A nurse is caring for a client who is 4 hr postoperative following an arterial

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?

1 temperature once a day 2 the armpits and genitals with a gentle cleanser daily 3 the litter boxes while wearing gloves 4 dishes in warm water ; 1 temperature once a day = A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client’s secretions?

1 humidified oxygen 2 chest physiotherapy prior to suctioning 3 the suction catheter tip with sterile saline when suctioning the airway 4 the client with 100% oxygen before suctioning the airway ; 1 humidified oxygen = Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client’s comfort?

1 the client’s feet briskly for several minutes 2 a pair of slipper socks for the client 3 the client’s oral fluid intake 4 a moist heating pad under the client’s feet ; 2 a pair of slipper socks for the client = A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse to report to the provider?

1 of 100 mL 2 temperature of 37 C (99 F) 3, red-colored urine 4 level of 4 on a 0 to 10 rating scale ; 3, red-colored urine = A nurse is caring for a client who has a temperature of 39° C (103° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket?

1. Shivering

2. Infection

3. Burns

4. Hypervolemia ;

5. Shivering

   A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

6. "I will carry a complex carbohydrate snack with me when I exercise."

7. "I should exercise first thing in the morning before eating breakfast."

8. "I should avoid injecting insulin into my thigh if I am going to go running."

9. "I will not exercise if my urine is positive for ketones." ;

10. "I will not exercise if my urine is positive for ketones."

    A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?

11. Cover the client's wound with a moist, sterile dressing.

12. Have the client lie supine with knees flexed.

13. Check the client's vital signs.

14. Inform the client about the need to return to surgery. ;

15. Cover the client's wound with a moist, sterile dressing.

    A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect?

16. Cool, clammy skin.

17. Hyperventilation

18. Increased blood pressure

19. Bradycardia ;

20. Hyperventilation

    A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching?

21. Avoid bending at the waist.

22. Remove the eye shield at bedtime.

23. Limit the use of laxatives if constipated.

24. Seeing flashes of light is an expected finding following extraction. ;

25. Avoid bending at the waist.

    A nurse is caring for a client who has heart failure and has been taking digoxin 0 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

26. Suggest that the client rests before eating the meal.

27. Request a dietary consult.

28. Check the client's vital signs.

29. Request an order for an antiemetic. ;

30. Check the client's vital signs.

    A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

31. Sanguineous

A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report?

1. Hot flashes

2. Recurrent urinary tract infections

3. Blood in the stool

4. Abnormal vaginal bleeding ;

5. Abnormal vaginal bleeding

   A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority?

6. Altered level of consciousness

7. Oral temperature of 37° C (100° C)

8. Muscle spasms

9. Headache ;

10. Altered level of consciousness

    A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider?

11. Abdomen is distended

12. Chest tube drainage of 70 mL in the last hour

13. Subcutaneous emphysema is noted to the left chest wall

14. Pain level of 6 on a 0 to 10 scale ;

15. Abdomen is distended

    A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

16. Change the ostomy pouch daily.

17. Empty the ostomy pouch when it is 2/3 full.

18. Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.

19. Apply lotion to the peristomal skin when changing the ostomy pouch. ;

20. Change the ostomy pouch daily.

    A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?

21. Position the client supine while in bed.

22. Change the nasal drip pad as needed.

23. Encourage frequent brushing of teeth.

24. Encourage the client to cough every 2 hr following surgery. ;

25. Change the nasal drip pad as needed.

A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?

1. To provide analgesia

2. To reduce inflammation

3. To prevent blood clotting

4. To prevent fever ;

5. To prevent blood clotting

   A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?

6. Loss of peripheral vision

7. Headache

8. Halos around lights

9. Discomfort in the eyes ;

10. Loss of peripheral vision

    A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?

11. Weight loss of 3% of total body weight.

12. Blood glucose 150 mg/dL.

13. Potassium 2 mEq/L

14. Urine specific gravity 1. ;

15. Potassium 2 mEq/L

    A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching?

16. "I should increase my intake of protein and vitamin C."

17. "I will no longer have menstrual periods."

18. "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience discomfort."

19. "I will take a tub bath instead of a shower." ;

20. "I will take a tub bath instead of a shower."

    A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take?

21. Loosen the knots on the ropes if the client is experiencing pain.

22. Ensure the client’s weights are hanging freely from the bed.

23. Check the client’s bony prominences every 12 hr.

24. Cleanse the client’s pin sites with povidone-iodine. ;

25. Ensure the client’s weights are hanging freely from the bed.

    A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?

26. Measure abdominal girth daily.

27. Use sterile water to irrigate the nasogastric tube..

28. Maintain the client in Fowler’s position.

29. Moisten the client’s lips with lemon-glycerin swabs. ;

30. Maintain the client in Fowler’s position.

    A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.)

31. Buffalo hump

32. Purple striations

33. Moon face

34. Tremors

35. Obese extremities ;

36. Buffalo hump

37. Purple striations

38. Moon face

    A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?

