2023 PN Adult Medical Surgical Online Practice A Test Bank Exam Updated 2025 New Latest Ve, Exams of Nursing

Download 2023 PN Adult Medical Surgical Online Practice A Test Bank Exam Updated 2025 New Latest Ve and more Exams Nursing in PDF only on Docsity! 2023 PN Adult Medical Surgical Online Practice A Test Bank Exam Updated 2025 New Latest Version with All Questions and Answers A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? "You should have a screening for glaucoma every 5 years." "You should have a physical examination every other year." "You should have your hearing checked every 2 years." "You should have a pneumococcal immunization every 10 years." ---------- Correct Answer ----------- "You should have a pneumococcal immunization every 10 years." A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration? Instill 10 mL of air through the NG tube. Place the client in the supine position. Irrigate the NG tube. Pinch the NG tube. ---------- Correct Answer ----------- Pinch the NG tube. A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? --------- Correct Answer ---------- "I don't cross my legs anymore." A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective? --------- Correct Answer ---------- Hgb 11 g/dL A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? --------- Correct Answer ---------- Mask A nurse is monitoring a client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? Administer doxazosin. Palpate the abdomen. Insert an indwelling urinary catheter. Notify the provider. ---------- Correct Answer ----------- Palpate the abdomen. A nurse is assisting with the care for a client who has age-related macular degeneration. Which of the following findings should the nurse expect? ---------- Correct Answer ------------ Distorted central vision of the eyes. A nurse is contributing to the plan of care for ac client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan? ---------- Correct Answer ------------ Use a turn sheet to reposition the client. A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? ---------- Correct Answer ------------ "Consume foods that are low in sodium." A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? Increased weight Increased heart rate Decreased urinary output Decreased shortness of breath ---------- Correct Answer ----------- Decreased shortness of breath A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan? Observe for impulsive behavior. Approach the client from the right side. Use simple verbal cues when directing tasks. Place the client in low-Fowler's position during meals. ---------- Correct Answer ----------- Use simple verbal cues when directing tasks A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) ---------- Correct Answer ----------- 0.7 A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? Apply a mask on the client if the transport is needed. Wear a mask when working within 1.2 m (4 feet) of the client Don a gown when visiting with the client Wear an N95 mask when entering the client's room. ---------- Correct Answer ----------- Apply a mask on the client if transport is needed. • A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? "I apply rubbing alcohol to my feet every day to prevent infection." "I will wear clean, knee-high wool socks every day to help improve my circulation." "I use hot water bottles to keep my feet warm at night." "I don't cross my legs anymore." ---------- Correct Answer ----------- "I don't cross my legs anymore." A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.) Ceftriaxone Diltiazem Pioglitazone Hydrocodone 5 mg/acetaminophen 500 mg ---------- Correct Answer ----------- Ceftriaxone A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Notify the charge nurse. Stop the infusion. Elevate the affected arm. Withdraw the IV catheter. Check the IV site. ---------- Correct Answer ----------- Check the IV site. Stop the infusion. Withdraw the IV catheter. Elevate the affected arm. Notify the charge nurse. A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first? Determine the client's daily elimination habits. Administer a suppository to the client 30 min prior to defecation time. Offer the client 4 oz of warm prune juice to promote elimination. Provide dietary bulk to the client to ease the passage of stool. ---------- Correct Answer -- --------- Determine the client's daily elimination habits. A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? Allow for 30 min of rest before meals. Provide a straw for drinking liquids. Serve foods at room temperature. Place 2 tsp of food in the client's mouth at a time. ---------- Correct Answer ----------- Allow for 30 min of rest before meals. A nurse is caring for a client who is at risk for developing pressure injuries. Which of the following actions should the nurse take? Position pillows between the bony prominences. Check for incontinence every 3 hr. Massage areas indicating potential breakdown of the skin. Elevate the head of the bed to 45°. ---------- Correct Answer ----------- Position pillows between the bony prominences. A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction? Halitosis Hemorrhoids Rebound tenderness Small liquid stools ---------- Correct Answer ----------- Small liquid stools A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next? Administer epinephrine. Monitor the client's vital signs. Monitor the client's oxygen saturation level. Administer an antihistamine ---------- Correct Answer ----------- Administer epinephrine. A nurse is reinforcing teaching with the caregiver of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? Clean the pin sites every 72 hr. Use the halo ring to reposition the client when in bed. Change the sheepskin liner weekly. Tighten the traction bar as needed. ---------- Correct Answer ----------- Change the sheepskin liner weekly. A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? Store the CPM machine on the floor when it is not in use. Keep a sheepskin pad between the client's extremity and the CPM machine. Check the cycle and range-of-motion settings at least every 12 hr. Align the frame joint of the CPM machine with the middle of the client's calf. ---------- Correct Answer ----------- Keep a sheepskin pad between the client's extremity and the CPM machine. A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching? "Take the medication on an empty stomach." "Limit contact with large groups of people." "Avoid taking over-the-counter calcium supplements." "Follow a low-protein diet." ---------- Correct Answer ----------- "Limit contact with large groups of people." A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take? Use a traction boot to keep the client's right leg internally rotated. Have the client sit in a reclining chair when out of bed. Maintain abduction of the client's right leg while in bed. Encourage the client to perform passive range-of-motion exercises. ---------- Correct