for a client with a complete large bowel obstruction. What assessment findings would the nurse expect? SATA

Obstipation

Abdominal distention

Abdominal pain

A client has a new diagnosis of irritable bowel syndrome (IBS) with diarrhea. What health teaching by the nurse is appropriate for this client?

Avoid dairy products and caffeinated beverages.

A client is receiving adefovir for management of hepatitis B. What health teaching will the nurse provide for the client about this drug?

Avoid places with crowds and individuals who have infection

Get your lab work done regularly because the drug can affect your kidneys

Which statement by the client who is prescribed to take pancreatic enzyme replacements indicates a need for further teaching by the nurse?

I should chew each capsule carefully so that it works in my stomach

The nurse is planning care for a client who had laparoscopic Whipple surgery. For which complications will the nurse assess? SATA

Bleeding

Wound infection

Intestinal obstruction

Diabetes mellitus

Abdominal abscess

The nurse is caring for four clients who have been recommended to consider bariatric surgery. Which assessment data require immediate nursing intervention?

BMI of 23 with gastrointestinal reflux

What discharge teaching will the nurse provide to a client who had gastric bypass surgery? SATA

Be certain to stay hydrated by drinking water

Report any back, shoulder, or abdominal pain to the surgeon

Each of your meals should initially contain about 5 tablespoons of food.

Performance of which assessment is a priority for the nurse before giving a client the first oral dose of hormone replacement for hypothyroidism?

Measuring heart rate and rhythm.

Which assessment findings in a client with hyperthyroidism indicate to the nurse that the client is in danger of thyroid storm? SATA

Client report increased palmar sweating

An increase in temperature from 99.5f (37.5 C) to 101.3 F (38.5 C)

Increase in premature ventricular heart contractions from 4 per minute to 28 per minute

The nurse reviewing the laboratory values of a client with hypoparathyroidism finds a serum calcium level of 7.9 mg/dl (1.76 mmol/L). Which parameter is most important for the nurse to assess to prevent harm?

Deep tendon reflexes

A client who had the Stretta procedure to treat severe GERD. Which client statement requires further nursing teaching ? SATA

Dysphagia after this procedure is normal

It's important to stop my proton pump inhibitor

I might cough up some blood following this procedure

A public health nurse is assessing community clients for oral health disorders. Which clients are identified at highest risk?

34- year old with schizophrenia

Which client being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function?

An 80 year old man who has benign prostatic hyperplasia

Which client assessment data is essential for the nurse to report to the health care provider before a renal scan is performed?

Reports pregnancy

Which adverse drug effects will the nurse assess for in a hospitalized client who is prescribed an anticholinergic drug to manage incontinence? SATA

Blurred vision

Constipation

Dry mouth

Worsening mental function

A 28 year old female client states, “I don’t know why I get cystitis every year. I don’t drink much at work so that I can avoid using the public toilet”. Which teaching by the nurse is most likely to reduce her risk for cystitis? SATA

Suggest that she drink at least 2 to 3L of fluid throughout the day.

Instruct her to always wipe her perineum from front to back after each toilet use.

Reinforce that she should complete the entire course of antibiotics as prescribed.

Instruct her to empty her bladder immediately before intercourse.

A client is diagnosed with renal colic. What would the nurse do first?

Administer opioids as prescribed.

Which nursing intervention is appropriate when caring for a female client who has undergone a mastectomy and will receive chemotherapy? SATA

Provide self-care resources to the primary caretaker

Teach client about birth control options that area available

Refers to support groups for people who have had mastectomy

Involve a partner in discussions about sexuality if the client desires.

Which assessment finding in a client who recently had a right mastectomy 2 days ago will the home health nurse report to the health care provider?

Tingling sensation in the right arm

What teaching will the nurse provide to a 30 year old female client who has never been sexually active about decreasing her risk of developing cervical cancer? SATA

You cannot receive the Gardasil-9 immunization

Use condom when you plan to be sexually intimate

The nurse has provided teaching to a client statement indicating that nursing intervention is required ? SATA

I will wash with fragranced soap to prevent odor

The nurse is teaching a client with erectile dysfunction about taking sildenafil to achieve an erection. Which client statement demonstrates an understanding of this drug?

I might get a headache or stuffy nose when this drug is used.

A client with a history of BPH calls the telehealth nurse reporting the sudden onset of testicular pain after moving heavy furniture. What is the appropriate nursing response?

Please go to your closest emergency department right away

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to

discontinue the patient’s oral food intake.

A young woman who has Crohn’s disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient?

Fistulas can form between the bowel and bladder.

The nurse is caring for older client receiving total enteral nutrition via a small-bore nasoduodenal tube. For what priority complication would the nurse assess?

Aspiration pneumonia

Which action by the unlicensed assistive personnel (UAP) who are assisting with the care of male patients with reproductive problems indicates that the nurse should provide more teaching?

The UAP leave the foreskin pulled back after cleaning the glans of a patient who has a retention catheter.