All NCLEX Exam: Respiratory, Neuro, GI, Ortho Cardio GI, Endocrine, Integumentary Integumentary. NCLEX. Exam Questions and Answers in 174Pages.

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A client with dermatitis has been prescribed a topical corticosteroid for use on the affected areas, and the nurse has reinforced instructions about the use of this medication. Which statement by the ... client indicates a need for further teaching? Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication? Isotretinoin (Amnesteem, Clavaris) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the health care provider's prescription sheet to see if which therapy has been prescribed for site care? A client with eczema has a prescription for a topical corticosteroid. The nurse cautions the client to use the product carefully in which area where the risk of systemic absorption is greater? The nurse is providing instructions to a client with a diagnosis of scabies regarding the administration of crotamiton (Eurax). Which statement by the client indicates an understanding regarding the application of this medication? The health care provider has prescribed silver sulfadiazine (Silvadene) for the client with a partial-thickness burn, which has cultured positive for gram-negative bacteria. The nurse is reinforcing information to the client about the medication. Which statement made by the client indicates a lack of understanding about the treatments? A client is seen in the clinic for complaints of skin itchiness that has been persistent over the past several weeks. Following data collection, it has been determined that the client has scabies. Lindane is prescribed, and the nurse is asked to provide instructions to the client regarding the use of the medication. How should the nurse teach the client to apply the cream? The nurse is applying a topical glucocorticoid on a client with eczema. The nurse monitors for systemic absorption of the medication if the medication is being applied to which body areas? Coal tar has been prescribed for a client with a diagnosis of psoriasis, and the nurse reinforces instructions to the client about the medication. Which statement by the client indicates a need for further teaching? Isotretinoin (Accutane) is prescribed for a client to treat severe cystic acne. The nurse tells the client that the length of the usual prescribed course of treatment is which? Mafenide acetate (Sulfamylon) is prescribed for the client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which is the most appropriate nursing action? The burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client knowing that which indicates a systemic effect has occurred? Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse is preparing to reinforce instructions to the client and spouse regarding the wound treatment. Which directions should the nurse include in the instructions? The nurse is assigned to care for a client with a leg ulcer. Sutilains (Travase) treatments are prescribed. The nurse should avoid which action when performing the treatment? A client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes that the chest and neck are red, and the client is complaining of pain at the radiation site. How should the nurse interpret this data? A client with severe acne is seen in the clinic, and the health care provider (HCP) prescribes isotretinoin (Amnesteem, Clavaris). The nurse reviews the client's medication record and should contact the HCP if the client is taking which medication? The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption of the medication if the medication is being applied to which body area? A client with a burn injury is applying mafenide acetate (Sulfamylon) to the wound. The client calls the health care provider's office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. Which instructions should the nurse reinforce to the client? The nurse reinforces instructions to a client regarding the use of tretinoin (Retin- A). Which statement by the client indicates the need for further teaching? The nurse is caring for a client with a burn injury to the lower legs. Silver sulfadiazine (Silvadene) is prescribed to be applied to the sites of injury. Which indicates the appropriate method to apply this medication? The nurse is caring for a client diagnosed with scabies who has just been prescribed crotamiton (Eurax). The nurse provides which instruction for application of this medication? Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? The nurse reviews the laboratory results for a client diagnosed with leukemia who is receiving chemotherapy. The nurse notes that the white blood cell (WBC) count is 2000 cells/mm3. The nurse identifies the finding as indicative of which? The nurse in a health care provider's office has scheduled a client with dermatitis to be seen in 1 week for a patch test. The nurse should reinforce instructions to the client to do which action before the procedure? The clinic nurse is collecting data on a client being admitted. The nurse notes that the client is taking azelaic acid (Azelex). Because of the medication prescription the nurse should suspect that the client is being treated for which condition? 1. An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? 2. A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which describes a characteristic of this type of a lesion? 3. The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as malignant melanoma. The nurse should expect which characteristic of this type of lesion to be documented in the client's record? 4. The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching? 5. A client arrives at the emergency department and has experienced frostbite to the right hand. Which should the nurse expect to find when inspecting the client's hand? 6. The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which should the nurse expect to find when checking the client's sacral area? 7. The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present? 8. Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? 9. The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn? 10. The nurse is assigned to care for a client with herpes zoster. Which characteristics should the nurse expect to note when checking the lesions of this infection? 11. The nurse is caring for a client with a diagnosis of pemphigus vulgaris. The nurse understands that which is a characteristic of this condition? 12. A client asks the nurse about the causes of acne. The nurse should respond by making which statement to the client? a. " 13. The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which? 14. The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position should the nurse anticipate being prescribed for the client? 15. The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further teaching? a. "I 16. The nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder? 17. The nurse is reinforcing discharge instructions to a client who had a skin biopsy. Which statement by the client indicates the need for further teaching? 18. The nurse prepares to assist a health care provider examine the client's skin with a Wood's light. Which action should be included in the plan for this procedure? 19. The nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritus. Which client statement indicates the need for further teaching? 20. A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse makes which statement to the client? a. 21. A client is being admitted to the hospital for the treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. Which response should the nurse give to the client's question 22. The nurse prepares to care for a client with acute cellulitis of the lower leg. Which treatment should the nurse anticipate being prescribed for the client? 23. The health care provider suspects a client has herpes zoster. To confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equipment? 24. A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse should make which response to the client? a. "The local anesthetic may cause a burning or stinging sensation." 25. The nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area should provide the best information? 26. The nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further teaching? 27. The nurse prepares to assist in instructing a client about prevention of Lyme disease. Which should the nurse include in the instructions? 28. Following diagnostic evaluation, it has been determined that the client has Lyme disease, stage 2. The nurse understands that which is most indicative of this stage? 29. A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate? 30. A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been determined by which? 31. Which individual is least likely at risk for the development of Kaposi's sarcoma?The nurse reviews a client's chart and notes that the health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which should the nurse expect to note during data collection? 32. The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition? 33. The nurse is checking her clients for skin breakdown. Which client should have the lowest priority for concern in the development of skin breakdown? 34. A client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes that the chest and neck are red, and the client is complaining of pain at the radiation site. How should the nurse interpret this data? a. 35. Sodium hypochlorite (Dakin's solution) is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which in the plan? a. 36. Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication? a. 37. The nurse inspects a pressure ulcer on a client's sacrum and notes that the ulcer has partial-thickness skin loss and the formation of a blister. The nurse should document the ulcer as which category? a. 38. A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the health care provider to prescribe which measure to maximize the effectiveness of this therapy? a. 39. Which individuals is least likely at risk for the development of psoriasis? a. 40. The nurse is assisting in caring for a client with a severe burn who has just received an autograft to the knee area of the right leg. The nurse plans to keep the right leg in which position? a. 41. A client with a burn injury is scheduled for a heterograft. The nurse is preparing the client for the skin grafting, and the client asks the nurse what "heterograft" means. Which is the most appropriate response to the client? a. " 42. The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury would be which percentage? a. 43. A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The "stinger" is still visible in her arm. What should be the nurse's first action? a. 44. A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure, the nurse observes that the flap has a slightly blue hue. The nurse draws which conclusion? a. . 45. A client has a non-infected pressure ulcer on the left heel. The nurse should use which sterile solutions to cleanse the wound as part of a dressing change procedure? a. 46. A client sustains a burn injury to the entire right and left arms, right leg, and anterior thorax. According to the rule of nines, the nurse should determine that this injury constitutes which body percentage? 47. The nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day after injury, the client's vital signs include an oral temperature of 102.8° F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially perform which action? a. 48. The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for further teaching about the measures that will prevent the spread of infection? a. 49. A client, admitted to the emergency department, is suspected of having frostbite of the hands. Which finding should the nurse note in this condition? a. 50. Which clients are at risk for developing skin breakdown? Select all that apply. a. 51. The nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to take which action next in the care of this client? a. 52. A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse reinforces instructions to the client regarding preparation for the test. Which statement by the client indicates an understanding regarding the preparation for this procedure? a. 53. The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse should question which prescription? a. 54. The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure ulcer in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure ulcer? Select all that apply. a. Clean with mild soap and water. b. Encourage adequate nutritional intake. c. Apply a dressing that allows oxygen to pass through. 55. A client with a burn injury begins to cry and states to the nurse, "I don't want anyone seeing me. I look awful." The nurse determines that the client is experiencing which associated problem? a. 56. An older client is transferred to the nursing unit following a graft to a stage 4 pressure ulcer. Which combination of dietary items should the nurse encourage the client to eat to promote wound healing? a. 57. The nurse is preparing a client for skin grafting and identifies that the health care provider has documented that the client is scheduled for a heterograft. The nurse understands that a heterograft used for the burn client is skin from which source? a. 58. During the inspection of a client's skin, the nurse notes redness and an abrasion type wound on the sacrum area. The nurse determines that this finding is indicative of which stage of pressure ulcer? a. 59. After 7 days of wound care, a client who has a well-granulated pressure ulcer reports to the nurse, "I'm feeling better overall." Which nursing intervention most likely contributed to the client's feelings? a. 60. Using the rule of nines, calculate the burn percentage for the client. Refer to the figure; the burned area is the darkly shaded area. Fill in the blank. Refer to figure. 61. A client comes to a health care provider's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick? a. 62. A client with jaundice is complaining of pruritus. Which strategy should the nurse institute to help control the problem and prevent injury? a. . 