Answer ----------- Maintain abduction of the client's right leg while in bed. A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse make? "Are you experiencing abdominal pain?" "You should talk about this with the people you're closest to." "Many people who have cancer feel this way." "You feel like you want to discontinue treatment?" ---------- Correct Answer ----------- "You feel like you want to discontinue treatment?" A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following actions should the nurse take first? Collaborate with a dietitian. Ensure that the client is provided with a high-ber diet. Implement recommendations from the speech-language pathologist. Abdominal cramps Renal insufficiency Insomnia ---------- Correct Answer ----------- Abdominal cramps A nurse is caring for a client who has a new cast on their left forearm and reports severe pain in the affected arm with numbness in the ngers. The nurse nds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect? Compartment syndrome Fat embolism Deep-vein thrombosis Osteomyelitis ---------- Correct Answer ----------- Compartment Syndrome A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? Expect decreased sensation for the rst postoperative week. Avoid lying on the operative side. Obtain a raised toilet seat. Cross legs at the ankles ---------- Correct Answer ----------- Obtain a raised toilet seat. A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? Collect a sputum culture Administer ceftriaxone by intermittent IV bolus. Initiate oxygen at 4 L/min via nasal cannula Obtain blood cultures. ---------- Correct Answer ----------- Initiate oxygen at 4 L/min via nasal cannula A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? HbA1c 6% Prealbumin 12 mg/dL WBC count 8,000/mm3 Creatinine 0.8 mg/dL ---------- Correct Answer ----------- Prealbumin 12 mg/dL A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? Keep the door of the client's room closed at all times. Remove gloves after leaving the client's room. Wear a mask when working within 1 m (3 feet) of the client. Have a designated stethoscope in the client's room. ---------- Correct Answer ----------- Have a designated stethoscope in the client's room. A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? Perform pin site care daily. Remove the overbed trapeze. Remove the boot every 2 hr. Keep the weights on a stable, at surface. ---------- Correct Answer ----------- Perform pin site care daily. A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include? Incontinence of the bowel and bladder Increase in heart rate Warmness of the skin Hypertension ---------- Correct Answer ----------- Incontinence of the bowel and bladder A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching? "This type of insulin should be given at the same time every day." "This insulin can be mixed with short-acting insulin in a single syringe." "This type of insulin can be used in a pump." "This insulin has an increased risk for hypoglycemia." ---------- Correct Answer ----------- This type of insulin should be given at the same time every day. A nurse is caring for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take? Minimize the time the head of the bed is elevated. Apply a sterile gauze dressing to the site. Massage the site with moisturizing lotion. Place a donut-shaped cushion under the client's sacral area. ---------- Correct Answer --- -------- Minimize the time the head of the bed is elevated. A nurse is reinforcing teaching about the management of constipation with a client who has hypothyroidism. Which of the following instructions should the nurse include in the teaching? Increase intake of fiber-rich foods. Take a laxative every morning Maintain a fluid intake of 1,200 mL/day. Limit activity to preserve energy. • ---------- Correct Answer ----------- Increase intake of fiber-rich foods. A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching? Do not eat or drink for 6 hr prior to the test Ensure that the stool specimen is obtained in the morning. Take ibuprofen for mild pain until the test is complete. Avoid eating red meat for 3 days prior to the test. ---------- Correct Answer ----------- Avoid eating red meat for 3 days prior to the test. A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? Muscle weakness Dysrhythmia Abdominal pain Lethargy ---------- Correct Answer ----------- Dysrhythmia A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot ashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? Five-year history of menopause manifestations History of treatment for blood clots Topiramate use for migraine headaches Increased serum cholesterol levels ---------- Correct Answer ----------- History of treatment for blood clots A nurse is caring for a client who is receiving chemotherapy. The client mentions that they have a loss of appetite because of sores in their mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? Drink water before and after each bite. Consume foods that are served hot rather than cold. Rinse with a glycerin-based mouthwash before meals. Eat several, small-portioned meals daily. ---------- Correct Answer ----------- Eat several, small-portioned meals daily. A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective? BUN 40 mg/dL Hgb 11 g/dL Urine specific gravity 1.035 Blood glucose 105 mg/dL ---------- Correct Answer ----------- Hgb 11 g/dL A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors? Visitors should call prior to visiting the client. Visitors must don a gown and gloves prior to entering the client's room. Visitors need to wear a mask when in close proximity to the client. Visitors may not bring fresh flowers into the client's room. ---------- Correct Answer -------- --- Visitors must don a gown and gloves prior to entering the client's room. A nurse is contributing to the plan of care for a client who has partial hearing loss. Which of the following interventions should the nurse include in the plan of care? Face the client while speaking. Use a high-pitched tone when talking to the client. Avoid using gestures when communicating. Repeat misunderstood phrases. ---------- Correct Answer ----------- Face the client while speaking. A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client? Intrauterine device Latex condom Combination oral contraceptives Contraceptive sponge ---------- Correct Answer ----------- Combination oral contraceptives A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? Scaly patches Silvery white plaques Irregular borders Raised edges ---------- Correct Answer ----------- Irregular borders A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? Place the client on a low-calorie diet to prevent weight gain. Remind the client to avoid watching their feet when walking. Use small area rugs in the client's home for traction. Instruct the client to take tub baths instead of showers ---------- Correct Answer ----------- Remind the