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A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?
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A nurse is assessing a client 15 min after administering morphine sulfate 2 mg via VI push. The nurse should identify which of the following findings as an adverse effect of the medication?
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Med surg Final 3
| Question | Answer |
|---|---|
| A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? | A self-report pain rating scale |
| A nurse is assessing a client 15 min after administering morphine sulfate 2 mg via VI push. The nurse should identify which of the following findings as an adverse effect of the medication? | Respiratory rate 8/min |
| A nurse is administering morphine 2 mg VI every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects? | Orthostatic hypotension |
| A nurse is caring for a client who had total hip arthroplasty 1day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take? | Auscultate bowel sounds. |
| A nurse is reviewing the medication administration records of four clients who have a prescription for morphine PRN. Which of the following findings should the nurse identify as a contraindication to this medication? | The client has a paralytic ileus |
| A client is admitted to the emergency room with a respiratory rate of 7/ min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Satura | Respiratory acidosis |
| A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? | pH below 7.35 |
| Nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client for which of the following clinical manifestations? | Metabolic alkalosis |
| A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 Pa02 78 mm Hg | Respiratory Acidosis |
| A nurse is caring for a client whose arterial blood gas results show a pH of 7,3 and a PaCO2 of 50 mm Hg: The nurse should identify that the client is experiencing which of the following acid-base imbalances? | Respiratory acidosis |
| Patient with respiratory alkalosis? | Hyperventilation |
| A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? | The P wave falls before the QRS complex. |
| 5. A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? | Atrial depolarization |
| A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? | Pacemaker spikes before each QRS complex |
| A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select al that apply.) | Count your pulse for 1mni each morning. Do not wear tight clothing over hte insertion area. |
| A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations? | Fatigue |
| A nurse is caring for a client who has a serum potassium level of 5.5 mEq/ L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client’s ECG? | Reduction of T-wave amplitude |
| 8. A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization? | QT interval |
| A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) | Increased blood pressure -Increased heart rate -Increased respiratory rate. |
| A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.) | Bounding pulse Pitting edema Crackles upon auscultation |
| A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? | Different apical and radial pulses |
| A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? | Irregular |
| A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor for which of the following complications? | Pulmonary embolism |
| A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias sho | Atrial fibrillation |
| 11. A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury? | Lactated Ringer's |
| A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? | Administer IV fluids. |
| A nurse is monitoring a client who was admitted with a severe burn injury and is receiving VI fluid resuscitation therapy. The nurse should identify a decrease ni which of the following findings as an indication of adequate fluid replacement? | Heart rate |
| A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care? | Offer the client 240 mL (8 oz) of oral fluids every 4 hr. |
| A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? | Evaluate urine for amount and for specific gravity |
| A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration? | A client who has a temperature of 39° C (102° F) |
| A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated? | Skin tenting present |
| A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect? | Furrows in the tongue |
| A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? | The client who has gastroenteritis and is febrile. |
| A nurse is reviewing the laboratory test results of a client who is scheduled for a carotid endarterectomy in 3 days. Which of the following results should the nurse report to the provider? | Sodium 151 mEq/L |
| A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect? | Paralytic ileus |
| A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? | Fatigue |
| A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in in the teaching? | Instruct the client about the use of a sequential compression device |
| A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication? | Output of burgundy colored urine |
| A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition? | Hypoxemia |
| A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? | Arterial blood gases |
| A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the drain was placed for which of the following purposes? | To prevent fluid from accumulating in the wound |
| A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider? | WBC 2300/mm3 |
| A nurse is reviewing the diagnostic test results of an older adult female client who is preoperative for ankle arthroplasty. The nurse should notify the surgeon of which of the following results? | WBC count 20,000/mm3 |
| CBC findings on a adolescent female client an d WBC is 16,000 mm3.Wich is the appropriate analysis of the results ? | An acute infectious process |
| Pt with idiopathic thrombocytopenic. Expected to be decreased? | Platelets |
| A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider? | Systolic blood pressure changed from 140 mm Hg to 120 mm Hg |
| A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse’s priority? Oxygen saturation | Oxygen saturation |
| A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions sh | Encouraging the client to drink 2 to 3 L water dialy |
| A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? | Barrel |
| A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? | Instruct the client to use pursed-lip breathing |
| A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) | Dyspnea Barrel chest Clubbing of the fingers |
| A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assess | Increased anteroposterior diameter of the chest |
| 20. A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? | Assess the client's respiratory status. |
| A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching? | "I will be sure to take the albuterol before taking the cromolyn." |