63. The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse understands that moist desquamation is best described as which? a. 64. The nurse is discussing skin biopsy with a client scheduled for the procedure. The nurse tells the client to expect which amount of discomfort during the procedure? a. 65. The nurse in a health care provider's office has scheduled a client with dermatitis to be seen in 1 week for a patch test. The nurse should reinforce instructions to the client to do which action before the procedure? a. 66. An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage? A 67. A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client should monitor for which sign/symptom during the first 24 hours after the burn injury? a. 68. An older client is complaining of chronic dry skin and occasional pruritus. The nurse reinforces instructions for the client to avoid which skin care regimen that will aggravate the condition? a. 69. A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the health care provider's prescription sheet to see if which therapy has been prescribed for site care? a. 70. The nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse should include on the poster instructions to avoid which activities? a. 71. A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In reinforcing instructions to the client about the medication, the nurse incorporates which aspect of this medication? a. Can stain the skin and hair 72. The nurse is caring for a client on transmission-based precautions who has herpes zoster or shingles. Which are some of the most important skin issues associated with this condition? Select all that apply. a. Full-thickness skin necrosis can result. b. Lesions are very contagious when they are fluid-filled blisters. c. Eruptions can last several weeks, and the severe pain (postherpetic neuralgia) often persists after the lesions have resolved. d. To reduce the risk of transmitting the virus to others, keep clients with lesions separated from other clients until lesions have crusted. 73. The nurse is conducting a focused evaluation on a postoperative client's integumentary system. Which priority objective physical examination assessments are related to inspection? Select all that apply. a. b. Nails for shape, contour, color, thickness and cleanliness c. Skin for color, integrity, scars, lesions, and signs of breakdown d. Facial and body hair for distribution, color, quantity and hygiene 74. The nurse is caring for a postoperative client. The nurse knows that the primary processes of normal wound healing include which phases? Select all that apply. a. Inflammatory or (lag) phase b. Maturation or (remodeling) phase c. Proliferative or (connective tissue repair) phase 75. The nurse is working on a surgical unit. Which surgical clients are most at risk for wound infection? Select all that apply. a. Wound from repair of a perforated appendix b. Gunshot wound that punctured the small intestine c. Traumatic wound to the abdomen and intentionally left open for several days d. Wound related to debridement of a chronic pressure ulcer resulting in a cavity-like defect 76. An African-American client has been admitted for a skin rash on his lower back. Which should the nurse rely on when assessing the skin rash? Select all that apply. a. Palpation b. Induration 1. After a liver biopsy, the nurse should place the client in which position? 2. The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion? 3. The nurse is checking a client for the correct placement of a nasogastric (NG) tube. The nurse aspirates the client's stomach contents and checks its pH level. Which pH value indicates the correct placement of the tube? 4. A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. The LPN should reinforce instructing the client to perform which action? Take and hold a deep breath. 5. The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency? Vitamin B12 6. The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. On review of the postoperative prescriptions, which should the nurse clarify? 7. The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse include in client teaching to help prevent dumping syndrome? 8. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence? 9. The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to see documented in the record? 10. The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to note? Select all that apply. Administer antacids as prescribed Encourage coughing and deep breathing. Administer anticholinergics, as prescribed. 11. It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing? 12. The nurse is reviewing the health care provider's prescriptions written for a client admitted with acute pancreatitis. Which health care provider prescription should the nurse verify if noted in the client's chart? 13. A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid? 14. The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred? 15. Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding? 16. The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa? 17. A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse tells the client to avoid which position that could aggravate the pain? 18. The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse determines that the client understands the instructions given if the client states that which food item is acceptable to include in the diet? 19. A client is admitted to the hospital with acute viral hepatitis. Which sign/symptom should the nurse expect to note based on this diagnosis? A 20. Which infection control method should be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure? 21. A client is admitted to the hospital with viral hepatitis and is complaining of a loss of appetite. In order to provide adequate nutrition, which action does the nurse encourage the client to take? 22. The nurse is caring for a client with acute pancreatitis and a history of alcoholism and is monitoring the client for complications. Which data should be indicative of paralytic ileus? 23. A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention should be appropriate? . 24. The nurse is participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse plans to include which risk factor for colorectal cancer in the material? Personal history of ulcerative colitis or gastrointestinal (GI) polyps A client has undergone esophagogastroduodenoscopy (EGD). The nurse places highest priority on which action as part of the client's care plan? 25. The nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement made by the client supports the diagnosis of gastric ulcer? 26. A client has been diagnosed with acute gastroenteritis. Which diet should the nurse anticipate to be prescribed for the client? 27. A client has asymptomatic diverticular disease. Which type of diet should the nurse anticipate being prescribed? 28. The nurse is caring for a client suspected of having appendicitis. Which should the nurse anticipate will be prescribed for this client? 29. The nurse has given the client with hepatitis instructions about postdischarge management during convalescence. The nurse determines that the client needs further teaching if the client makes which statement? 30. The nurse is assigned to care for a client who had a Sengstaken-Blakemore tube inserted when more conservative treatment failed to alleviate the condition. The nurse should suspect that the client has which diagnosis? 31. The nurse has been caring for a client with a Sengstaken-Blakemore tube. The health care provider arrives on the nursing unit and deflates the esophageal balloon. Following deflation of the balloon, the nurse should monitor the client closely for which? 32. A health care provider places a Miller-Abbott tube in a client who has a bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next? 33. The nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which history is least likely associated with this disease? 34. A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which finding would indicate adequate location of the tube? 35. The nurse is caring for a client with a nasogastric tube. Which observation is most reliable in determining that the tube is correctly placed? 5. 36. A client is admitted to the hospital with a bowel obstruction secondary to a recurrent malignancy, and the health care provider plans to insert a Miller- Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, "I don't want to hear about that. Just let the doctor do it." Based on the client's statement, which is the nurse's best action? 37. The nurse is assisting in planning stress management strategies for the client with irritable bowel syndrome. Which suggestion should the nurse give to the client? 38. A calcium supplement is prescribed for a client with hypoparathyroidism in the management of hypocalcemia. The client arrives at the clinic for a follow- up visit and complains of chronic constipation, and the nurse reinforces instructions to the client about measures to alleviate the constipation. Which comment by the client would indicate a need for further teaching? 39. A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures are most likely to promote coping? Select all that apply. . 40. Which statement by the spouse of a client with end-stage liver failure indicates the need for further teaching by the multidisciplinary team regarding the management of pain? 41. After the deflation of the balloon of a client's Sengstaken-Blakemore tube, the nurse monitors the client closely for which esophageal complication? 42. The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of liver disease. Which medication prescription should the nurse question? 43. A nurse planning care for a client with hepatitis plans to meet the client's safety needs by performing which action? Monitoring prothrombin and partial thromboplastin values 44. The nurse is collecting admission data on the client with hepatitis. Which finding would be a direct result of this client's condition? 45. The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. Which data noted in the record indicate poor absorption of dietary fats? 46. A client is admitted to an acute care facility with complications of celiac disease. Which question should be helpful initially in obtaining information for the nursing care plan? "What is your understanding of celiac disease?" 47. A client is seen in the ambulatory care office for a routine examination. Which statement by the client would be important for the nurse to follow up? "I just lost a family member to gastrointestinal cancer." 48. A client with a possible hiatal hernia complains of difficulty swallowing. Which other sign/symptom is associated with a hiatal hernia? 49. The nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent recurrence of symptoms. Which statement should be included in the teaching? "Avoid lying down for an hour after eating." 50. The nurse documents that a client with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which action? 51. Treatment measures have been implemented for a client with bleeding esophageal varices and have been unsuccessful. The health care provider states that a Sengstaken-Blakemore tube will be used to control the resulting hemorrhage. The nurse prepares for insertion via which route? 52. The nurse is caring for a client with a Sengstaken-Blakemore tube. To prevent ulceration and necrosis of oral and nasal mucosa, the nurse should plan to perform which action? Provide frequent oral and nasal care on a regular basis. 53. A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. Which data would further support this diagnosis? 54. The nurse should include which information when reinforcing home care instructions for a client who has peptic ulcer disease? 55. The nurse is reinforcing dietary instructions for a client with peptic ulcer disease. Which action does the nurse encourage the client to do? 56. The nurse has been reinforcing dietary teaching for a client with gastroesophageal reflux disease (GERD) who has a routine follow-up visit. Which behavior is the best indicator of a successful outcome for this client? 57. A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which items concerning ongoing self-management should the nurse reinforce to the client? Select all that apply. 58. The nurse who is reinforcing instructions to a client following gastric resection should include which suggestions? Select all that apply. Take action to prevent dumping syndrome 59. The nurse reinforces instructions to a client following a gastrectomy about the signs and symptoms of pernicious anemia, knowing what information? Regular monthly injections of vitamin B12 will prevent this complication. 60. The nurse who is assisting in the care of a client within the first 24 hours following a total gastrectomy for gastric cancer should avoid which intervention? 61. The nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to absorb food. While carrying out this function, the nurse recalls that absorption is defined as which? The transfer of digested food molecules from the GI tract into the bloodstream 62. A health care provider asks the nurse to obtain a Salem Sump tube for gastric intubation. The nurse should correctly select which tube from the unit storage area? 63. The nurse has assisted in the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse plans to set the suction to which pressure? Low and intermittent 64. A client has had a partial gastrectomy and the nurse is reinforcing discharge instructions. The nurse should tell the client about the need for which? Select all that apply. Calcium supplements Vitamin B12 injections 65. A client in the emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply. Milk of magnesia Heat pad to the abdomen 66. The nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse should place the client in which position during and after the feedings? 67. The nurse is reinforcing discharge instructions to a client who has had a total gastrectomy. The nurse tells the client about the importance of returning to the health care clinic as scheduled for which priority assessment? 68. The nurse assigned to care for a client with cirrhosis reviews the medical record and notes that the client has difficulty maintaining an effective breathing pattern due to pressure on the diaphragm. The nurse plans care knowing that which client position will best assist in facilitating breathing? A client arrives at the emergency department and complains of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the health care provider's prescriptions. Which prescription should the nurse question if written on the health care provider's prescription form? 69. The nurse is caring for a client with a nasogastric (NG) tube and tests the pH of the aspirate to determine correct placement. The nurse notes that the pH is 5. Which information does this indicate? Placement of the NG tube is accurate. 70. A generally healthy 63-year-old man is seen in the health care provider's office for a routine examination. Which statement made by the client is important for the nurse to follow up on? ." 71. A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse should gather further information about the presence of which sign or symptom? 