2023 NGN ATI RN Adult Medical Surgical Online Practice A & B, Exams of Nursing

Download 2023 NGN ATI RN Adult Medical Surgical Online Practice A & B and more Exams Nursing in PDF only on Docsity! 2023 NGN ATI RN Adult Medical Surgical Online Practice A & B Questions, Answers and Rationale New Latest Version A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? --------- Correct Answer --------- This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid. A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? --------- Correct Answer ---------- Wear a mask. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? --------- Correct Answer ---------- Instruct the client to allow the machine to breathe for them. A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take? --------- Correct Answer ---------- Instruct the client on alternative therapies for pain reduction. A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? --------- Correct Answer --------- "I will avoid direct exposure to the sun." Rationale: The client should avoid exposure of irradiated skin areas to the sun for at least 1 year after completing radiation therapy. Skin in the radiation path is especially sensitive to sun damage. SN: Head and neck radiation can damage the salivary glands and cause dry mouth, which predisposes the client to mucositis. The client should rinse the mouth with plain water or 0.9% sodium chloride. A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate? --------- Correct Answer --------- Airborne. Rationale: Airborne precautions are required for clients who have infections due to micro-organisms that can remain suspended in air for lengthy periods of time, such as tuberculosis, measles, varicella, and disseminated varicella zoster. A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) --------- Correct Answer --------- Serum creatinine. Rationale: A client who has an elevated serum creatinine level should not receive gentamicin because the medication is nephrotoxic. A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? --------- Correct Answer --------- Use crutches with rubber tips. Rationale: Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls. A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? (Select all that apply.) --------- Correct Answer --------- Calf pain is correct. Calf pain is an indication of deep-vein thrombosis. The client should report this finding to the provider immediately. Numbness in the arms is correct. Numbness in the arms can indicate a cerebrovascular accident, which is an adverse effect of hormone replacement therapy. The client should report this finding to the provider immediately. Intense headache is correct. An intense headache can indicate a cerebrovascular accident, which is an adverse effect of hormone replacement therapy. The client should report this finding to the provider immediately. SN: Vaginal dryness is an expected finding of menopause. Night sweats are a manifestation of menopause and do not require notification of the provider. A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? --------- Correct Answer --------- "Ibuprofen can cause gastrointestinal bleeding in older adult clients." Rationale: A common adverse effect of ibuprofen is gastrointestinal bleeding, and older adult clients have an increased risk for gastrointestinal toxicity and bleeding. A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? --------- Correct Answer ---------- "I will use my hands rather than a washcloth to clean the radiation area." The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation. A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? --------- Correct Answer ---------- Remind the client to scan their complete range of vision during ambulation. The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls. A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse assess first? --------- Correct Answer ---------- A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider? --------- Correct Answer ---------- Hgb 8 g/dL A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew? --------- Correct Answer ---------- Naproxen An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? --------- Correct Answer ---------- Urine specific gravity 1.045 A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside? --------- Correct Answer --------- - Suction machine A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication? --------- Correct Answer ---------- Report of a night cough A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) --------- Correct Answer ---------- 167 X mL/hr = Volume (mL)/Time (hr) X mL/hr =4000mL/24 hr X mL/hr = 166.67 Round if necessary. 166.67 = 167 mL/hr A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority? --------- Correct Answer ---------- Turn the client to the side. A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan? --------- Correct Answer ---------- Monitor the client's temperature every 4 hr. A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care? --------- Correct Answer ---------- Wear a lead apron while providing care to the client. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? --------- Correct Answer ---------- Remain with the client for the first 15 min of the infusion. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion? --------- Correct Answer ---------- Digoxin A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? --------- Correct Answer ---------- Initiate airborne precautions. A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid? --------- Correct Answer ---------- Aged cheese A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication? --------- Correct Answer ---------- Hypokalemia A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect? --------- Correct Answer ---------- Stone fragments in the urine A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make? --------- Correct Answer ---------- "You will not be able to use sildenafil if you are taking nitroglycerin." A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? --------- Correct Answer ---------- Demonstrate ways to deep breathe and cough. A nurse is caring for a client in the emergency department (ED). --------- Correct Answer ---------- Administer morphine Ensure the patient is NPO Cholecystitis Monitor the color of the client's stools Monitor the client for dark urine A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions? --------- Correct Answer ---------- Suppressing gastric acid production A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? --------- Correct Answer ---------- Calcium A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis. A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement? --------- Correct Answer ---------- The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity. A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include? --------- Correct Answer ---------- Wrap fingers with individual dressings. A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings? --------- Correct Answer ---------- Dysphagia A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer? --------- Correct