| A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects? | Oral candidiasis |
| A nurse is teaching a client who has chronic obstructive pulmonary disease and is to start using fluticasone by MDI twice daily. Which of the following instructions should the nurse include? | "Inspect your mouth for lesions daily. |
| A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider? | White coating in the mouth |
| Pt taking Prednisone and most stop medication. Nurse explain to reduce gradually to prevent? | Adrenocortical insufficiency |
| A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take? | Administer a short-acting ß2 –agonist (SABA) |
| A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse’s highest priority? | Administering a nebulized beta-adrenergic |
| A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms? | Albuterol via jet nebulizer |
| Medications to avoid in patient with asthma? A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? | Propranolol |
| The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? | Carvedilol |
| A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all t | The student should use his quick-relief inhaler. The student's asthma is not well controlled. The student's peak flow is 50% to 80% of his best peak flow. The nurse should obtain a second expiratory flow rate |
| A nurse is teaching a client who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the client to use to abort an acute asthma attack? | Albuterol |
| A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client? | 1 cup canned black beans |
| A nurse is creating a dietary plan for an adult female client who has a hemoglobin level of 9.8 g/dL. Which of the following foods should the nurse recommend? | Raisins |
| A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan? | Red meat |
| A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client’s plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for th | Bleeding |
| A nurse is reviewing the laboratory findings for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should the nurse expect to be decreased? | Platelets |
| A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor? | Eccymosis |
| A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm3. The nurse should monitor the client for which of the following conditions? | Spontaneous bleeding |
| A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory values should the nurse expect? (Select all that apply.) | -Decreased platelet count -Decreased leukocyte count -Decreased erythrocyte count |
| A nurse is assessing a client who is postoperative following a vaginal hysterectomy. Which of the following findings is a manifestation of deepvein thrombosis (DVT)? | Unilateral leg edema |
| A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus? | Dull, aching calf pain |
| A nurse is planning care for a client who has deep-vein thrombosis (DVT) and is receiving anticoagulation therapy. Which of the following interventions should the nurse include in the plan of care? | Encourage the client to walk. |
| nurse is providing discharge instructions to a client who developed deepvein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? | Flexing her knees and feet frequently |
| A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care? | Keep the client's affected leg elevated while in bed. |
| A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? | Massaging her legs |
| A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? | Encourage the use of an incentive spirometer |
| A nurse in the emergency department is caring for a client who has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. Which of the follo | Provide the client with supplemental oxygen at 5 L/min via facemask. |
| A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include? | Eat foods that contain plenty of potassium. |
| A nurse is reviewing a client’s laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following? | Cellular hypoxia |
| A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? | Fatiuge |
| Plastic anemia. Which of the following include in the teaching? | Aplastic anemia results from decreased bone marrow production of RBCs |
| A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspect which of the following types of anemia? | Iron-deficiency anemia |
| A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement? | Vitamin B12 injections |
| A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests? | Schilling test |
| During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following type | Basal cell carcinoma |
| A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include? | Basal cell carcinoma has a low incidence of metastasis. |
| A nurse is assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings? | A small, translucent papule with rolled borders |
| A nurse is assessing a lesion on a client who has basal cell carcinoma. The nurse should expect which of the following findings? | A pearly, shiny nodule |
| A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention? | Surgical excision. |
| A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? | Facial rash |
| A nurse is preparing a presentation at a community center about systemic lupus erythematosus (SLE). The nurse should plan to include which of the following findings as a manifestation of SLE? | A raised rash |
| A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider? | Presence of peripheral edema. |
| A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function? | Serum creatinine |
| A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants risks of basal cell carcinoma (BCC)? | Teaching participants to limit their sun exposure. Eating a high fiber diet will reduce my risk for developing skin cancer." |
| A nurse is teaching a client about risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching? | "I should apply sunscreen prior to going outside, even in the winter months." |
| A nurse is developing an education program about skin cancer for a community center. Which of the following instructions should the nurse plan to include? | Keep a body map of skin lesions. |
| A nurse is teaching a class at a community center to a group of young adult, adult, and older adult clients regarding regular screening recommendations for cancer prevention. Which of the following information should the nurse include? | Clients should have a yearly test for fecal occult blood. |
| A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support? | Talk with the client during wound care |
| A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? | A reddened area over the sacrum |
| A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take? | Log roll the client every 2 hr. |
| A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan? | Reposition the client every 2 hr |
| A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assess | Airway obstruction |
