question

A nurse is receiving report on a client who is postoperative following an open repair of Zenker's Diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

answer

A.) Throat

question

A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?

answer

Hypoactive bowel sounds

question

A nurse is providing discharge instructions to a client who has a partial thickness burn of the hand. Which of the following instructions should the nurse include?

answer

Wrap fingers with individual dressings

question

A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effects should the nurse monitor?

answer

Respiratory Paralysis

question

A nurse is assessing a client's hydration status. Which of the following findings indicated fluid volume overload.

answer

Distended neck veins

question

A nurse is assessing a client following the administration of IV penicillin G. Which of the following findings should indicate to the nurse that the client is experiencing an anaphylactic reaction?

answer

Flushing

question

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching?

answer

My joints ache because I have Lyme disease.

question

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

answer

Obtain vital signs

question

A nurse is assessing a client following IV urography. Which of the following findings is the priority?

answer

Swollen lips

question

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following statements by the client indicates an understanding of the teaching?

answer

I will count my heart beats before taking this medication.

question

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?

answer

I will monitor my blood pressure while taking this medication.

question

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer?

answer

Regular insulin 20 units IV bolus

question

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction(MI)?

answer

Troponin I 8 ng/mL

question

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?

answer

Remain with the client for the first 15 min of the infusion.

question

A nurse is assessing a client who had extracorporeal shock wave lithotripsy(ESWL) 6 hr ago. Which of the following findings should the nurse expect?

answer

Stone fragments in the urine

question

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

answer

Ibuprofen can cause gastrointestinal bleeding in older adult clients.

question

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

answer

Loosen restrictive clothing

question

A nurse is assessing a client who has Cushing's disease. Which of the following findings should the nurse expect?

answer

muscle atrophy

question

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure ulcer. Which of the following actions should the nurse take?

answer

Use a 30mL syringe

question

A nurse is reviewing the laboratory results of a client who had a recent exposure to hepatitis C virus. Which of the following tests should the nurse identify as indicating the presence of hepatitis C antibodies?

answer

Enzyme immunoassay (EIA)

question

A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?

answer

It's like a curtain closed over my eye.

question

A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to audio clip. (Click on the audio button to listen to the clip.) Murmur S4 Pericardial friction rub Ventricular gallop

answer

Pericardial friction rub

question

A nurse is caring for a client who has active bleeding from peptic ulcer disease. Which of the following findings is an indication that the client is experiencing compensatory shock?

answer

Increased heart rate

question

A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further screening?

answer

Shellfish allergy

question

A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching?

answer

Consume at least 30 g of fiber daily

question

A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client?

answer

Take insulin even if you are unable to eat your regular diet.

question

A nurse is reviewing the laboratory report of a client who is receiving nonsurgical treatment for Cushing's disease. Which of the following laboratory findings should the nurse identify as a positive outcome of the treatment?

answer

Decreased sodium

question

A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication?

answer

BUN 34 mg/dL

question

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?

answer

Urine specific gravity is 1.045

question

A nurse is caring for a client who has had a cerebrovascular accident. Which of the following findings indicates that the client has homonymous hemianopsia?

answer

The client has to turn her head to see the entire visual field.

question

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus and is planning a trip. Which of the following instructions should the nurse include in the teaching?

answer

Take additional pairs of shoes.

question

A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide?

answer

Hemodialysis is sometimes needed following surgery.

question

A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Disease process Laboratory findings Current medications Family history

answer

Current medications

question

A nurse is assessing a client who is receiving morphine via a PCA pump. Which of the following findings indicates an adverse effect of the medication?

answer

Urinary retention

question

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad?

answer

Bradycardia

question

A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching?

answer

Void before and after intercourse

question

A nurse is providing education to a client who has tuberculosis (TB) and his family. Which of the following information should the nurse include in the teaching?

answer

Family members in the household should undergo TB testing

question

A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority?

answer

Apply firm pressure to the insertion site

question

A nurse is caring for a client who has cirrhosis of the liver with esophageal varies. Which of the following activities should the nurse instruct the client to avoid?

answer

Straining to have bowel movements

question

A nurse is developing a teaching plan for a client who has gout. Which of the following recommendations should the nurse include?

answer

Decrease intake of purine meats

question

A nurse is providing dietary teaching to a client who has celiac disease. Which of the following food choices should the nurse identify as an indication that the client understands the teaching?

answer

Grilled chicken breast

question

A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?

answer

Increase fluid intake

question

A nurse in an emergency department is caring for a client who reports chest pain of 8 on a pain scale of 0 to 10. Which of the following actions should the nurse take first?

answer

Administer morphine

question

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

answer

Low urine specific gravity

question

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion.

answer

Bubbling in the water-seal chamber has ceased.

question

A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIB treatment?

answer

Decreased viral load

question

A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?

answer

Extremity cool upon palpation

question

A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric cerebrovascular accident(CVA). Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.) Expressive aphasia Visual spatial deficitis Left hemianopsia Right hemiplegia One-sided neglect

answer

Visual spatial deficits Left hemianopsia One-sided neglect

question

A nurse in an ICU is planning care for a client who is in cariogenic shock. The nurse should prepare to administer which of the following medications to increase cardiac output?