Answer ---------- Calcium carbonate Place the client in Trendelenburg position is indicated Administer a 0.9% sodium chloride 200 mL IV bolus is indicated Apply oxygen at 2 L/min via nasal cannula is indicated Notify the provider immediately is indicated. Obtain the client's blood glucose level is not indicated A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect? --------- Correct Answer ---------- Elevated bilirubin level A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include? --------- Correct Answer ---- ------ Roll each testicle between the thumb and fingers. A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? --------- Correct Answer ---------- "I will monitor my blood pressure while taking this medication." A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change? ------- -- Correct Answer ---------- A client who has multiple sclerosis and is experiencing progressive difficulty ambulating A nurse is caring for a client has who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis? --------- Correct Answer ---------- hyperkalemia A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? --------- Correct Answer ---------- Tachycardia The client is experiencing manifestations of.. due to.. --------- Correct Answer ---------- Peritonitis X-ray results A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? --------- Correct Answer ---------- BUN 32 mg/dL A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority? --------- Correct Answer ---------- Apply firm pressure to the insertion site. A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? --------- Correct Answer ---------- Calcium A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? --------- Correct Answer ---------- A client who is receiving preoperative teaching for a right knee arthroplasty The nurse is reviewing the client's diagnostic results. Which of the following findings requires follow-up by the nurse? Select all that apply. --------- Correct Answer ---------- PCO2 WBC Chest X-ray Oxygen saturation BUN Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again. --------- Correct Answer ---------- Client is short of breath and has a productive cough with yellow mucus "I could barely breathe when I got up this morning and I had a throbbing headache Crackles heard in posterior lungs Client is diaphoretic The nurse should first address the client's .. followed by the client's.. --------- Correct Answer ---------- Oxygen saturation Temperature For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. --------- Correct Answer -------- -- Cough and deep breathe every 2 hr is anticipated. Obtain a sputum culture and sensitivity is anticipated. Perform neurological checks every 2 hr is nonessential. Administer oxygen at 3 L/min via nasal cannula is anticipated. Limit the client's fluid intake to 1,500 mL per day is contraindicated. Acetaminophen 500 mg PO every 6 hr as needed is anticipated. Famotidine 40 mg PO daily is nonessential. The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention. --------- Correct Answer ---------- Temperature WBC Potassium The nurse is reviewing the client's medical record from Day 5. Click to highlight the findings below that indicate the client is improving. To deselect a finding, click on the finding again. --------- Correct Answer ---------- Heart rate is 72/min Respiratory rate is 20/min Blood pressure is 128/56 Oxygen saturation is 96% A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide? --------- Correct Answer ---------- Increase fluid intake. A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to the nurse that the client has exophthalmos? --------- Correct Answer -- -------- D A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching? --------- Correct Answer ---------- "You should void every 4 hours to decrease the risk of urinary retention." A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy A nurse is providing teaching for the client. Which of the following instructions should the nurse include? --------- Correct Answer ---------- Avoid drinking fluids with meals Eat several small meals per day Consume high-protein snacks Avoid highly seasoned foods A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider? --------- Correct Answer --- ------- Heart rate 55/min A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching? --------- Correct Answer ---------- "I am dieting to lose weight." A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? --------- Correct Answer ---------- Administer an opioid analgesic to the client. A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first? --------- Correct Answer ---------- Call for help. A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? --------- Correct Answer --------- place a pressure bag around the flush solution Rationale: The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line. An arterial line is not appropriate access for administering antibiotics. The nurse should use the arterial line to obtain arterial blood gas samples and monitor hemodynamic pressures. A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? --------- Correct Answer --------- Report of sore throat Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis. A nurse is reviewing the medical record of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? --------- Correct Answer --------- Facial butterfly rash Rationale: A butterfly rash is a manifestation of SLE. It appears as a dry, red rash on the client's cheeks and nose and can disappear during times of remission. A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? --------- Correct Answer --------- Place tracheostomy tray at the bedside Rationale: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to place a tracheostomy tray at the client's bedside in case of airway obstruction. A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? --------- Correct Answer --------- Low urine specific gravity Rationale: An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone. A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include? --------- Correct Answer --------- You will need to stay still in the bed during each treatment session." Rationale: The nurse should instruct the client that they will need to remain on bed rest with very limited movement because excessive movement can cause the radioactive source to become dislodged. The nurse should instruct the client that there is not excreted radiation between treatments. The nurse should instruct the client that there will likely be between two and five treatments, once or twice each week. The nurse should instruct the client that blood in the urine is an adverse effect of brachytherapy and is not an expected finding. A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? --------- Correct Answer ----- ---- Encourage the client to take deep breaths after the procedure. Rationale: After a thoracentesis, the client should deep breathe to re-expand the lung. A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? --------- Correct Answer --------- Slow the infusion rate