client to avoid watching their feet when walking. A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? Consume a low-purine diet. Avoid stopping this medication suddenly. Use chamomile tea to alleviate insomnia. Take this medication on an empty stomach. ---------- Correct Answer ----------- Avoid stopping this medication suddenly. A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? Mohs surgery is a horizontal shaving of thin layers of the tumor. Mohs surgery uses liquid nitrogen to destroy the cancerous tissue. Mohs surgery is the preferred treatment for melanoma skin cancer. Mohs surgery is a palliative treatment for metastatic skin cancer. ---------- Correct Answer ----------- Mohs surgery is a horizontal shaving of thin layers of the tumor. A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Lower the side rails of the client's bed. Apply wrist restraints to the client. Position the client in the semi-Fowler's position. Loosen clothing around the client's neck. ---------- Correct Answer ----------- Loosen clothing around the client's neck. A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? Apply cold packs to the inamed joints. Participate in high-impact exercise. Carry a hand purse rather than a shoulder bag. Sleep on a soft foam mattress. ---------- Correct Answer ----------- Apply cold packs to the inamed joints. A nurse is reinforcing teaching with a client who is to begin using an insulin pump. Which of the following instructions should the nurse include? "Insert the infusion needle into intramuscular tissue." "Change the needle every 5 days." "Calculate the insulin for each meal by using an insulin-to-protein ratio." "Use rapid-acting insulin in the infusion device." ---------- Correct Answer ----------- "Use rapid-acting insulin in the infusion device." A nurse is contributing to the plan of care for a client who has peripheral arterial disease of the lower extremities. Which of the following interventions should the nurse include? Place moist heat pads on the extremities. Perform manual massage of the affected extremities. Dangle the extremities o the side of the bed. Apply support stockings before getting out of bed. ---------- Correct Answer ----------- Dangle the extremities o the side of the bed. A nurse is contributing to the plan of care for a client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? Increase fluid intake. Encourage range-of-motion exercises. Massage bony prominences. Encourage weight-bearing exercises. ---------- Correct Answer ----------- Encourage weight-bearing exercises. A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? Provide small, frequent meals. Tell the client to extend their neck when swallowing. Provide mouth care before meals. Give the client liquids with increased viscosity. ---------- Correct Answer ----------- Give the client liquids with increased viscosity. A nurse is assisting with the care of a client who has a newly-inserted water-seal closed chest tube. Which of the following findings should the nurse report to the provider? Chest drainage is greater than 70 mL/hr. Water fluctuates in the water-seal chamber. Chest drainage is clear in color. "I should drink my liquids through a straw." ---------- Correct Answer ----------- "I should wait at least 2 hours after eating before going to bed." A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? --------- Correct Answer ---------- Determine the client's understanding of the procedure. A nurse is contributing to the plan of care for a client who has peripheral arterial disease of the lower extremities. Which of the following interventions should the nurse include? - -------- Correct Answer ---------- Dangle the extremities off the side of the bed. A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan? --------- Correct Answer ---------- Use simple verbal cues when directing tasks. A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include? --------- Correct Answer ---------- Incontinence of the bowel and bladder A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration? --------- Correct Answer --------- - Pinch the NG tube. A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? --------- Correct Answer -------- -- Stop the medication infusion. A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? --------- Correct Answer ---------- "Consume foods that are low in sodium." A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching? --------- Correct Answer ---------- Avoid eating red meat for 3 days prior to the test. A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) --------- Correct Answer ---------- 0.7 mL A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching? --------- Correct Answer -- -------- "This type of insulin should be given at the same time every day." A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors? --------- Correct Answer ---------- Visitors must don a gown and gloves prior to entering the client's room. A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? --------- Correct Answer ---------- History of treatment for blood clots A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following instructions should the nurse include in the teaching? --------- Correct Answer ---------- Increase intake of fiber-rich foods. A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? --------- Correct Answer ---------- Avoid stopping this medication suddenly. A nurse is caring for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take? --------- Correct Answer -- -------- Minimize the time the head of the bed is elevated. A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) --------- Correct Answer ----- ----- Check IV site Stop the infusion Withdraw the IV catheter Elevate the affected arm Notify the charge nurse Drag words from the choices below to fill in each blank in the following sentence. During the emergent phase of burn care, the client is at risk for developing____________ and _____________. --------- Correct Answer ---------- Hypovolemia Respiratory failure A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? --------- Correct Answer ---------- Mohs surgery is a horizontal shaving of thin layers of the tumor. A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? - -------- Correct Answer ---------- Keep a sheepskin pad between the client's extremity and the CPM machine. A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? --------- Correct Answer ---------- Apply cold packs to the inflamed joints. A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? --------- Correct Answer ------- --- Give the client liquids with increased viscosity. A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? --------- Correct Answer ---------- "You should have a pneumococcal immunization every 10 years." A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? --------- Correct Answer ---------- Apply a mask on the client if transport is