| A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? | Difficulty swallowing |
| A nurse in an emergency room is caring a the client who sustained partialthickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? | Inspect the mouth for signs of inhalation injuries |
| A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury? | Maintain the airway. |
| A nurse is caring for a client who has herpes zoster. Which of the following findings should the nurse expect? | Painful lesions following a nerve pathway |
| A nurse is assessing a client at a dermatology clinic. Which of following findings places the client at risk for developing malignant melanoma? | History of chronic skin irritation |
| A nurse is caring for a client who has malignant melanoma. Which of the following findings should the nurse expect when assessing the lesion? | Purplish in color |
| A nurse is caring for an adult client who has atopic dermatitis. Which of the following findings should the nurse expect? | Chronic rash with thick skin |
| A nurse is teaching a client who has a new diagnosis of atopic dermatitis. Which of the following statements should the nurse include in the teaching? | "Your provider may recommend a daily antihistamine to help control your symptoms |
| A nurse is planning care for an older adult client who has herpes zoster. Which of the following interventions should the nurse include in the plan? | Administer analgesics for pain. |
| A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take? | Prepare to administer acyclovir. |
| A nurse is formulating a teaching plan about herpes zoster for a group of older adults at a community center. The nurse should include which of the following information in the plan? | Many clients experience pain in the affected area for weeks after the lesions have resolved. |
| Many clients experience pain in the affected area for weeks after the lesions have resolved. | Silvery, white scales |
| A nurse is developing a teaching plan for a client who has psoriasis. Which of the following actions should the nurse include in the plan? | Identify effective stress reduction techniques |
| A nurse is developing a teaching plan for a client who has psoriasis. Which of the following information should the nurse include in the plan? | Use bath oils to soften and soothe the skin. |
| A nurse is providing teaching to a client who has psoriasis and a new prescription for the topical corticosteroid cream betamethasone valerate. Which of the following information should the nurse include in the teaching? | Wrapping plastic around the site can increase the medication's effectiveness |
| While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patient’s car. The nurse knows that this lesion is consistent with what type of skin cancer? | Malignant melanoma. |
| A nurse is assessing a client who reports a nevus that has increased in size and an irregularly shaped lesion that varies in color. These findings are consistent with which of the following medical diagnoses? | Malignant melanoma. |
| A nurse is assessing a client who presents to the provider's office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy? | Irregular borders |
| A nurse is caring for a client who has malignant melanoma. Which of the following findings should the nurse expect when assessing the lesion? | Purplish in color |
| A nurse is providing teaching to a client who has a superficial lesion and has had a biopsy indicates malignant melanoma. The nurse should include which of the following options as the treatment of choice? | Surgical excision |
| A patient with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy? | Skin biopsy |
| A nurse is assessing a client who has viral rhinitis and a history of herpes simplex virus type 1 (HSV-1) lesions. The nurse should assess which of the following areas of the body for the recurrence of HSV-1 lesions? | Mouth |
| A nurse is teaching a client who has herpes simplex virus type 2 about disease transmission. Which of the following statements by the client indicates understanding of the teaching? | "Itching or tingling occurs at the site where a blister forms. |
| A nurse in a provider’s office is assessing a client who has AIDS. The nurse notes that the client has multiple and widespread raised, purplish-brown skin lesions. The nurse should recognize that these findings indicate which of the following conditions? | Kaposi's sarcoma |
| A 65-year-old man presents at the clinic complaining of nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish. What | Classic Kaposis sarcoma |
| A nurse is providing care for a patient who has developed Kaposis sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body? | Endothelial cells lining small blood vessels |
| A nurse is teaching a client who has a new prescription for topical betamethasone to treat contact dermatitis. Which of the following instructions should the nurse include | "Use the cream for a few days after the area has healed." |
| A nurse in a provider's office is caring for a client who reports pruritus and reddened, oozing lesions on her lower leg. The nurse should suspect which of the following disorders? | Contact dermatitis |
| A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take? | Administer an antiemetic prior to the procedure. |
| A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching? | Tingling feeling in the extremities |
| A nurse is teaching a client about the side effects of chemotherapy medication. Which of the following nursing statements should the nurse include in the teaching? | "Hair loss is common and includes eyebrows and eyelashes." |
| 56. Pt with lice-Do not share comb, personal item, pillow case in a ziplot | Tx: Lindano, Permethrin |
| A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following actions should the nurse take? | Provide mittens for the client to wear at night |
| A patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have? | 18% |
| A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client’s total body surface area (TBSA)? | 54 percent |
| A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect? | Hyperkalemia |
| A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases? | Tuberculosis |
| A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiolog | Have the client wear a mask. |
| A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client? | Place the client in a private room with a special ventilation system. |
| A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? | Airborne |
| A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? | Sputum culture for acid-fast bacillus |
| A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take? | Wear an N95 respirator mask |
| A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet p | Assess the cranial nerves. |
| At what moment the patient with meningitis is no longer contagious? | After 24 hours W/ Antibiotic tx no longer contagious |
| A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse’s priority? | Administer antibiotics to the client. |