72. The nurse is teaching a client who is newly diagnosed with a hiatal hernia about measures to prevent recurrence of symptoms. The nurse should make which accurate statement to the client? "Be sure to sleep with your head elevated in bed." 73. The nurse is reinforcing discharge instructions to a client with a hiatal hernia. Which should the nurse include in the teaching session? Select all that apply. Wait at least 1 hour after meals to perform chores. Be sure to elevate the head of the bed during sleep. 74. The nurse is reinforcing instructions to a client about insertion of a Sengstaken-Blakemore tube. Which statement by the client indicates an understanding of the teaching? 75. The nurse is assisting in caring for a client with a Sengstaken-Blakemore tube. Which article should the nurse place at the bedside? 76. A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting, and a gastric ulcer is suspected. The nurse should gather which additional supportive data from the client for this diagnosis? 77. The nurse should include which instruction in a teaching plan for a client who has peptic ulcer disease? 78. The nurse is reinforcing dietary instructions for a client with peptic ulcer disease. Which statement made by the client indicates a need for further teaching? 79. A client has undergone subtotal gastrectomy and the nurse is preparing the client for discharge. Which item should be included when reinforcing instructions to the client about ongoing self-management? Smaller, more frequent meals should be eaten 80. The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse should include which instruction? Take actions to prevent dumping syndrome. 81. The nurse provides information to a client following a gastrectomy who is now diagnosed with pernicious anemia. Which instructions about pernicious anemia should the nurse reinforce? Select all that apply. hygiene. Use additional lightweight blankets as needed. Check blood serum vitamin B12 levels every 1 to 2 years. 82. The nurse is caring for a client within the first 24 hours following a total gastrectomy for gastric cancer. During this time frame, on which intervention should the nurse focus? 83. The nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to digest food. Which processes are involved in the complete digestive process? Select all that apply. Chemical Absorption Mechanical Active transport 84. A licensed practical nurse (LPN) is helping a registered nurse (RN) conduct an abdominal assessment. The LPN assists the client into which position? 85. A health care provider asks the nurse to obtain a Salem Sump tube for gastric intubation. The nurse selects which tube from the unit storage area? 86. The nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression. Which settings will the health care provider prescribe? Select all that apply. Intermittent 87. The nurse is working with a client diagnosed with anorexia nervosa. The nurse plans care, focusing on which as the primary problem? Impaired nutritional status 88. A client has been diagnosed with chronic gastritis and has been told that there is too little intrinsic factor being produced. The nurse tells the client that which therapy will be prescribed to treat the problem? 89. The nurse is caring for a client in the emergency department who has right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescription? 90. The nurse is performing an abdominal assessment on a client. The nurse interprets that which finding is abnormal and should be reported to the registered nurse (RN) or health care provider? 91. The nurse is interpreting the laboratory results of a client who has a history of chronic ulcerative colitis. Which result indicates a complication of ulcerative colitis? 92. A client diagnosed with pernicious anemia asks the nurse what caused the deficiency. The nurse replies that it is likely a result of which condition that is part of the client's health history? 93. The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning and all connections are snug. The tube is secured properly and does not appear to have been dislodged. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. The nurse analyzes this problem as which? 94. The nurse is preparing to administer a soapsuds enema to a client. Into which position does the nurse place the client to administer the enema? Refer to figure. 3 95. A postgastrectomy client is at high risk for hyperglycemia related to uncontrolled gastric emptying of fluid and food into the small intestine (dumping syndrome). Because of this risk, the nurse plans to monitor which data? 96. The nurse is caring for a client with pneumonia with a history of bleeding esophageal varices. Based on this information, the nurse plans care, knowing that which could result in a potential complication? 97. A client is admitted to the hospital with a diagnosis of acute pancreatitis. The nurse plans care, knowing that which problem occurs with this disorder? Alteration in comfort related to abdominal pain 98. A postgastrectomy client who is being discharged from the hospital tells the nurse, "I hope my stomach problems are over. I need to get back to work right away. I've missed a lot of work, and I'm really behind. If I don't get my act together, I may lose my job." Based on the client's statement, the nurse determines that at this time, it is appropriate to discuss which topic? 99. The nurse gathers data from a client admitted to the hospital with gastroesophageal reflux disease (GERD) who is scheduled for a Nissen fundoplication. Based on an understanding of this disease, the nurse determines that the client may be at risk for which complication? Aspiration 100. The nurse analyzes the results of laboratory studies performed on a client with peptic ulcer disease (PUD). Which laboratory value would indicate a complication associated with the disease? 101. The nurse is admitting a client to the hospital for the treatment of dehydration. The client reports nausea, vomiting, diarrhea, and cramping for the past week. The nurse asks the client about medications he is taking. The client denies taking prescription medications but states he has been taking some herbs given to him by his cousin. The nurse alerts the health care provider when the client states he has been taking which herb? Senna 102. The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed the nasogastric tube to be discontinued. To determine the client's readiness for discontinuation of the nasogastric tube, which measure should the nurse check? 103. A sexually active 20-year-old client has developed viral hepatitis. Which statement made by the client would indicate a need for teaching? "I can never drink alcohol again." 104. A client is admitted to the hospital with severe jaundice and is having diagnostic testing. Because the client has no complaints of fatigue, the client is encouraged to ambulate in the hall to maintain muscle strength. The client paces around the room but will not enter the hall. Which problem most likely is the reason for the client's reluctance to walk in the hall? Feeling self-conscious about appearance 105. A client with viral hepatitis states to the nurse, "I am so yellow." The nurse should take which action? Assist the client in expressing feelings 106. The nurse is reviewing the medication record of a client with acute gastritis. Which medication noted on the client's record should the nurse question? Ibuprofen (Motrin) 107. A client with peptic ulcer disease is scheduled for a pyloroplasty, and the client asks the nurse about the procedure. The nurse bases the response on which information? 108. A client with a peptic ulcer is scheduled for a vagotomy, and the client asks the nurse about the purpose of this procedure. The nurse tells the client that a vagotomy serves which purpose? Reduces the stimulation of acid secretions 109. The nurse is instructing a client who had a herniorrhaphy about how to reduce postoperative swelling following the procedure. Which should the nurse suggest to the client to prevent swelling? 110. The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. Which is the appropriate nursing action? 111. A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse should time the medication so that each dose is taken at which time? 30 minutes before meals 112. A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. To aid the client in symptom management, the nurse suggests which diet? 113. A client is resuming a diet after partial gastrectomy. To minimize complications, the nurse should tell the client to avoid which practice? A 114. The nurse has assisted the health care provider with a liver biopsy, which was done at the bedside. Upon completion of the procedure, the nurse assists the client into which position? 115. A licensed practical nurse (LPN) is assisting in the insertion of a nasogastric (NG) tube for an adult client. The LPN helps determine the correct length to insert the tube by performing which measurement? From the tip of the client's nose to the earlobe and then down to the xiphoid process 116. A postoperative client has regained bowel sounds and is ready to start a clear liquid diet. The nurse is told that the health care provider has written a prescription to remove the nasogastric (NG) tube. The nurse assists in the procedure and asks the client to do which during tube removal? . 117. The nurse has a prescription to give 30 mL of an antacid to a client through a nasogastric (NG) tube that is connected to wall suction. The nurse should do which action to perform this procedure correctly? Clamp the NG tube for 30 minutes following administration of the medication. 118. The nurse is caring for a client with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times? 119. The nurse will be providing postprocedure care to a client who has undergone esophagogastroduodenoscopy (EGD). The nurse should plan to do which action first? A health care provider asks the licensed practical nurse (LPN) to reinforce preprocedure instructions to a client who will undergo a barium swallow (esophagography) in a few days. The LPN should include which instruction in this discussion? Remove all metal and jewelry before the test. 120. The nurse notes that the medical record of a client with cirrhosis states that the client has asterixis. To verify this information the nurse should take which action? 121. A health care provider is about to perform a paracentesis on a client with abdominal ascites. The nurse should assist the client to assume which position? Upright 122. A client is receiving bolus feedings via a nasogastric tube. The nurse plans to place the client's head of the bed (HOB) in which optimal position once the feeding is completed? 123. A client receiving a high cleansing enema complains of pain and cramping. The nurse should take which corrective action? . 124. The nurse is getting a client who underwent umbilical hernia repair ready for discharge. The nurse tells the client that it is important to continue to do which action after discharge? 125. A client presents to the urgent care center with complaints of abdominal pain. Suddenly the client vomits bright red blood. The nurse takes which immediate action? 126. The nurse is reinforcing medication instructions to a client with peptic ulcer disease. Which represents correct information given by the nurse? 127. A client with acute pancreatitis is experiencing severe pain. After noting an absence of an analgesic prescription on the health care provider prescription sheet, the nurse should suggest contacting the health care provider to request a prescription for which medication? 128. An acutely ill looking client arrives at the emergency department. The client complains of "the worst pain I ever felt in my belly. I can't get comfortable." The client is quiet but with each movement the client cries out in pain. The nurse suspects the client has peritonitis. Which data should the nurse collect to assist in validating this suspicion? Select all that apply. Inspect the abdomen for rigidity. Check for the presence of hiccups. Inspect the client's mucous membranes. 129. A client arrives at the emergency department complaining of severe abdominal pain and is placed on NPO status. During a quick assessment the nurse observes that the client has both Cullen's sign and Grey Turner's sign and pancreatitis is suspected. The nurse should perform the following actions/prescriptions in which priority order? Arrange the actions in the order they should be performed. All options must be used. Ensure the client receives intravenous pain medication. Hydrate the client with intravenous fluids. Place a nasogastric tube. Client is NPO (nothing by mouth). Inquire about when pain occurs and previous history including medications and alcohol. 130. A morbidly obese client, 3 days postoperative gastric bypass surgery, comes to the clinic complaining of pain. The nurse suspects that the client has an anastomotic leak requiring hospitalization. Which findings validate this suspicion? Select all that apply. Abdominal pain Unexplained tachycardia 131. The nurse is reinforcing instructions to a client and his family about alcohol abuse and chronic cirrhosis. The nurse knows to include which essential elements in the discharge teaching guide? Select all that apply. Teach symptoms of complications and when to seek prompt medical attention. Explain that cirrhosis of the liver is a chronic illness and the importance of continuous health care. Avoid spicy and rough foods and activities that increase portal pressure such as straining at stool, coughing, sneezing and vomiting. ORTHOPEDIC NCLEX 1. The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? 2. A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings? 3. A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? 4. The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place? 5. The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? 6. The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? Phlebitis of the vein 7. The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item? 8. A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? 9. The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately? 10. The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? A decrease in oozing from puncture sites and gums 11. A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? . 12. The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? Have the client void immediately before surgery. 13. The nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. Which action should alleviate the client's fears and misconceptions about surgery? 