needed. A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? --------- Correct Answer ---------- Keep the client in a side-lying position. A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? --------- Correct Answer ---------- Perform pin site care daily. A nurse is reinforcing discharge teaching about wound care with the caregiver of a client who is postoperative. Which of the following instructions should the nurse include in the teaching? --------- Correct Answer ---------- Report purulent drainage to the provider. A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? --------- Correct Answer ---------- Dysrhythmia Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. --- ------ Correct Answer ---------- Reduce the temperature in the clients room. Limit visitors Hyperthyroidism Increased temperature Weight daily Assist with the administration of gentamicin 100 mg IV. Assist with the administration of dextrose 5% in lactated Ringer's. Contact the wound, ostomy, and continence nurse. The nurse is reinforcing discharge teaching with the client. Which of the following client statements indicates an understanding of the teaching? Select all that apply. --------- Correct Answer ---------- "I should schedule several rest periods throughout the day" "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit". A home health nurse is reinforcing teaching about preventing asthma attacks with a client who has asthma. Which of the following instructions should the nurse include in the teaching? --------- Correct Answer ---------- "Do not allow visitors to smoke cigarettes in your home." A nurse is caring for a client who has a new cast on their left forearm and reports severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect? --------- Correct Answer ---------- compartment syndrome A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? --------- Correct Answer ---------- Have a designated stethoscope in the client's room. A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? --------- Correct Answer ---------- Decreased shortness of breath. A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? --------- Correct Answer ---------- Instruct the client to swish the medication in their mouth. A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? --------- Correct Answer ---------- Prealbumin 12 mg/dL A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? --------- Correct Answer ---------- Allow for 30 min of rest before meals. A nurse is reinforcing teaching with the client. Which of the following instructions should the nurse include? Select all that apply. --------- Correct Answer ---------- Avoid drinking fluids with meals. Eat several small meals per day. Consume high-protein snacks. A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care? --------- Correct Answer ---------- Administer an antiemetic to the client. A nurse is examining a client's IV site and notes a red line up their arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? --------- Correct Answer ---------- Thrombophlebitis A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? --------- Correct Answer ---------- "I will have my HbA1c checked twice per year." A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. After stopping the infusion, which of the following actions should the nurse take next? --------- Correct Answer -------- -- Take the client's vital signs. A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? --------- Correct Answer ---------- Encourage the client to complete ADLs. A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? --------- Correct Answer ---------- Dyspnea A nurse is contributing to the plan of care for a client who has partial hearing loss. Which of the following interventions should the nurse include in the plan of care? --------- Correct Answer ---------- Face the client while speaking. A nurse is reinforcing teaching with the caregiver of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? --------- Correct Answer ---------- Change the sheepskin liner weekly. A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present? --------- Correct Answer ---------- The client stops the nurse and asks for pain medication. A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication? ---- ----- Correct Answer ---------- Decreases pain during urination. A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep? --------- Correct Answer -------- -- Listen to soft music before sleeping. A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.) --------- Correct Answer ---------- "I never forget to rinse my mouth after using my budesonide inhaler" "Between office visits, I keep a record of how many times I use my albuterol inhaler" "I use my albuterol inhaler before I go swimming" The nurse is reviewing the client's diagnostic results. Which of the following findings require follow up? Select all that apply. --------- Correct Answer ---------- PaCO2 WBC count Chest x-ray Oxygen saturation BUN The nurse is reviewing the client's medical record. 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 States, "I could barely breathe when I got up this morning and I had a throbbing headache" Client is diaphoretic Crackles heard in posterior lung A nurse is prioritizing care for the client. Complete the following sentence by using the lists of options. At 1000, the nurse should first address the client's________, followed by the client's________. --------- Correct Answer ---------- Oxygen saturation Heart rate The nurse is assisting with the plan of care for the client. For each potential provider 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 Titrate oxygen to keep oxygen saturation greater than 90% is anticipated. Place client on a 1,500 mL fluid restriction is contraindicated Administer acetaminophen 500 mg PO every 6 hr PRN is anticipated. A nurse is assisting with the care for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take? ----------- Correct Answer ------------ Withhold the dose. A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? ----------- Correct Answer ------------ "I will have my HbA1c checked twice per year." A nurse is providing information regarding transmission-based precautions for a client who has Clostridium difficile to an assistive personnel (AP). Which of the following instructions should the nurse include? (Select all that apply.) ----------- Correct Answer -- ---------- "Provide the client with disposable utensils and dishes for meals." "Leave blood pressure equipment in the client's room." "Clean contaminated surfaces with a bleach solution." A nurse is reinforcing teaching with a client who has coronary artery disease. Which of the following instructions should the nurse include in the teaching? ----------- Correct Answer ------------ "Add oily fish to your diet twice weekly." A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? ----------- Correct Answer ------------ Mohs surgery is a horizontal shaving