| 66. Priority intervention in patient right side speech(hemiparesis)(slurred speech) | STAT CT scan to rule out ischemic or hemorrhagic stroke |
| The window time for Tx TPA (Tissue plasminogen activator), only for ischemic stroke frame of time when the stroke started | 4-5 hours |
| A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, re | Hemorrhagic stroke |
| A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? | Manifestations preceded by a severe headache WORSE |
| A nurse who is off duty finds a woman who has collapsed and has rightsided weakness and slurred speech. Which of the following actions should the nurse take? | Call emergency services. |
| A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? | Establish the ability to communicate effectively. |
| A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take? | Speak to the client about one idea at a time. |
| A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate? | "Incorporate nonverbal cues in the conversation. (Aphasia) give a clean board so patient can write what they want to tell you |
| A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected? | Pushes the painful stimulus away |
| Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? | The client opens his eyes when spoken to. |
| 74. Patient report headache and neck stiffness, what is the first thing you assess in this patient | Possible meningitis |
| A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first? | Evaluate the client's neurological status Evaluate the client's neurological status |
| A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion? | Restlessness |
| Pt with bacterial meningitis, Monitor for increased intracranial pressure as an indicated by wich of the following? | Widened pulse pressure |
| A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor? | Weakness |
| Myasthenia gravis at risk of- Respiratory infections A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis | Developing a respiratory infection |
| A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication? | Ask the client to take a few sips of water |
| Pt with M.G. Interventions to take? | Prepare for mechanical ventilation |
| A nurse is assessing a client who has a suspected diagnosis of GuillainBarré syndrome (GBS). Which of the following questions should the nurse ask the client? | "Have you had a recent influenza infection?" "Have you had a recent influenza infection?" "Have you had a recent influenza infection?" Have you had a recent influenza infection? |
| A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect? | Severe headache |
| A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? | A change in the Glasgow Coma Scale score from 13 to 1 |
| A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score? | The client needs total nursing care. |
| A nurse is reviewing a client’s laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following? | Cellular hypoxia |
| A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? | Fatigue |
| A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspect which of the following types of anemia? | Iron-deficiency anemia |
| A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care? | Fresh flowers and potted plants in the room |
| A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching? | Avoid crowds. |
| A nurse is preparing a client who has AIDS for discharge. Which of the following statements should the nurse include in the discharge instructions? | Prevent the spread of infection with good household cleaning practices |
| A charge nurse is teaching a group of health care workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching? | Use chlorhexidine to wash hands if the client is immunosuppressed |
| A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care? | vLimit the number of health care workers entering the room |
| A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching? | "I will avoid people who have just received an immunization." |
| A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse include in the plan? | Limit visitors to healthy adults |
| A nurse is caring for an older adult client who has a WBC count of 2,000/ mm3 after three rounds of chemotherapy. Which of the following actions should the nurse take? | Serve cooked fruit with meals |
| A nurse is teaching a client who has a new prescription for topical betamethasone. Which of the following instructions should the nurse include? | "Use the cream for a few days after the area has healed." |
| A nurse is providing teaching to a client who has psoriasis and a new prescription for the topical corticosteroid cream betamethasone valerate. Which of the following information should the nurse include in the teaching? | -Wrapping plastic around the site can increase the medication's effectiveness. |
| A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Whi | "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." |
| A client who has active Tuberculosis and is taking rifampin reports that this urine and sweat have developed a red orange tinge. Which of the following actions should the nurse take ? | Document this as an expected finding |
| A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin and pyrazinamide. Which of the following instructions should the nurse include? | "Drink at least 8 ounces of water when you take the pyrazinamide tablet." |
| Nurse teaching about Rifampin expected manifestation? | Red colored urine |
| A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? | Brudzinski's sign |
| A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following? | To reduce the risk of stroke in clients who have atrial fibrillation |
| A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? | The client’s bladder becomes distended |
| A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the fol | Place the client in a high-Fowler's position. |
| A nurse in a provider’s office is caring for a client who has a new diagnosis of tinea pedis. Which of the following findings should the nurse expect? | Scaling and redness between the client’s toes |
| A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take? | Log roll the client every 2 hr. |
| A nurse is caring for a client who is prescribed diphenhydramine to relieve pruritus. The client asks the nurse how he can minimize the daytime sedation he is experiencing. Which of the following responses should the nurse give? | " Take most of the daily dose at bedtime |
| A nurse is shopping and finds a woman who has collapsed with rightsided weakness and slurred speech. Which of the following action should the nurse take? | Notify emergency management services. |
| A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing | Place the client in a high-Fowler’s position. |
| 95. Pt with I.P. Interventions | Headache, slurred speech, pupilary changes, Disorientation |
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Maguirre1537