39. Provide a diet high in protein.

40. Provide ibuprofen for retroperitoneal discomfort.

41. Monitor intake and output hourly

42. Encourage the client to consume at least 2 L of fluid daily. ;

43. Monitor intake and output hourly

    A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching?

44. "A flexible tube is introduced through the nose during the procedure."

45. "During the procedure you are in a sitting position."

46. "You will remain NPO for 8 hours before the procedure."

47. "You will be awake while the procedure is performed." ;

48. "You will remain NPO for 8 hours before the procedure."

    A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

49. Aura phase

50. Presence of automatisms

51. Postictal phase

52. Presence of absence seizures ;

53. Postictal phase

    A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make?

54. "The pain results from lying in one position too long during surgery."

55. "The pain occurs as a residual pain from cholecystitis."

56. "The pain will dissipate if you ambulate frequently."

57. "The pain is caused from the nitrous dioxide injected into the abdomen." ;

58. "The pain will dissipate if you ambulate frequently."

    A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

59. Notify the provider.

60. Verify that the suction regulator is on.

61. Continue to monitor the client because this is an expected finding.

62. Milk the chest tube to dislodge any clots in the tubing that may be occluding it. ;

63. Verify that the suction regulator is on.

    A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)

64. Encourage fluid intake.

65. Monitor the puncture site for hematoma.

66. Insert a urinary catheter.

67. Elevate the client’s head of bed.

68. Apply a cervical collar to the client. ;

69. Encourage fluid intake.

70. Monitor the puncture site for hematoma.

    A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action?

71. Relieve the client's pain.

72. Check the client’s pressure points for redness.

73. Provide oral hygiene.

74. Prevent aspiration. ;

75. Prevent aspiration.

    A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?

76. A dry raised rash

77. Excessive salivation

78. Periorbital edema

79. Hardened skin ;

80. Hardened skin

    A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?

81. Re-establish communication.

82. Improve left-side motor function. ;

83. Re-establish communication.

    A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations?

84. Hypotension

85. Polyphagia

86. Hyperglycemia

87. Bradycardia ;

88. Hypotension

    A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7. PaCO2 68 mm Hg Base excess - PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L

Which of the following interpretations of the ABG values should the nurse make?

1. Metabolic acidosis

2. Respiratory acidosis

3. Metabolic alkalosis

4. Respiratory alkalosis ;

5. Respiratory acidosis

   A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

6. "I will avoid crossing my legs at the knees."

7. "I will use a thermometer to check the temperature of my bath water."

8. "I will not go barefoot."

9. "I will wear stockings with elastic tops." ;

10. "I will wear stockings with elastic tops."

    A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take?

11. Turn the water on and ask the client to test the temperature.

12. Obtain assistance to place mitten restraints on the client.

13. Firmly tell the client that good hygiene is important.

14. Calmly ask the client if he would like to listen to some music. ;

15. Calmly ask the client if he would like to listen to some music.

=

A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following?

1. Decreased perfusion

2. Infection

3. Granulation tissue

4. An inflammatory response ;

5. Granulation tissue

   A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client?

6. Baked chicken

7. Bagels

8. A factory-sealed box of chocolates

9. Fresh fruit basket ;

10. Fresh fruit basket

    A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan?

11. Perform the client's personal care activities for her.

12. Limit the client’s fluid intake.

13. Monitor the Homan’s sign.

14. Maintain abduction of the right hip. ;

15. Maintain abduction of the right hip.

    A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first?

16. Establish IV access.

17. Feel for a carotid pulse.

18. Establish an open airway.

19. Auscultate for breath sounds. ;

20. Feel for a carotid pulse.

    A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make?

21. "Why have you changed your mind about the surgery?"

22. "Bypass surgery must be very frightening for you."

23. "Your provider would not have scheduled the surgery unless you needed it."

24. "I will call your doctor and have him discuss your surgery with you." ;

25. "Bypass surgery must be very frightening for you."

A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.)

1. Decreasing anxiety

2. Controlling emesis

3. Relaxing skeletal muscles

4. Preventing surgical site infections

5. Reducing the amount of narcotics needed for pain relief ;

6. Decreasing anxiety

7. Controlling emesis

8. Reducing the amount of narcotics needed for pain relief

   A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication?

9. Vitamin D

10. Vitamin A

11. Iron

12. Niacin ;

13. Iron

    A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period?

14. Malnourishment related to NPO status and dysphagia

15. Impaired verbal communication related to the tracheostomy

16. High risk for infection related to surgical incisions

17. Ineffective airway clearance related to thick, copious secretions ;

18. Ineffective airway clearance related to thick, copious secretions

    A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility?

19. Walk with leg braces and crutches.

20. Drive an electric wheelchair with a hand-control device.

21. Drive an electric wheelchair equipped with a chin-control device.

22. Propel a wheelchair equipped with knobs on the wheels. ;

23. Propel a wheelchair equipped with knobs on the wheels.

    A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer?

24. Exposure to environmental pollutants

25. Sun exposure.

26. History of viral illness

27. Scars from a severe burn ;

28. Sun exposure.

    Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause?

29. "Do you sleep well at night?"

30. "Have you been experiencing chills?"

31. "Have you experienced increased hair growth?"