14. The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the health care provider and anticipates that the provider will prescribe which? 15. The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which nursing action should be performed? Continue to monitor the vital signs. 16. A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery? Patency of the airway 17. The nurse is monitoring an adult client for postoperative complications. Which is mostindicative of a potential postoperative complication that requires further observation? A 18. The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem? 19. The nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which action should the nurse avoid in the care of the drain? Secure the drain by curling or folding it and taping it firmly to the body. 20. The nurse checks the client's surgical incision for signs of infection. Which is indicative of a potential infection? 21. The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which should be the initial action by the nurse? Apply a sterile dressing soaked with normal saline to the wound. 22. The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 23. The nurse is assisting with caring for a client with abruptio placenta. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first? 24. A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action? . 25. The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item? 26. The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action? Administer oxygen by face mask, as prescribed. 27. The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action? 28. The nurse assists in planning care for a child who sustained a burn injury. The nurse plans care based on which accurate statement? Lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner. 29. The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Which interventions should the nurse perform? Select all that apply. Prepare to administer morphine sulfate. Prepare to administer intravenous fluids. Prepare to administer 100% oxygen by face mask. 30. The client arrives at the emergency department after a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client? 100% oxygen via a tight-fitting, nonrebreather face mask 31. The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless, and his color is becoming dusky. The nurse should interpret this data as indicating which? The burn has probably caused laryngeal edema, which has occluded the airway. 32. The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation? 33. A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? 34. The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action? Stay with the person and encourage the person to remain still 35. The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? Immobilize the leg before moving the client. 36. A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function? Provides comfort by reducing muscle spasms and provides fracture immobilization 37. The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? 38. The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first? Check the client's alignment in bed. 39. The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity? Performing active range of motion (ROM) to the right ankle and knee 40. The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection? 41. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition? The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention? Elevate the leg on pillows continuously for 24 to 48 hours. 42. A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention? 43. The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply. . 44. The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position? 45. The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action? 46. The nurse is caring for a client with fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? Elevating the limb and applying ice to the affected leg 47. A client is being discharged home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement? " 48. The client is brought to the emergency department and is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action? Maintaining a patent airway 49. The nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client's bedside? Suction equipment 50. The nurse notes the appearance of skin breakdown on a client's hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure. 51. A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate? "You are concerned that you don't feel any better after surgery?" 52. A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further skin care instructions are required if the client makes which statement? "I need to scrub the skin vigorously with soap and water." 53. A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which as a high-risk area for pressure and breakdown? 54. A client has been placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction? Slightly elevating the foot of the bed 55. A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy? 56. The health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood contains 250 mL, and the drop factor is 10 gtt/1 mL. Although an infusion pump will be used, the registered nurse asks the licensed practical nurse (LPN) to assist with monitoring the flow rate during the infusion. The LPN monitors the flow rate, knowing that how many gtt/min should infuse? Fill in the blank. Round the answer to the nearest whole number. 57. The nurse monitors a postoperative client for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication? Increasing restlessness 58. The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out? To allow the surgical team a chance to verbally verify its agreement about the client's name, the 59. The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action? The surgeon marking the area of the operative procedure 60. A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. Notify the registered nurse. Document the client's complaint. Instruct the client to remain quiet. Prepare the client for wound action should be the priority for this client? Determine vital signs. 61. The nurse is assisting in monitoring the condition of a client after pericardiocentesis for cardiac tamponade. Which observation indicates that the procedure was unsuccessful? 62. The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is non-reddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 cells/mm3. Which interpretation does the nurse make of these findings? The incision line is slightly edematous but shows no active signs of infection. 63. A client is receiving thrombolytic therapy by continuous infusion. The client suddenly becomes extremely anxious and complains of itching. The nurse hears stridor, and on examination of the client, notes generalized urticaria and hypotension. Which should be the priority action of the nurse? 64. A family of a spinal cord–injured client rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic, with a flushed face and neck, and complains of a severe headache. The pulse is 40 beats per minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, knowing that the client is experiencing which? 65. A client with diabetes mellitus has had a right below-knee amputation. The nurse should be especially vigilant in monitoring for which complication related to the client's history? 66. A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How does the nurse correctly interpret the client's statement? "It is a normal response and indicates the presence of phantom limb sensation." 67. The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client needs further teaching if the client verbalizes which should be done? Get out of bed by sitting straight up and swinging the legs over the side of the bed 68. A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The nurse should take which action? 69. A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate? A 70. A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs further teaching if the student states that which is an associated risk factor? 71. The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium? 72. The nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which is a sign/symptom associated with this disorder? 73. A client is treated in the health care provider's office for a sprained ankle. Before sending the client home, the nurse plans to reinforce instructions to the client about which item to avoid in the next 24 hours? 74. The nurse has reinforced instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client makes which statement? "I'll report fever or site inflammation to the health care provider." 75. The nurse in the health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client? "These sensations dissipate over several months and usually resolve after 1 year." 76. A client who has been receiving total parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is most likely experiencing which? 77. A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On data collection, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which has occurred? 78. One unit of packed red blood cells is infusing into a client over a 4-hour period. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt) per 1 mL. The nurse determines that the flow rate should be set at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. 79. The nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. Which action should the nurse immediately perform? Exert upward pressure against the presenting part with gloved fingers. 80. A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the health care provider diagnoses a pulmonary embolism. Which interventions apply to the care of this client? Select all that apply. Prepare to start an intravenous (IV) line 81. The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which in the care of the client? Select all that apply. Ensure the client doesn't sit or stand for long periods of time. Ensure the client doesn't cross the legs past the midline of the body. Ensure the client uses assistive/adaptive devices with activities of daily living. 82. Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed? Which is a correct response by the student? 83. The nurse is checking the date of an intravenous (IV) insertion in a client. The insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site should be changed on which date? 84. A child is admitted to the burn unit with partial- and full-thickness burns over 35% of the body. The nurse assisting in caring for the child develops the plan of care. Which nursing intervention is the priority? 85. The nurse is assisting in providing surgical instructions to a preoperative client. Which instruction would be most appropriate to include in the preoperative plan of care? 86. A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the child should prepare to assist in administering which medication? 87. The emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin). Which should the nurse anticipate as the likely initial treatment? The administration of activated charcoal 88. The nurse is assisting with care for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury? Leakage of clear fluid from the nose 89. The nurse is assisting in preparing to administer acetylcysteine to a client with an overdose of acetaminophen (Tylenol). How should the nurse administer the medication? Mix the medication in a flavored ice drink, and allow the client to drink the medication through a straw. 90. The nurse is collecting physical data of the musculoskeletal system on an assigned client. The nurse should document the presence of which as a normal finding? 91. The nurse is providing care for the client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client? 92. A client with possible rib fracture has never had a chest x-ray. The nurse should plan to tell the client which statement about the procedure? "It is necessary to remove jewelry and any other metal objects." 93. A client seeks treatment in the emergency department for a lower leg injury. There is visible deformity to the lower aspect of the leg, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. How should the nurse interpret this injury? 94. The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room? 95. The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further teaching if the client makes which statement about the casting? 96. The nurse is planning to teach a client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion should the nurse include in the teaching plan? 97. A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. How should the nurse correctly respond to this question? 98. The nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast about cast care at home. The nurse determines that the client needs further teaching if the client makes which statement? "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting." 99. A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse would be most useful in trying to provide good skin care to the client? Asking the client to pull up on a trapeze to lift the hips off the bed 100. A client has Buck's extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device? Inspecting the skin on the right leg at least once every 8 hours 101. A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse should respond knowing that which can occur if the crutches rest underneath the arm? 102. The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches? 103. The nurse has reinforced the client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching? "Crutch tips will not slip, even when wet." 104. A client has slight weakness in the right leg. Which type of mobility device would benefit the client the most? 105. A client who has experienced a stroke (brain attack) has partial hemiplegia of the left leg. The straight-leg cane formerly used by the client is no longer sufficient. Which device would suit the client better if greater support and stability is needed? Quad cane 106. A client with right-sided weakness needs to learn how to use a cane. How should the nurse teach the client to position the cane? 107. A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. How should the nurse tell the client to provide greater reassurance? The cane has a flared tip with concentric rings to provide stability. 108. The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome? Bleeding and swelling cause increased pressure in an area that cannot expand. 109. The nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which data obtained by the nurse could place the client at increased risk for disturbed thought processes? Eyeglasses left at home 110. The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client? 