Rationale: Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breathe, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload. A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? --------- Correct Answer --------- Hemodialys is something required following surgery. Rationale: When a kidney comes from a deceased donor, it might not function immediately, requiring the recipient to continue hemodialysis postoperatively. A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect? --------- Correct Answer --------- Constipation Rationale: A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism, resulting in slow motility of the gastrointestinal tract. The nurse should instruct the client to increase fiber and fluid intake to reduce the risk for constipation. A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make? --------- Correct Answer --------- I will refer you to community resources that can provide support. Rationale: The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body image changes. A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider? --------- Correct Answer --- ------ Client reports back pain Rationale: The nurse should notify the provider if the client reports back pain, which can indicate that the nephrostomy tube is dislodged or clogged. A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching? --------- Correct Answer --------- Create complete outfits and allow the client to select one each day Rationale: The family should place completed outfits on hangers and allow the client to select which one to wear each day. A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have acupuncture because it provides greater relief than pain medication. Which of the following statements should the nurse make? --------- Correct Answer --------- "I can speak to the provider about incorporating acupuncture into your treatment plan." Rationale: The nurse should serve as an advocate for the client by acting on behalf of the client and offering to speak with the provider. The client has the right to make choices and decisions about their treatment and the nurse should support these decisions and assist the client to carry them out. A nurse is caring for a client following extubation of an endotracheal tube 10 min ago. Which of the following findings should the nurse report to the provider immediately? ----- ---- Correct Answer --------- Stridor Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is stridor. Stridor can indicate a narrowing airway or possible obstruction caused by edema or laryngeal spasms. The nurse should report the finding immediately and implement an intervention. A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? --------- Correct Answer --------- Troponin I 8 ng/mL A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving? --------- Correct Answer ----- ---- Glucose 272 Rationale: A glucose reading less than 300 mg/dL indicates improvement in the client's status. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? --------- Correct Answer --------- Regular insulin 20 units IV. Rationale: DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be effective within 10 min when administered intravenously. A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? ------- -- Correct Answer --------- A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed. Rationale: A feeling of something popping or loosening with coughing might indicate a wound dehiscence. This client will need to have revisions to the plan of care, which can include management of the dehiscence, prevention of evisceration, or possible surgical repair of an evisceration if one occurs. A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching? --------- Correct Answer --------- Drink 240 mL (8 oz) of water after administration. SN: The client should take the medication after meals to prevent appetite suppression. The client should expect results in 12 to 24 hr and bowel regularity in 2 to 3 days. Reducing dietary fiber intake does not affect medication absorption. However, the client should increase dietary fiber intake for management of chronic constipation. A nurse is providing teaching to a client who has a recent diagnosis of constipation- predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching? --------- Correct Answer --------- Consume at least 30 g of fiber daily. A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? --------- Correct Answer --------- "I will take my temperature once a day." A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? --------- Correct Answer --------- INR 2.5 A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) --------- Correct Answer --------- AdminiSTER o2 Initiate IV therapy Insert an NG tube Administer ranitidine A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to the audio clip. (Click on the audio button to listen to the clip.) ------- -- Correct Answer --------- Pericardial friction rub A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis? --------- Correct Answer --------- Prednisone A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? --------- Correct Answer --------- Walk for 30 min four times per week. A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? --------- Correct Answer --------- "This identifies if the pacemaker cells of my heart are working properly." A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? --------- Correct Answer --------- Scan the bladder with a portable ultrasound. A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? ---- ----- Correct Answer --------- The client's heart rate increases. A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? --------- Correct Answer --------- Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.8° F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? --------- Correct Answer --------- Heart rate 110/min A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? - -------- Correct Answer --------- Bathe the client using chlorhexidine solution. FLAG A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload? --------- Correct Answer --------- Distended neck veins A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? --------- Correct Answer --------- Flex the foot every hour when awake. A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority? --------- Correct Answer --------- Applying oxygen via face mask A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority? --------- Correct Answer --------- Check the client's neurologic status. A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client? --------- Correct Answer --------- Keep the client occupied with a manual activity. A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make? --------- Correct Answer --------- "Discontinuing with the treatments is your choice if it is your wish to do so." A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? --------- Correct Answer --------- Place personal items, such as pictures, at the client's bedside. A nurse is providing teaching to a client who has asthma about the use of a metered- dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching? --------- Correct Answer --------- Holding breath for 10 seconds after inhaling