answer

Dopamine

question

A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?

answer

Nonrebreather mask

question

A client who has emphysema is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first?

answer

Instruct the client to allow the machine to breathe for him.

question

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following non pharmacological interventions should the nurse suggest to the client to reduce pain?

answer

Alternate application of heat and cold to the affected joints.

question

A nurse is assessing a client who is taking carvedilol for heart failure. which of the following findings is the priority for the nurse to report to the provider?

answer

Weight gain

question

A client who has a diagnosis of Clostridium difficile is placed on contact precautions. Which of the following actions should the nurse take?

answer

Leave a stethoscope in the room for blood pressure monitoring.

question

A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching?

answer

This identifies if the pacemaker cells of my heart are working properly.

question

A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range?

answer

Calcium

question

A nurse is caring for a client who has a stage III pressure ulcer. Which of the following findings contributes to delayed wound healing?

answer

Urine output 25 mL/hr

question

A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?

answer

Low back pain and apprehension

question

A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)?

answer

Heart rate 52/min

question

A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory plus should the nurse expect?

answer

Elevated bilirubin level

question

A nurse is assessing a client who is at risk for development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? A.) depicts oral candidiasis/thrush B.) depicts dry oral mucous membrane C.) depicts glossitis D.) depicts a healthy tongue dull in color

answer

C.) depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.

question

A nurse is caring for a client who is experiencing an acute myocardial infarction. The nurse should identify which of the following findings as a manifestation of cardiogenic shock?

answer

Hypotension

question

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and note clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take?

answer

Irrigate the indwelling urinary catheter

question

A nurse is obtaining the health history of a client who has an abdominal aortic aneurysm. Which of the following findings should the nurse expect?

answer

Bruit heard over the middle upper abdomen.

question

A nurse is administering meperidine IM in the right deltoid of a client. The nurse aspirates the pulse back blood in the syringe. Which of the following actions should the nurse take?

answer

Dispose of the medication

question

A nurse is preparing to administer amikacin 500 mg by intermittent IV bolus to a client. Available is amikacin mg in dextrose 5% in water (D5W) 200 mL to infuse over 30 min. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

answer

400 mL/hr

question

A nurse is caring for a client who is undergoing renal dialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in his hands. Which of the following medications should the nurse plan to administer?

answer

calcium carbonate

question

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?

answer

BUN 32 mg/dL

question

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?

answer

Slow the infusion rate

question

A nurse is planning care for a client who has community-acquired pneumonia. Which of the following interventions should the nurse include in the plan of care?

answer

Monitor the client for confusion

question

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority?

answer

Increased respiratory secretions

question

A nurse is providing teaching to a client who is at risk for developing type 1 diabetes mellitus. The nurse should inform the client that which of the following manifestations indicate diabetes? (Select all that apply.) Polyuria Dysphagia Polydipsia Photophobia Neuropathy

answer

Polyuria Polydipsia Neuropathy

question

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothryoxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?

answer

Calcium

question

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take?

answer

Contact the primary care provider to clarify the prescription

question

A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. The nurse should report which of the following adverse effects of this medication to the provider?

answer

Crackles heard on auscultation

question

A nurse is assessing an older adult client who has heart failure and takes digoxin. Which of the following findings should the nurse recognize as an indication of digoxin toxicity?

answer

Bradycardia

question

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

answer

I will use my hands rather than a washcloth to clean the radiation area.

question

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?

answer

Ginkgo biloba can cause an increased risk for bleeding.

question

A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?

answer

Report of a night cough

question

A nurse is providing teaching to a client who has angina and a new prescription for sublingual nitroglycerin. Which of the following instructions should the nurse include?

answer

Store the medication in its original container

question

A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

answer

-Adminiser oxygen via a nonrebreather mask. -Initiate IV therapy with a large bore catheter -Insert NG tube -Administer ranitidine

question

A nurse is planning acre for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care?

answer

Keep a lead-lined container in the client's room

question

A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client experiencing excessive stools. Which of the following findings is an adverse effect of this medication?

answer

Hypokalemia

question

A nurse is assessing a client who has a comminuted fracture of the femur. Which of the following findings should the nurse identify as an early manifestation of a fat embolism.

answer

Dyspnea

question

A home health nurse is providing teaching to a client who has a stage I pressure ulcer on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching?

answer

Change position every hour.

question

A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires a revision of his IV therapy prescription? (Click on the "Exhibit" button for additional information about the client. There are three tabes that contain separate categories of data.) Blood Pressure Prescribed medications Oxygen saturation BUN

answer

BUN

question

A nurse is caring for a client who has a peripherally inserted central catheter (PICC). Which of the following actions should the nurse take to manage the PICC?

answer

Flush the PICC line with 10 mL NS before and after medication administration.

question

A nurse is preparing a client who has supra ventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion?

answer

Digoxin

question

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy?

answer

INR 2.5

question

A nurse admits a client who has anorexia, low-grade fever, night sweats, and productive cough. Which of the following actions should the nurse take first?

answer

Initiate airborne precautions

Adult Med-Surg 2016B – Flashcards

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