111. A client who has had a right total knee replacement asks the nurse how long the right leg must be kept in the continuous passive motion (CPM) machine. How should the nurse answer this question for the client? As much as tolerated while in bed 112. The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which to protect the knee joint? Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting. 113. A client is complaining of low back pain, with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated with which action? 114. A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which to maintain client safety after this procedure? Overhead trapeze 115. A client who has had spinal fusion and insertion of hardware is extremely concerned about the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to work. The nurse understands that the client's needs should best be addressed by referral to which service? 116. The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client? The device is applied before getting out of bed in the morning. 117. A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful? Showing the client the cast cutter and explaining how it works 118. A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem? 119. The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care, knowing that this condition usually affects which bones? Axial skeleton including the vertebrae 120. The nurse plans dietary measures for a client with osteomalacia, knowing that the client is deficient in which vitamin? 121. The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure? Maintaining body weight at or above minimum recommended levels 122. The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client? Uric acid level of 8 mg/dL 1. The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? Vital signs 2. A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings? 3. A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? The blood bank 4. The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place? 5. The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? 6. The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? Phlebitis of the vein 7. The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item? Sterile 2 × 2 gauze 8. A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? 15 minutes 9. The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately? Chills, itching, or rash 10. The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? A decrease in oozing from puncture sites and gums 11. A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? Call the poison control center. 12. The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? Have the client void immediately before surgery. 13. The nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. Which action should alleviate the client's fears and misconceptions about surgery? Ask the client to discuss information known about the planned surgery. 14. The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the health care provider and anticipates that the provider will prescribe which? Discontinue the aspirin 48 hours before the scheduled surgery. 15. The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which nursing action should be performed? . 16. A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery? 17. The nurse is monitoring an adult client for postoperative complications. Which is mostindicative of a potential postoperative complication that requires further observation? A urinary output of 20 mL/hour 18. The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem? 19. The nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which action should the nurse avoid in the care of the drain? Secure the drain by curling or folding it and taping it firmly to the body. 20. The nurse checks the client's surgical incision for signs of infection. Which is indicative of a potential infection? 21. The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which should be the initial action by the nurse? Apply a sterile dressing soaked with normal saline to the wound. 22. The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 23. The nurse is assisting with caring for a client with abruptio placenta. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first? Turn the client onto her side. 24. A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action? Notify the registered nurse (RN) immediately. 25. The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item? 26. The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action? Administer oxygen by face mask, as prescribed. 27. The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action? 28. The nurse assists in planning care for a child who sustained a burn injury. The nurse plans care based on which accurate statement? Lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner. 29. The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Which interventions should the nurse perform? Select all that apply. . Prepare to administer intravenous fluids. Prepare to administer 100% oxygen by face mask. 30. The client arrives at the emergency department after a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client? 100% oxygen via a tight-fitting, nonrebreather face mask 31. The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless, and his color is becoming dusky. The nurse should interpret this data as indicating which? The burn has probably caused laryngeal edema, which has occluded the airway. 32. The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation? 33. A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? 34. The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action? Stay with the person and encourage the person to remain still 35. The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? 36. A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function? Provides comfort by reducing muscle spasms and provides fracture immobilization 37. The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? 38. The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first? 39. The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity? Performing active range of motion (ROM) to the right ankle and knee 40. The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection? Presence of a "hot spot" on the cast 41. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition? Impaired tissue perfusion 42. The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention? Elevate the leg on pillows continuously for 24 to 48 hours. 43. A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention? Petaling the cast edges with adhesive tape 44. The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply. 45. The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position? 8 inches to the front and side of the client's toes 46. The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action? Moves the cane when the right leg is moved 47. The nurse is caring for a client with fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? Elevating the limb and applying ice to the affected leg 48. A client is being discharged home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement? 49. The client is brought to the emergency department and is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action? 50. The nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client's bedside? Suction equipment 51. The nurse notes the appearance of skin breakdown on a client's hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure. 52. A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate? "You are concerned that you don't feel any better after surgery?" 53. A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further skin care instructions are required if the client makes which statement? 54. A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which as a high-risk area for pressure and breakdown? 55. A client has been placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction? Slightly elevating the foot of the bed 56. A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy? 57. The health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood contains 250 mL, and the drop factor is 10 gtt/1 mL. Although an infusion pump will be used, the registered nurse asks the licensed practical nurse (LPN) to assist with monitoring the flow rate during the infusion. The LPN monitors the flow rate, knowing that how many gtt/min should infuse? Fill in the blank. Round the answer to the nearest whole number. 58. The nurse monitors a postoperative client for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication? 59. The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out? To allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure, and the site 60. The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action? The surgeon marking the area of the operative procedure 61. A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. Notify the registered nurse. Document the client's complaint. . 62. A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. Which nursing action should be the priority for this client? 63. The nurse is assisting in monitoring the condition of a client after pericardiocentesis for cardiac tamponade. Which observation indicates that the procedure was unsuccessful? 64. The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is non-reddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 cells/mm3. Which interpretation does the nurse make of these findings? The incision line is slightly edematous but shows no active signs of infection. 65. A client is receiving thrombolytic therapy by continuous infusion. The client suddenly becomes extremely anxious and complains of itching. The nurse hears stridor, and on examination of the client, notes generalized urticaria and hypotension. Which should be the priority action of the nurse? 66. A family of a spinal cord–injured client rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic, with a flushed face and neck, and complains of a severe headache. The pulse is 40 beats per minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, knowing that the client is experiencing which? 67. A client with diabetes mellitus has had a right below-knee amputation. The nurse should be especially vigilant in monitoring for which complication related to the client's history? 68. A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How does the nurse correctly interpret the client's statement? "It is a normal response and indicates the presence of phantom limb sensation." 69. The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client needs further teaching if the client verbalizes which should be done? Get out of bed by sitting straight up and swinging the legs over the side of the bed 70. A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The nurse should take which action? 71. A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate? 72. A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs further teaching if the student states that which is an associated risk factor? 73. The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium? Pork 74. The nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which is a sign/symptom associated with this disorder? Dull aching pain in the affected joints 75. A client is treated in the health care provider's office for a sprained ankle. Before sending the client home, the nurse plans to reinforce instructions to the client about which item to avoid in the next 24 hours? Application of a heating pad 76. The nurse has reinforced instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client makes which statement? 77. The nurse in the health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client? "These sensations dissipate over several months and usually resolve after 1 year." 78. A client who has been receiving total parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is most likely experiencing which? 79. A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On data collection, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which has occurred? 80. One unit of packed red blood cells is infusing into a client over a 4-hour period. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt) per 1 mL. The nurse determines that the flow rate should be set at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. 81. The nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. Which action should the nurse immediately perform? Exert upward pressure against the presenting part with gloved fingers. 82. A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the health care provider diagnoses a pulmonary embolism. Which interventions apply to the care of this client? Select all that apply. . Prepare to administer morphine sulfate. Prepare to start an intravenous (IV) line 83. The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which in the care of the client? Select all that apply. Ensure the client doesn't sit or stand for long periods of time. Ensure the client doesn't cross the legs past the midline of the body. Ensure the client uses assistive/adaptive devices with activities of daily living. 84. Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed? Which is a correct response by the student? 85. The nurse is checking the date of an intravenous (IV) insertion in a client. The insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site should be changed on which date? 86. A child is admitted to the burn unit with partial- and full-thickness burns over 35% of the body. The nurse assisting in caring for the child develops the plan of care. Which nursing intervention is the priority? 87. The nurse is assisting in providing surgical instructions to a preoperative client. Which instruction would be most appropriate to include in the preoperative plan of care? Coughing and deep breathing exercises 88. A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the child should prepare to assist in administering which medication? 89. The emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin). Which should the nurse anticipate as the likely initial treatment? The administration of activated charcoal 90. The nurse is assisting with care for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury? 91. The nurse is assisting in preparing to administer acetylcysteine to a client with an overdose of acetaminophen (Tylenol). How should the nurse administer the medication? Mix the medication in a flavored ice drink, and allow the client to drink the medication through a . 