of thin layers of the tumor. A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as an expected change associated with aging? ----------- Correct Answer ------------ "My food tastes bland even after I add seasoning." A nurse is reinforcing dietary teaching with a client about increasing the intake of foods containing vitamin C to enhance absorption of oral iron supplements. Which of the following food choices should the nurse include in the teaching? ----------- Correct Answer ------------ 1 cup of boiled broccoli A nurse is assisting with the care for a client who is 2 hr postoperative following the amputation of a foot. Which of the following actions should the nurse take first? ----------- Correct Answer ------------ Check the incisional dressing. A nurse is assisting with the care of a client who is postoperative following abdominal surgery. Exhibit 1 Nurses' Notes 1100: Client received from PACU; initial vital signs recorded. Client is drowsy but arouses to verbal stimuli. Oriented to person, place, and time. Client is able to move all extremities. Normal sinus rhythm noted. Breath sounds are clear upon auscultation. Dressing to abdomen is intact with a small amount of serosanguinous drainage noted and marked. No bowel sounds in all four quadrants. Indwelling urinary catheter is in place and draining clear, yellow urine. Lactated Ringer's is infusing at 100 mL/hr via IV catheter in the right forearm.1200: Client reports nausea and pain as an 8 on a scale of 0 to 10. Abdominal dressing is intact with no further drainage noted. Urine output of 15 mL noted since arrival from PACU. Analgesic and antiemetic were administered as prescribed.1230: Client reports rel ----------- Correct Answer ------------ Which of the following actions should the nurse take? Select all that apply. Instruct the client to splint their abdomen with a pillow when coughing. Report the client's urinary output to the charge nurse. Monitor the client's pain level. A nurse is assisting with monitoring a client who is receiving dialysis treatment. Exhibit 1 Nurses' Notes 0530:Client is awake and alert. Arteriovenous fistula (AVF) to right forearm with thrill palpated and auscultated for bruit. Breath sounds are clear upon auscultation; client denies shortness of breath. No peripheral edema noted; capillary refill is less than 3 seconds; +2 bilateral pedal and radial pulses.AVF access prepared and cannulated twice with no difficulty. Lines are taped and secured; treatment is initiated.0600:Client is reading a book. Access is visible, and lines are secure. Client reports no discomfort or pain.0630:Client reports feeling warm, nauseated, and lightheaded; appears restless and slightly confused. Exhibit 2 Vital Signs 0530:Current weight 88 kg (194 lb)Temperature 37° C (98.6° F)Blood pressure• Lying - 152/92 mm Hg• Sitting - 148/90 mm Hg• Standing - 144/88 mm HgHeart rate 90/m ------- ---- Correct Answer ------------ For each potential nursing intervention, click to specify if the intervention is indicated or not indicated. Nursing Intervention Request a chest x-ray - not indicated Place the client in reverse Trendelenburg position - indicated Assist with administering a 0.9% sodium chloride 200 mL IV bolus - indicated Apply oxygen at 2 L/min via nasal cannula - indicated Notify the charge nurse immediately - indicated Obtain the client's blood glucose level - not indicated A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? ----------- Correct Answer ------------ Remind the client to swish the medication in their mouth. A nurse is reinforcing teaching with the caregiver of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? ----------- Correct Answer ------------ Change the sheepskin liner weekly. A nurse is assisting in the care of a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ----------- Correct Answer ------------ 864 cal A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include? ----------- Correct Answer ------------ Withdraw the regular insulin before withdrawing the NPH insulin. A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first? ----------- Correct Answer ------------ Obtain the client's blood pressure. A nurse is assisting with the care for a client who has age-related macular degeneration. Which of the following findings should the nurse expect? ----------- Correct Answer ------------ Distorted central vision of the eyes A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following foods should the nurse recommend? ----------- Correct Answer ------------ Lemon juice A nurse is preparing to assist with the insertion of a double-lumen gastric sump tube for a client who has peptic ulcer disease and has developed gastrointestinal bleeding. Which of the following images depicts the tube that the nurse should select? ----------- Correct Answer ------------ clear with blue tube A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include? ----------- Correct Answer --------- --- Place the client in a negative-pressure airflow room. A nurse is contributing to the plan of care for a client who had a stroke. For which of the following interprofessional team members should the nurse recommend a referral prior to initiating oral intake for the client? ----------- Correct Answer ------------ Speech- language pathologist blood pressure ----------- Correct Answer ------------ oxygenation blood pressure For each potential provider prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. ----------- Correct Answer ------------ Transfuse packed RBCs - anticipated Place the client in Trendelenburg position - contraindicated Prepare the client for chest tube insertion - anticipated Cover the client with a cooling blanket - contraindicated Initiate NPO status - anticipated The nurse is assisting with the care of the client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? Select all that apply. ----------- Correct Answer ------------ Ensure that all chest tube connections are securely attached. Palpate the chest tube insertion site for subcutaneous emphysema. Place two rubber-tipped hemostats in the client's room. Place the client in high-Fowler's position. The nurse is assisting with the care of the client 1 hr following chest tube insertion. Click to highlight the findings that indicate the client's condition is improving. To deselect a finding, click on the finding again. ----------- Correct Answer ------------ Client reports pain as a 3 on a scale of 0 to 10. Client reports shortness of breath has decreased. Wound dressing is dry and intact. Respiratory rate 24/min Blood pressure 108/74 mm Hg Oxygen saturation 95% on oxygen 2 L/min via nasal cannula A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first? ----------- Correct Answer ------------ Ventilate the client with 100% oxygen. A nurse in a health clinic is reinforcing teaching with a client about tuberculosis (TB). Which of the following client statements indicates an understanding of the teaching? ---- ------- Correct Answer ------------ "I can develop TB by breathing in the infection." A nurse is assisting with the care for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) ----------- Correct Answer ------------ Lower client to the floor. Place a pad beneath the client's head. Loosen the clothing around the client's neck. Time the length of the client's seizure. Reorient and reassure the client. A nurse is examining a client's IV site and notes a hardened vein above their IV site. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? -- --------- Correct Answer ------------ Thrombophlebitis A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? ----------- Correct Answer ------------ A client who is dehydrated, has mental confusion, and has tried to get out of bed several times during the night A nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM) machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching? (Select all that apply.) --- -------- Correct Answer ------------ "Your knee is flexed and extended as prescribed by your provider." "The machine is padded with sheep skin." A nurse is assisting with the care for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? ----------- Correct Answer ------------ Give the client liquids with increased viscosity. A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care? ----------- Correct Answer ------------ Administer an antiemetic to the client. A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching? ----------- Correct Answer ------------ "I will limit my daily intake of protein." A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? ----------- Correct Answer ------------ Obtain a raised toilet seat. A nurse is assisting with the care for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG? ----------- Correct Answer ------------ Cleanse the client's skin prior to electrode placement. Exhibit 1 Nurses' Notes 0730 Vital signs Temperature 38° C (100.4° F)Heart rate 72/min and regularRespiratory rate 16/minBlood pressure 128/78 mm HgPain rating 6/10 Exhibit 2 History and Physical History of type 2 diabetes mellitus and hypertension Allergies: 1) Penicillin reaction severe2) Aspirin3) Heparin Exhibit 3 Diagnostic Results Capillary blood glucose 102 mg/dL ----------- Correct Answer ------------ A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? Ceftriaxone A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate? ----------- Correct Answer ------------ Elevated serum amylase level Exhibit 1 Nurses' Notes1000:Client reports visual disturbances, including flashing lights in their vision, especially on the right side.Client is alert and oriented to person, place, and time; client appears anxious. No facial drooping noted. Hand grasps are equal and strong bilaterally.Client reports throbbing pain behind the left eye, photophobia, and nausea. The client rates the pain as a 7 on a scale of 0 to 10. Exhibit 2 Graphic Record1000:Temperature 36.9° C (98.4° F)Heart rate 112/minRespiratory rate 22/minBlood pressure 138/80 mm HgOxygen saturation 98% on room air Exhibit 3 History and PhysicalHistory of high cholesterol, diet controlledFamily history of coronary artery disease, epilepsy, and migraines ----------- Correct Answer ------------ Select the 3 findings that require follow-up by the nurse. Visual disturbances Headache Nausea For each finding below, click to specify if the finding is consistent with migraine, stroke, or meningitis. Each finding may support more than 1 disease process. ----------- Correct Answer ------------ Findings Nausea - migraine, meningitis Visual changes - migraine, stroke, meningitis Pain - migraine, stroke, meningitis Family history - migraine, stroke Complete the following sentence by using the lists of options. The nurse should identify that the client is most likely experiencing inhalers? (Select all that apply.) ----------- Correct Answer ------------ "I never forget to rinse my mouth after using my budesonide inhaler." "Between office visits, I keep a record of how many times I use my albuterol inhaler." "I use my albuterol inhaler before I go swimming." "I should use my budesonide inhaler before using my albuterol inhaler." A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include? ----------- Correct Answer -- ---------- "The virus can be transmitted without lesions being present." A nurse is assisting with the care for a client who has neutropenia. Which of the following nursing interventions should the nurse implement? ----------- Correct Answer --- --------- Limit visitors to healthy adults. A nurse is assisting with the care for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome? --- -------- Correct Answer ------------ Place the client in the supine position after meals. A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort? ----------- Correct Answer ------------ Sleep on a firm mattress. A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? ----------- Correct Answer ------------ Apply a mask to the client if transport is needed. A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching? ----------- Correct Answer ------------ HbA1c results measure glucose control for the prior 3 months. A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan? ----------- Correct Answer ------------ Use a turn sheet to reposition the client. A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? ----------- Correct Answer ------------ "Consume foods that are low in sodium." A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching? ----------- Correct Answer ------------ Household family members should be tested for TB. A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration? ----------- Correct Answer ------- ----- Pinch the NG tube. A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction? ----------- Correct Answer ------------ Elevated troponin A nurse is assisting with the care of client. Exhibit 1 Nurses' Notes 1000:Client is alert and oriented and reports not feeling well for a few days.Client is on continuous ambulatory peritoneal dialysis (CAPD) and reports that dialysate appeared cloudy this morning.Client reports abdominal pain as a 4 on a scale of 0 to 10. Bowel sounds are active in all quadrants.Peritoneal dialysis access site is red and warm to the touch, with a small amount of purulent drainage noted on the dressing.1300:Client is lying in bed with their knees flexed, guarding their abdomen. Abdomen is slightly distended; hypoactive bowel sounds are present. Client reports nausea and pain as a 6 on a scale of 0 to 10. Provider notified and updated with client condition and diagnostic results. Exhibit 2 Vital Signs 1000:Blood pressure 142/90 mm HgRespiratory rate 18/minTemperature 38.3° C (101° F)Heart rate 90/minOxygen saturation 96% on room ai ----------- Correct Answer ---------- -- The client is experiencing manifestations of peritonitis due to the client's abdominal x-ray results A nurse is assisting with the care of a client who was admitted from the emergency department with a burn injury. Exhibit 1 Nurses' Notes 1800: Client has full thickness burns over both forearms; partial thickness burns are present on the client's neck.Sinus tachycardia noted. Pulses to extremities are palpable. 