32. "When did you begin your menses?" ;

33. "Do you sleep well at night?"

    A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching?

34. Cottage cheese

35. Fresh berries

36. Bran cereal

37. Skim milk ;

38. Fresh berries

    A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

39. Polyuria

40. Battle's sign

41. Nuchal rigidity

42. Lethargy ;

43. Lethargy

    A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching?

44. "Tonometry is performed to evaluate peripheral vision."

45. "This test will diagnose the type of your glaucoma."

46. "Tonometry will allow inspection of the optic disc for signs of degeneration."

47. "This test will measure the intraocular pressure of the eye." ;

48. "This test will measure the intraocular pressure of the eye."

    A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider?

49. Increase in serum glucose

50. Increase in serum creatinine

51. Decrease in white blood cell count

52. Decrease in platelets ;

53. Increase in serum creatinine

54. "If you just sit quietly with your mother, I'm sure she will calm down."

55. "I'll talk with your mother and see if I can comfort her."

56. "It must be hard to see your mother so ill and upset."

57. "Your mother's crying seems to bother you more than it does her." ;

58. "It must be hard to see your mother so ill and upset."

    A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching?

59. Temporary, reversible loss of brain function

60. Forgetfulness gradually progressing to disorientation

61. Sleeping more during the day than nighttime

62. Hyper vigilant behaviors ;

63. Forgetfulness gradually progressing to disorientation

    A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan?

64. Limit fluid intake..

65. Monitor client’s cardinal fields of vision.

66. Encourage ambulation.

67. Ensure the room is brightly lit. ;

68. Monitor client’s cardinal fields of vision.

    A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?

69. Apply ice to the extremity

70. Monitor platelet levels

71. Restrict oral fluids

72. Administer vasodilating medications ;

73. Monitor platelet levels

    A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client?

74. Tuberculin skin test

75. Sputum culture for acid fast bacillus (AFB)

76. Bacille Calmette-Guérin (bCG) vaccine

77. Chest x-ray ;

78. Chest x-ray

    A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus?

79. Serum sodium 145 mEq/L

80. Urine specific gravity 1.

81. Urine output 650 mL/hr

82. Blood glucose 198 mg/dL

;

1. Urine output 650 mL/hr

   A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client?

2. "I took a laxative yesterday."

3. "I took my metformin before breakfast."

4. "I haven't had anything to eat or drink since last night."

5. "The last time I voided it was painful." ;

6. "I took my metformin before breakfast."

   A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds?

7. Expiratory wheeze

8. Pleural friction rub

9. Fine rales

10. Rhonchi ;

11. Expiratory wheeze

    A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take?

12. Remove the entire dressing at once.

13. Loosen the dressing by pulling the tape away from the wound.

14. Don clean gloves to remove the dressing.

15. Open sterile supplies before removing the dressing. ;

16. Don clean gloves to remove the dressing.

    A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?

17. Prone with arms raised over the head.

18. Sitting, leaning forward over the bedside table.

19. High Fowler’s position

20. Side-lying with knees drawn up to the chest. ;

21. Sitting, leaning forward over the bedside table.

    A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect?

22. Denial

23. Bargaining

24. Acceptance

25. Anger ;

26. Denial

=

A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?

1. "You shouldn't feel any pain since the local area is anesthetized."

2. "Most clients report more discomfort from the preparation than from the procedure itself."

3. "You may feel some cramping during the procedure."

4. "Don't worry; you won't remember anything about the procedure due to the effects of the medication." ;

5. "You may feel some cramping during the procedure."

   A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities?

6. Observing for facial asymmetry

7. Checking pupillary responses to light

8. Eliciting the gag reflex

9. Testing visual acuity ;

10. Checking pupillary responses to light

    A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects?

11. Reducing anxiety

12. Increasing blood pressure

13. Increasing coughing

14. Increasing the client's respiratory rate ;

15. Reducing anxiety

    A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report?

16. Frequent mood changes

17. Constipation

18. Sensitivity to cold

19. Weight gain ;

20. Frequent mood changes

    A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

21. Serosanguineous drainage

22. Mild erythema

23. Warmth

24. Fever ;

25. Fever

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.)

1. Polyuria

2. Blurry vision

3. Tachycardia

4. Polydipsia

5. Sweating ;

6. Blurry vision

7. Tachycardia

8. Sweating

   A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)

9. Edema

10. Erythema

11. Tophi

12. Tight skin

13. Symmetrical joint pain ;

14. Edema

15. Erythema

16. Tophi

17. Tight skin

    A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a complication of MG for which the nurse should monitor?

18. Respiratory difficulty

19. Confusion

20. Increased intracranial pressure

21. Joint pain ;

22. Respiratory difficulty

    A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?

23. Review stress factors that can cause disease exacerbation.

24. Evaluate fluid and electrolyte levels.

25. Provide emotional support.

26. Promote physical mobility. ;

27. Evaluate fluid and electrolyte levels.

    A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching?

28. "You should wear glasses instead of contacts while taking this medication."

29. "The medication causes amenorrhea if taken along with an oral contraceptive."