92. The nurse is collecting physical data of the musculoskeletal system on an assigned client. The nurse should document the presence of which as a normal finding? Hypertrophy on the client's dominant side 93. The nurse is providing care for the client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client? Administering intramuscular opioid analgesics 94. A client with possible rib fracture has never had a chest x-ray. The nurse should plan to tell the client which statement about the procedure? "It is necessary to remove jewelry and any other metal objects." 95. A client seeks treatment in the emergency department for a lower leg injury. There is visible deformity to the lower aspect of the leg, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. How should the nurse interpret this injury? 96. The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room? 97. The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further teaching if the client makes which statement about the casting? The client may bear weight on the cast in 30 minutes. 98. The nurse is planning to teach a client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion should the nurse include in the teaching plan? 99. A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. How should the nurse correctly respond to this question? 100. The nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast about cast care at home. The nurse determines that the client needs further teaching if the client makes which statement? "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting." 101. A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse would be most useful in trying to provide good skin care to the client? Asking the client to pull up on a trapeze to lift the hips off the bed 102. A client has Buck's extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device? Inspecting the skin on the right leg at least once every 8 hours 103. A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse should respond knowing that which can occur if the crutches rest underneath the arm? Injury to the brachial plexus nerves 104. The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches? 105. The nurse has reinforced the client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching? 106. A client has slight weakness in the right leg. Which type of mobility device would benefit the client the most? Straight-leg cane 107. A client who has experienced a stroke (brain attack) has partial hemiplegia of the left leg. The straight-leg cane formerly used by the client is no longer sufficient. Which device would suit the client better if greater support and stability is needed? Quad cane 108. A client with right-sided weakness needs to learn how to use a cane. How should the nurse teach the client to position the cane? Left hand, and 6 inches lateral to the left foot 109. A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. How should the nurse tell the client to provide greater reassurance? The cane has a flared tip with concentric rings to provide stability. 110. The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome? 111. The nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which data obtained by the nurse could place the client at increased risk for disturbed thought processes? 112. The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client? Pillow to keep the right leg abducted during turning 113. A client who has had a right total knee replacement asks the nurse how long the right leg must be kept in the continuous passive motion (CPM) machine. How should the nurse answer this question for the client? 114. The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which to protect the knee joint? Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting. 115. A client is complaining of low back pain, with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated with which action? 116. A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which to maintain client safety after this procedure? Overhead trapeze 117. A client who has had spinal fusion and insertion of hardware is extremely concerned about the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to work. The nurse understands that the client's needs should best be addressed by referral to which service? 118. The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client? The device is applied before getting out of bed in the morning. 119. A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful? Showing the client the cast cutter and explaining how it works 120. A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem? 121. The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care, knowing that this condition usually affects which bones? Axial skeleton including the vertebrae 122. The nurse plans dietary measures for a client with osteomalacia, knowing that the client is deficient in which vitamin? 123. The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure? Maintaining body weight at or above minimum recommended levels 124. The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client? 120.) A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem? Concerns about appearance 121.) The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care, knowing that this condition usually affects which bones? Axial skeleton including the vertebrae 122.) The nurse plans dietary measures for a client with osteomalacia, knowing that the client is deficient in which vitamin? 123.) The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure? 124.) The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client? Uric 125.) The nurse is caring for a client with osteoarthritis. The nurse monitors the client, knowing that which is a sign/symptom associated with the disorder? Pain that 126.) The nurse is assigned to care for a client who has experienced uterine rupture. The nurse plans care knowing that which is the priority concern in caring for the client? Impaired gas exchange 127.) The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicates to the nurse favorable resolution of the fat embolus? Clear chest x-ray 128.) A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site? 129.) The nurse has provided instructions to a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which early symptom of compartment syndrome? Numbness and tingling in the fingers 130.) A client is brought to the emergency department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse should anticipate which observation on inspection of the client's leg? 131.) A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted? The client advances the walker with reciprocal motion. 132.) A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. Which action should the nurse implement? . 133.) The nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse should immediately perform which action? compression bandage 134.) A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which? Muscle spasm in the area of the herniated disk 135.) The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed in which position? In semi-Fowler's position with the knee gatch slightly raised 136.) The nurse is caring for a client who has had spinal fusion with insertion of hardware. The nurse should be especially concerned with which finding? 137.) The nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which statement? "I'm doing these exercises so I can begin to fasten my buttons and dress myself again." 138.) The nurse is caring for a client with a diagnosis of osteoarthritis. Which would be least helpful for the client? Increasingly vigorous and high-impact exercise 139.) The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which is the most appropriate action? Remove the IV. 140.) The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery? 141.) The nurse is preparing to reinforce instructions to a client regarding how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. Which priority data would be included? The client's vital signs, muscle strength, and previous activity level 142.) A client who sustained an inhalation injury arrives in the emergency department. On data collection, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing which? 143.) A client is brought to the emergency department following a smoke inhalation injury. The initial nursing action is to prepare the client to receive which treatment? 100% humidified oxygen by face mask 144.) An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. Which data would indicate that the client sustained a respiratory injury as a result of the burn? 145.) The nurse is preparing a plan of care for a client in skeletal leg traction with an overbed frame. Which nursing intervention should be included in the plan of care to assist the client with positioning in bed? 146.) The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which action should the nurse take next? Notify the registered nurse 147.) The nurse is caring for a client who has a cast applied to the left lower leg. On data collection, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate? . 148.) A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands what is necessary in this situation and prepares the client for which treatment? Emergency surgery 149.) Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table? Apply the safety strap 2 inches above the knees. 150.) During a surgical procedure, the nurse prevents a client's extremities from dangling over the sides of the table, knowing that this action may cause what? Nerve and muscle damage 151.) The nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which is an expected measurement determined by the pulse oximeter? Oxygen saturation 95% to 100% 152.) The nurse is providing care to a client with this type of cast. (Refer to figure.) The nurse documents that the nurse has which? A hip spica cast 153.) The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from a nurse to monitor drainage and perform dressing changes. Which statement by the client indicates a need for further teaching? "I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home. 154.) The nurse is caring for a client who had a below-the-knee amputation of the right leg. A cast that was placed on the residual limb has fallen off. Which action should the nurse take immediately? Wrap the residual limb with an elastic compression bandage. 155.) The nurse assists in administering first aid to a client who has been bitten by a snake on the right leg. The nurse should take which action? Ensure that the victim is lying down, and remove restrictive items. 156.) The nurse receives a telephone call from a neighbor who states that her child was found sitting on the floor near the kitchen sink playing with several bottles of cleaning fluids. The bottles of cleaning fluid were opened and spilled on the child and the floor, and the mother suspects that the child may have consumed some of the cleaning fluid. Which action should the nurse tell the mother to do immediately? Call the area poison control center. 157.) The nurse discusses emergency nursing measures that are implemented at the site of an injury with a nursing student. Which initial action does the nurse tell the student to perform in the event of carbon monoxide poisoning? Carry the client to fresh air. 158.) A client who sustained a severe burn injury is brought to the emergency department. The nurse prepares to implement which immediate action? Administer 100% humidified oxygen. 159.) The nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should perform which immediate action? Notify the registered nurse 160.) The nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for what data first? A patent airway 161.) The nurse notes that a client who is attached to a cardiac monitor suddenly develops atrial fibrillation at a rate of 130 beats per minute. The nurse immediately notifies the registered nurse and prepares the client for which initial intervention? Administration of a calcium channel blocker 162.) A client who experienced ventricular fibrillation has just been defibrillated. Following the defibrillation, which action should the nurse take immediately? Resume cardiopulmonary resuscitation (CPR). 163.) The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. Based on these findings, the initial nursing action is which? Remove the IV. 164.) The nurse hangs a 1000-mL bag of intravenous (IV) fluid on an assigned client. Forty-five minutes later, the nurse notes that the client is complaining of a pounding headache, is dyspneic, is apprehensive, and has an increased pulse rate. The IV bag has 500 mL remaining. The nurse should take which action? Shut off the IV infusion. 165.) A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, Which is the initial nursing assessment? Vital signs 166.) The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change? Checking the wound site for drainage from the drain 167.) The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which finding would indicate a sign of a potential complication? Increasing restlessness 168.) The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action? Apply a sterile dressing soaked with sterile normal saline to the wound. 169.) The nurse is preparing a client for surgery. Which would be a component of the plan of care? Review the results of the preoperative laboratory studies. 170.) A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions to the client regarding preparation for the surgical procedure. Which statement by the client indicates an understanding of the preoperative instructions? "I cannot drink or eat anything after midnight on the night before surgery." 171.) The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate? Notify the registered nurse. 172.) The nurse is preparing to collect data from a client who has sustained a pelvic fracture following a motor vehicle crash. The nurse reviews the health care provider's (HCP) prescriptions and notes that the HCP has prescribed a pelvic (skin) sling. The nurse prepares to place the client in which device? Refer to figure. 3 173.) A client has had extensive surgery on the gastrointestinal tract and has been started on total parenteral nutrition (TPN). The client tells the nurse, "I think I'm going crazy. I feel like I'm starving, and yet that bag is supposed to be feeding me." Which is the best response from the nurse? "That is because the empty stomach sends signals to the brain to stimulate hunger." 174.) A mother of a 6-year-old-child calls the nurse who lives in the neighborhood and tells the nurse that her child accidentally rubbed waterproof sunscreen in his eyes. Which should the nurse tell the mother to immediately perform? Call the poison control center. 