1+ edema to upper extremities noted.Respirations are even and labored with scattered rhonchi.Hypoactive bowel sounds are present.16 French indwelling urinary catheter was inserted with return of 250 mL of yellow urine.Lactated Ringer's is infusing to the right antecubital.1830: Client's voice is becoming hoarse, and client reports difficulty swallowing. Wheezes are present in upper lobes bilaterally. Charge nurse was notified. Client is positioned upright, and oxygen 40% is being delivered via face tent. Blood collected for ABGs. Exhibit 2 Vital Signs 1800: Temperature 37.2° C (99° F)Heart rate 112/minRespi ----------- Correct Answer ------------ During the emergent phase of burn care, the client is at risk for developing hypovolemia and respiratory failure .A nurse is assisting with the care of a client who has prostate cancer. The client asks the nurse why they are having difficulty with urination. Which of the following responses should the nurse make? ----------- Correct Answer ------------ "The tumor causes obstruction of urine from the urethra." A nurse is assisting with the care of a client. Exhibit 1 Diagnostic Results Aspartate aminotransferase (AST) 45 units/L (0 to 35 units/L)Alanine aminotransferase (ALT) 39 international units/L (4 to 36 international units/L)Total lactic dehydrogenase (LDH) 200 units/L (100 to 190 units/L)WBC count 12,000/mm3 (5,000 to 10,000/mm3) Exhibit 2 Vital Signs Blood pressure 132/86 mm HgHeart rate 101/minRespiratory rate 18/minTemperature 37.2° C (99° F)Oxygen saturation 97% on room air Exhibit 3 Physical Examination Client presents to the ED with upper abdominal pain that radiates to the right shoulder. Pain is rated as a 7 on a scale of 0 to 10. Client also reports nausea, vomiting, and dyspepsia.Client awake, alert, and oriented to person, place, and time. Lung sounds are clear bilaterally. S1 and S2 heart tones noted. All pulses are palpable. Bowel sounds are active in all four quadrants. ----------- Correct Answer ------------ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Administer morphine IV. (action) Ensure the client is NPO. (action) Cholecystitis (condition) Jaundice (monitor) Increasing temperature (monitor) A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) ----------- Correct Answer --- --------- Check iv site Stop infusion Withdraw the iv catheter Elevate the affected arm A nurse is examining a client's IV site and notes a hardened vein above their IV site. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? -- -------- Correct Answer ------------ Thrombophlebitis A nurse is reinforcing teaching with a client prior to the removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching? ---------- Correct Answer ------------ "I will feel vibrations on my leg from the cast cutter." A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? ---------- Correct Answer ------------ Irregular borders A nurse is assisting with the care for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? ---------- Correct Answer ------------ Give the client liquids with increased viscosity. A nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM) machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching? (Select all that apply.) --- ------- Correct Answer ------------ "Your knee is flexed and extended as prescribed by your provider." "The machine is padded with sheep skin." A nurse is assisting with the care for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take? ---------- Correct Answer ------------ Withhold the dose. A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? --------- - Correct Answer ------------ History of treatment for blood clots A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include? ---------- Correct Answer ------------ Withdraw the regular insulin before withdrawing the NPH insulin. A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? ---------- Correct Answer ------------ "I will have my HbA1c checked twice per year." A nurse is assisting in the care of a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ---------- Correct Answer ------------ 864 calories A nurse is assisting with the care for a client who is 2 hr postoperative following the amputation of a foot. Which of the following actions should the nurse take first? ---------- Correct Answer ------------ Check the incisional dressing. A nurse in a health clinic is reinforcing teaching with a client about tuberculosis (TB). Which of the following client statements indicates an understanding of the teaching? ---- ------ Correct Answer ------------ "I can develop TB by breathing in the infection." A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first? ---------- Correct Answer ------------ Obtain the client's blood pressure. A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care? ---------- Correct Answer ------------ Administer an antiemetic to the client. A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first? ---------- Correct Answer ------------ Ventilate the client with 100% oxygen. A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ------------ "I will limit my daily intake of protein." A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? -- -------- Correct Answer ------------ "I should call my doctor if my ankles swell." A nurse is assisting with the care of a client who has prostate cancer. The client asks the nurse why they are having difficulty with urination. Which of the following responses should the nurse make? ---------- Correct Answer ------------ "The tumor causes obstruction of urine from the urethra." A nurse is assisting with the care for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome. ---- ------ Correct Answer ------------ Place the client in the supine position after meals. A nurse on a medical-surgical unit is assign with the care of a newly admitted client. Select the 3 findings that require follow-up by the nurse. ---------- Correct Answer --------- --- Oxygen Saturation Pain level Wound dressing The nurse is assisting with the care of the client. Complete the following sentence by using the lists of options. ---------- Correct Answer ------------ The client is most likely experiencing a hemothorax as evidenced by the client's respiratory findings. The nurse is assisting with the care of the client. Drag words from the choices below to fill in each blank in the following sentence. ---------- Correct Answer ------------ The nurse should first address the client's blood pressure, followed by the client's oxygenation. For each potential provider prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. ---------- Correct