175.) A mother of a 9-year-old child calls the emergency department and tells the nurse that her child received a minor burn on the hand after accidentally touching a grill during a family cookout. The mother asks the nurse for advice on how to treat the burn. Which action should the nurse tell the mother to immediately perform? Place the child's hand under cool running water. 176.) A client in labor states to the nurse, "I think my water just broke." On examination of the client, the nurse sees that the umbilical cord is protruding from the vagina. Which should the nurse do immediately? Place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. 177.) The nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse should immediately place the client in which position? With the hips elevated 178.) The nurse stops at the scene of an automobile accident to assist a victim. The victim complains of severe leg pain, is unable to get out of the automobile, and is frightened. Which is the appropriate nursing action? Stay with the victim. 179.) A client with skeletal traction applied to the right leg complains to the nurse about severe right leg pain in spite of being medicated with a prescribed analgesic. Which action should the nurse take? Notify the registered nurse. 180.) A client with a left arm fracture complains of severe, diffuse pain that is unrelieved with pain medication. Based on these findings, the nurse should take which action? Notify the registered nurse. 181.) The nurse who is assisting in caring for a client with a tracheostomy tube notes heavy bleeding from the stoma. The nurse also notes that the tracheostomy tube pulsates with the client's heartbeat. The nurse immediately performs which action? Applies pressure to the artery at the stoma site 182.) The nurse is caring for a client who had a tracheostomy tube inserted 1 week ago. The client begins to cough vigorously, and accidental decannulation of the tracheostomy tube occurs. Which action should be the nurse's immediate response? Replace the tracheostomy tube 183.) The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL. Based on this finding, what should be the nurse's first action? Check the client's overall intake and output record. 184.) The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? Lower the head of the bed slowly until the dizziness is relieved. 185.) The nurse is preparing for the intershift report when a nurse's aide pulls an emergency call light in a client's room. On answering the light, the nurse finds a client experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first? Place the client in modified Trendelenburg's position. 186.) The nurse administers scopolamine as prescribed to a client in preparation for surgery. The nurse monitors the client for side effects related to the administration of this medication. Which should the nurse determine is an expected side effect of this medication? Client complaints of a dry mouth 187.) A client arrives at the emergency department with an acetaminophen (Tylenol) overdose. Acetylcysteine is prescribed to be administered to the client immediately. The nurse prepares to administer the medication by which route? Orally 188.) The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client? High-Fowler's 189.) The nurse employed in the emergency department is preparing to administer syrup of ipecac to a 7-month-old child. The nurse prepares 5 mL of the syrup and administers one half glass of water following administration of the ipecac syrup. Which response should the nurse expect? vomiting 190.) The nurse employed in the emergency department receives a telephone call from the emergency alert system informing the department that a child who ingested a bottle of acetaminophen (Tylenol) is en route to the emergency department. The nurse prepares the room for the arrival of the child and checks the medication supply to determine whether which medication that is the antidote is available? Acetylcysteine 191.) Following surgical removal of a brain tumor, the health care provider writes a prescription to maintain the child in a semi-Fowler's position. In the postoperative period, the nurse is monitoring the child and notes that the child is restless, the pulse rate is elevated, and the blood pressure has dropped significantly from the baseline value. The nurse suspects that the child is in shock. Which nursing action would be appropriate? Notify the registered nurse. 192.) A licensed practical nurse (LPN), employed in the emergency department, prepares to assist in treating a child with an acetaminophen (Tylenol) overdose. The LPN checks the medication supply room, anticipating that which medication will be prescribed? Acetylcysteine 193.) A 4-year-old child has been brought to the emergency department after the grandparents found him with an open bottle of chewable, orange-flavored 81-mg aspirin tablets. In order to determine whether the child is experiencing a toxic effect, which question should the nurse ask the child? "Do you hear a sound like a bell ringing in your ears?" 194.) The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the client has not successfully met all of the goals formulated if which outcome is noted? 195.) The nurse is assisting in caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide level reveals a level of 45%. Based on this level, the nurse should anticipate which sign in the client? 196.) A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which prescription should the nurse anticipate for the client? 100% oxygen via a tight-fitting non-rebreather face mask 197.) The nurse has administered a dose of salmeterol (Serevent Diskus) to a client. Following administration, the client develops a generalized rash and urticaria and the eyelids begin to swell. Which action should the nurse take? Notify the registered nurse immediately 198.) The nurse is assisting in caring for a client admitted to the emergency department with diabetic ketoacidosis. The nurse anticipates that the health care provider will prescribe which type of insulin for intravenous administration to treat this disorder? Regular 199.) A client has been taking prednisone for 3 years to treat symptoms of lupus erythematosus. She is scheduled for abdominal hysterectomy because of menorrhagia. The nurse plans care realizing that postoperatively the client is at risk for which condition? Increased likelihood of surgical site infection 200.) A depressed client is found unconscious on the floor in the dayroom of a psychiatric nursing unit. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. What is the immediate action of the nurse? 201.) A client has undergone total hip replacement of the right hip, which was damaged by osteoarthritis. Which action should be included in the postoperative plan of care? Partial weight bearing on the operative leg is usually permitted 72 hours 202.) Several clients arrive simultaneously at the emergency department after sustaining burn injuries in a house fire. Which client will require the closest observation for signs of respiratory distress? A client who has singed nasal hairs and worsening hoarseness 203.) The nurse is assisting in admitting a client to the emergency department with suspected carbon monoxide poisoning. The nurse understands that which sign/symptom is least reliable for determining the oxygenation status of this client? Skin color 204.) The nurse is assisting in the preparation of a client for a blood transfusion. Which item is the most important for the completion of the identification process? Identification bracelet 205.) A client requiring upcoming surgery is extremely anxious about the need for a possible blood transfusion and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client consider which as an effective method to minimize this risk? Arrange an autologous blood donation before the planned surgery. 206.) A client who currently underwent abdominal surgery experiences an evisceration. Which statement made by the client supports this diagnosis? 207.) An emergency department nurse prepares to collect data from a pregnant woman. The woman tells the nurse that she felt a large gush of fluid on the way to the hospital. The nurse checks the fetal heart rate (FHR) and notes that it is 90 beats per minute. On physical examination, the nurse notes that the umbilical cord is protruding from the vagina. Which is the initial nursing action? Wrap the cord loosely in a sterile normal saline saturated towel. 208.) When assisting in the identification process required before a blood transfusion, which action will the nurse take when it is noted that all of the necessary information is correct, except for the client's name? 209.) The nurse is monitoring a client who is receiving a unit of packed red blood cells. Within an hour after the initiation of a transfusion, the nurse finds the client to be restless, with reports of chills and back pain. The nurse notes that there is dark urine in the Foley catheter drainage bag. The nurse interprets that the client is experiencing which reaction? Acute hemolytic 210.) Which statement by the client who has received home care instruction following an arthroscopy of the knee indicates a need for further teaching? I can apply heat to my knee if it becomes uncomfortable." 211.) The nurse is working in the primary care office and is conducting an interview with the parents of a child. The parents of the child state that syrup of ipecac is kept at home in case of an accidental poisoning. The nurse provides which appropriate instruction specific to the use of this medication? "Ipecac syrup should not be given unless the poison control center indicates to do so." 212.) The nurse caring for a client at home arrives to find the client in the bedroom, unconscious and with a pill bottle of the selective serotonin reuptake inhibitor, sertraline (Zoloft), on the bed. Which assessment has priority? Respirations 213.) During admission data collection, the nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has interference in which area? Balance and coordination 214.) An assessment of a woman at 32 weeks of gestation indicates moderate fetal distress. Which intervention is the nurse's priority? Administer oxygen with a face mask at 7 to 10 L/min. 215.) When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction when in which position? Lithotomy 216.) A client has returned to the nursing unit following abdominal hysterectomy. To most effectively gather data on the client's postoperative bleeding, the nurse would implement which intervention? Rolling the client to one side to view bedding 217.) The nurse is monitoring a client receiving a blood transfusion for circulatory overload. The nurse understands that which is a clinical indication of circulatory overload? Moist, productive cough 218.) A pregnant client tells the nurse that she felt wetness on her peri-pad and that she found some clear fluid. The nurse immediately inspects the perineum and notes the presence of both a clear liquid and a portion of the umbilical cord. Which initial action should the nurse take? Gently hold the presenting part upward. 219.) The nurse checks the peripheral intravenous (IV) site dressing and notes that it is damp and that the tape is loose. Which is the first action by the nurse? Check that the tubing is 220.) The nurse assisting in caring for a client with a myocardial infarction is monitoring for cardiogenic shock. The nurse should monitor for which peripheral vascular symptoms? Cool, clammy skin with either weak or thready pedal pulses 221.) The nurse evaluates the client following treatment for carbon monoxide poisoning. The nurse should document that the treatment has been successful if which result is obtained? The carboxyhemoglobin levels are less than 5%. 222.) The nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client reports chest pain. When the administration of a sublingual nitroglycerin tablet as prescribed does not relieve the chest pain, which is the next nursing action? Check the blood pressure and administer another nitroglycerin tablet. 223.) The nurse is caring for a client with a long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by checking which criteria? Select all that apply. The client's mental status; The client's respiratory function 224.) The nurse is caring for a client who sustained multiple fractures in a motor vehicle accident 12 hours ago. The client develops severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the nurse's initial action? Place the client in a Fowler's position. 225.) The nurse is caring for a client who was admitted to the hospital with a fractured right femur sustained from a fall 5 hours ago. The client's plan of care includes interventions related to monitoring for signs of fat embolism. The nurse provides appropriate care by performing which action? Monitoring for signs of dyspnea 226.) The nurse is caring for a comatose client at risk for fat embolism because of a fractured femur and pelvis sustained in a fall. Which findings does the nurse identify as early signs of possible fat embolism? Increased heart rate and adventitious breath sounds 227.) The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. Which is the initial nursing action? Check the neurovascular status of the toes on the casted leg. 228.) The nurse is caring for a client following the application of a plaster cast because of a fractured left radius. The nurse monitors the neurovascular status of the client's casted extremity for which reason? Compartment syndrome may lead to irreversible nerve and muscle tissue injury. 229.) The skin surrounding a postoperative client's abdominal wound is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which is the appropriate nursing action? Apply Montgomery ties. 230.) A client presents to the urgent care center with a chemical burn of the right eye. The priority for the nurse is to prepare the client for which? Flushing the right eye with copious amounts of sterile solution 231.) A client has been on total parenteral nutrition for 8 weeks. The health care provider prescribes that the total parenteral nutrition be weaned down by 50 mL/hr/day until discontinued. The client asks the nurse, "Why doesn't the doctor just stop the parenteral nutrition instead of dragging it on for 3 days?" The nursing response should be to explain that the health care provider is concerned about which phenomenon? Rebound hypoglycemia 232.) A client has been receiving parenteral nutrition at 125 mL/hr for 5 days. On data collection, the LPN notes bilateral crackles and 2+ pedal edema and that the client has gained 3 pounds in 5 days. Which would be appropriate as the initial nursing action? Notify the registered nurse of the findings. 