Answer ------------ Anticipated- Transfuse packed RBC's. Prepare the client for the chest tube insertion. Initiate NPO status. Contraindicated- Place the client in Trendelenburg position. Cover the client with a cooling blanket. The nurse is assisting with the care of the client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? Select all that apply ---------- Correct Answer ------------ Place the client in high-Fowler's position Place two rubber-tipped hemostats in the client's room Palpate the chest tube insertion site for subcutaneous emphysema Ensure that all chest tube connections are securely attached The nurse is assisting with the care of the client 1 hr following chest tube insertion. Click to highlight the findings that indicate the client's condition is improving. To deselect a finding, click on the finding again. ---------- Correct Answer ------------ Client reports pain as a 3 on a scale of 0 to 10. Client reports shortness of breath has decreased. Wound dressing is dry and intact. Respiratory rate 24/min. Blood pressure 108/74 mm Hg Oxygen saturation 95% on oxygen 2 L/min via nasal cannula. A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as an expected change associated with aging? ---------- Correct Answer ------------ "My food tastes bland even after I add seasoning." A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching? ---------- Correct Answer ------------ Household family members should be tested for TB A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ------------ "I should wait at least 2 hours after eating before going to bed." A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication. ---------- Correct Answer ------------ Frequent colds A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? ---------- Correct Answer ------------ Decreased Shortness of breath A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify that which of the following client statements indicates an understanding of the teaching? ---------- Correct Answer ---------- -- "Pursed-lip breathing works best for activities like walking up stairs." A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking their medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis? ---------- Correct Answer ------------ Prednisone A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching? ---------- Correct Answer ------------ HbA1c results measure glucose control for the prior 3 months. A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort? ---------- Correct Answer ------------ Sleep on a firm mattress. A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? ---------- Correct Answer ------------ Remind the client to swish the medication in their mouth. A nurse is assisting with the care for a client who is receiving chemotherapy. The client mentions that they have a loss of appetite because of sores in their mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? ---------- Correct Answer ------------ Eat several small-portioned meals daily. A nurse is assisting with the care for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) ---------- Correct Answer ------------ Lower the client to the floor. Place a pad beneath the client's head. Loosen the clothing around the client's neck. Time the length of the client's seizure. Reorient and reassure the client. A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? ---------- Correct Answer ------------ Apply a mask to the client if transport is needed. A nurse is reinforcing discharge teaching with a client who has Crohn's disease. Which of the following statements should the nurse include in the teaching? ---------- Correct Answer ------------ "Maintain a low-residue diet." A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate? ---------- Correct Answer ------------ Elevated serum amylase level A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? ---------- Correct Answer ------------ Apply cold packs to the inflamed joints. A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? ------ ---- Correct Answer ------------ Decrease potassium A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include? ---------- Correct Answer ---------- -- Place the client in a negative-pressure airflow room. A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? ---------- Correct Answer ------------ Bradycardia A nurse is assisting with the care for a client who has neutropenia. Which of the following nursing interventions should the nurse implement? ---------- Correct Answer ---- -------- Limit visitors to healthy adults. A nurse is contributing to the plan of care for a client who had a stroke. For which of the following interprofessional team members should the nurse recommend a referral prior to initiating oral intake for the client? ---------- Correct Answer ------------ Speech- language pathologist A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.) ---------- Correct Answer ------------ "I never forget to rinse my mouth after using my budesonide inhaler." "Between office visits, I keep a record of how many times I use my albuterol inhaler." "I use my albuterol inhaler before I go swimming." A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform he following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) ---------- Correct Answer ---- -------- Check the IV site. Stop the infusion. Withdraw the IV catheter. Elevate the affected arm. Notify the charge nurse. A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include? ---------- Correct Answer --- --------- "The virus can be transmitted without lesions being present." A nurse is assisting with the care for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client? ---------- Correct Answer ------------ Combination oral contraceptives A nurse is reinforcing teaching with the caregiver of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? ---------- Correct Answer ------------ Change the sheepskin liner weekly. A nurse is reinforcing dietary teaching with a client about increasing the intake of foods containing vitamin C to enhance absorption of oral iron supplements. Which of the following food choices should the nurse include in the teaching? ---------- Correct Answer ------------ 1 cup of boiled broccoli A nurse is assisting in monitoring a client who is receiving dialysis treatment. For each potential nursing intervention, click to specify if the intervention is indicated or not indicated. ---------- Correct Answer ------------ Indicated- Place the client in reverse Trendelenburg position. Assist with administering a 0.9% sodium chloride 200 mL IV bolus. Apply oxygen at 2 L/min via nasal cannula. Notify the charge nurse immediately.\ Not Indicated- Request a chest x-ray. Obtain the client's blood glucose level. A nurse is assisting with the care of a client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. ---------- Correct Answer ------------ Administer morphine IV, Ensure the client is NPO.