233.) A health care provider prescribes a parenteral nutrition solution to start at 50 mL/hr by infusion pump via an established subclavian central line. After 2 hours of initiating the parenteral nutrition infusion, the client suddenly complains of difficulty in breathing and chest pain. Which action would the nurse prepare to do first? Clamp the parenteral nutrition infusion. 234.) The nurse is assigned to care for a client receiving total parenteral nutrition via the subclavian vein. The nurse should identify which intervention in the plan of care for the client as the priority? Monitoring the insertion site for signs of infection 235.) A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which question would assist the nurse in the collection of data regarding the client's problem? "What have you been eating and drinking since the surgery?" 236.) The nurse is caring for a client who was admitted to the maternity unit at 8:00 am with contractions occurring every 2 minutes, lasting 1½ minutes, and who is dilated 4 cm with a cervical effacement of 60%. At 10:30 am, the contractions cease. The client reports chest pain and manifests signs and symptoms of shock. The nurse quickly plans care, suspecting which complication? Ruptured uterus 237.) Which finding in the prenatal client supports the medical diagnosis of placental abruption? Tender, rigid abdomen 238.) The nurse caring for a client diagnosed with placental abruption should plan which action? Prepare the client for a cesarean birth. 239.) A client with a Sengstaken-Blakemore tube in place to treat esophageal varices suddenly becomes restless, the heart rate and blood pressure increase, and the client's pulse oximetry reading is decreasing. The nurse calls for the registered nurse and plans to take which immediate nursing action? Cut the tube, and pull it out. 240.) An adult client is admitted to the emergency department following a burn injury. The burn initially affected the client's upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the entire face (anterior half of the head) and the upper half of the posterior torso. Using the rule of nines, which percentage would characterize the burn injury? Refer to the figure. Fill in the blank. 31.5% 241.) The nurse is visiting an older client whose family has gone out for the day. During the visit, the client experiences chest pain that is unrelieved by nitroglycerin given by the nurse. Which action by the nurse would be appropriate at this time? Call for an ambulance to transport the client to the emergency department. 242.) The nurse collecting data on a client during the second stage of labor notes a slowing of the fetal heart rate (FHR) with a loss of variability and determines that these are indicators of possible complications. Which priority interventions should the nurse perform? Turn client to her side and administer oxygen by mask at 8 to 10 L/min. 243.) A client has had surgery to repair a fractured left hip. The nurse plans to use which important item when repositioning the client from side to side in the bed? Abductor splint 244.) A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. The nurse avoids using which intervention in an effort to relieve the spasm? Cold 245.) The nurse has reviewed activity restrictions with a client who is being discharged following hip surgery and insertion of a femoral head prosthesis. The nurse determines that the client understands the material presented if the client makes which statement? "I will use a raised toilet seat." 246.) The nurse is talking to a client who underwent a below-the-knee amputation 2 days earlier. The client says to the nurse, "I hate looking at this; I feel that I'm not even myself anymore." The nurse understands that the client is experiencing which problem? Disturbed body image 247.) A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. Which action should the nurse take first? Place the client on the left side with the head lowered. 248.) A licensed practical nurse (LPN) assisting a registered nurse in the cardiac care unit (CCU) prepares to admit a client with a diagnosis of myocardial infarction (MI). The LPN should be certain to have which item(s) readily available on the unit when the client arrives by stretcher? Oxygen cannula and flowmeter 249.) A client receiving a blood transfusion begins to exhibit flushing, stridor, and a drop in blood pressure. The nurse should obtain which medication from the emergency cart to have ready for use as prescribed? Epinephrine (Adrenalin) (Tara) 250-374 A client sustains a burn injury to the anterior right and left legs and perineal area. According to the rule of nines, the nurse should determine that this injury constitutes which body percentage? 19% Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet for a postoperative client who has had general anesthesia? Suction equipment The nurse is reinforcing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a need for further teaching? "I should perform pronation and supination exercises of my wrist starting 24 hours after surgery." The nurse is caring for a client following total hip replacement who has a wound suction drain in place. At the end of the 8-hour shift, the nurse empties 45 mL of drainage from the wound-suction device. Based on this amount of drainage, which action is appropriate? Document the findings. An emergency department nurse is assigned to assist in caring for a client who has suffered a head injury following a motor vehicle crash. The nurse understands that the initial data collection should focus on which sign/symptom? Respiratory status The nurse is assigned to care for a client being admitted to the mental health unit following a suicide attempt. The client attempted the suicide by lacerating both wrists. Which is the initial nursing action upon admission of the client? Check the wound sites. The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery. When asking the client whether the client takes over-the-counter medications, which statement should concern the nurse? "Yes, I take a full-strength aspirin every day." A postoperative client received a spinal anesthetic. The client has not experienced pain because the anesthetic has not yet worn off. The nurse will monitor the client closely for pain and provide the client with which instruction? "You will need to let me know when you start to get feeling back in your legs." The nurse is caring for a client who had a total knee replacement. Postoperatively, the nurse monitors for which highest priority assessment? Calf Pain When a client progresses from preeclampsia to eclampsia, which is the nurse's first action? Clear and maintain an open airway. The nurse assists in developing a plan of care for a client admitted to the hospital with an acute myocardial infarction (MI). Which is the priority problem during the acute phase? The nurse is monitoring a client at risk for placental abruption. Which findings are indicative of this complication? Select all that apply. The nurse is assisting in caring for a client in transfer from the postanesthesia care unit following nasal surgery. Nasal packing and a mustache dressing are in place. The nurse places the client in which position to best reduce swelling? Semi-Fowler's The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving parenteral nutrition. These findings indicate which potential complication? Infection of a central catheter site can lead to septicemia. The nurse is assisting in caring for a client who is receiving morphine sulfate by continuous intravenous infusion. The nurse ensures that which medication is readily available if a morphine overdose occurs? The nurse assisting in caring for a client hospitalized with acute pericarditis is monitoring the client for signs of cardiac tamponade. The nurse determines that which finding is unrelated to possible cardiac tamponade? A client suffered smoke inhalation and burns to the anterior trunk during a house fire. The nurse reviews the plan of care and notes that the client has an airway problem. Which findings support an airway problem? Select all that apply. Bradypnea Hoarse voice Guttural respiratory sounds A client with a major burn is admitted to the emergency department. In priority order which actions should the nurse take? Arrange the actions in the order that they should be used. All options must be used. Establish A client newly admitted to the labor unit reports to the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse checks the client and notes that the umbilical cord is protruding from the vagina. Which action should the nurse take first? Place the client in the Trendelenburg position. The nurse is explaining the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery to a group of nursing students. Which action does site marking involve? . The nurse is explaining the concept of time-out in the perioperative area to a group of nursing students. What is the purpose of a time-out? To allow the surgical team a chance to verbally verify their agreement on the client's A client receiving total parenteral nutrition through a central intravenous line is exhibiting signs and symptoms of an air embolism. The nurse immediately places the client in which position? Left side in Trendelenburg's The nurse is checking a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the site. The nurse should do which first? Remove the IV. One unit of packed red blood cells has been prescribed for a client postoperatively because the client's hemoglobin level is low. The health care provider prescribes diphenhydramine (Benadryl) to be administered before the administration of the transfusion. Why is this medication being given? A client wishes to donate blood for a family member and asks the nurse about the procedure for identifying compatibility. The nurse tells the client that which test will be done to test compatibility? The nurse is caring for a client with liver disease. Laboratory studies are performed, and the client's serum calcium level is 13 mg/dL. The nurse checks to see that which medication is available in the stock medication supply area on the clinical nursing unit that may be needed to treat this calcium imbalance? A health care provider prescribes an intravenous fat emulsion solution for a client who will be receiving parenteral nutrition (PN). The nurse should explain to the client the administration of the fat emulsion solution is for which reason? To provide essential fatty acids and additional calories A client with a fractured femur is placed in skeletal traction. The nurse should do which to monitor for nerve injury? A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse, "The IV is not running right." Which findings would indicate an infiltrated IV? Select all that apply. A registered nurse has just hung a 250-mL bag of packed red blood cells (PRBCs) on a client. The licensed practical nurse assisting in caring for the client plans to remain with the client for at least how many minutes following the start of the infusion? 15 minutes A client is complaining of pain at the site of the intravenous (IV) infusion device. The nurse checks the IV site and determines that the client has developed phlebitis. Which action should the nurse take? Remove the IV. A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important? The nurse is caring for a new postoperative client and is monitoring the client for signs of shock. The nurse monitors for which signs of this postoperative complication? A client's preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action should the nurse take first? Compare these values to those recorded previously. A client has an intravenous infusion (IV) started before surgery for a right below-the-knee amputation. In addition to the intravenous infusion, blood is drawn and a surgical skin preparation is done. The nurse anticipates that the client is likely to experience which psychosocial problem in the preoperative period? The nurse is caring for a client who had a small bowel resection the previous day and has continuous gastric suction attached to the nasogastric tube. Which intravenous solution should the nurse anticipate to be prescribed for the client? A client who is scheduled for surgery and who is to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture." Based on the client's statement, the nurse should make which response to the client? "You have concerns about skeletal versus skin traction for your type of fracture?" The nurse enters a client's room and finds the client slumped down in the chair. Breathing is shallow and a pulse is present. Based on this data, the nurse determines that which action is the priority? An older client with advanced Alzheimer's disease is placed in balanced suspension traction, and the health care provider expects to internally fixate the client's femur in 1 week. Based on this information, the nurse determines that the priority relates to addressing which client problem? Risk for constipation Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia? Suction equipment This morning a client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines that the client's symptoms are indicative of which complication? A client has a newly fractured fibula that is plaster casted in the emergency department. Because the client will need to use crutches, the nurse plans to teach the client which crutch-walking gait before discharge? Three-point gait A client who has undergone a cardiac catheterization using the right femoral approach is returned to the nursing unit. Thirty minutes later the client complains of numbness and tingling of the right foot. The pedal pulse is weak, and the foot is pale. The nurse notifies the registered nurse because these symptoms are consistent with which problem? The nurse is caring for a client diagnosed with Paget's disease. The nurse understands that this condition usually affects which bones? The nurse is caring for a client who has just had rotator cuff repair. The client asks the nurse how soon he can resume his tai chi classes. The nurse should make which statement to the client? "You shouldn't be doing any exercises that require the use of your upper arms until you have been cleared to do so by the health care provider." A lethargic, yet easily aroused 6-year-old child is brought to the emergency department with a diagnosis of an overdose with diazepam (Valium). During the initial data collection, the nurse determines that the child's blood pressure and respirations are below normal for his age. The Glasgow Coma Scale is performed and reveals a score of 10. Based on this information the nurse determines that which problem should have the highest priority? Altered respiratory status A toddler ingested drain cleaner found under the sink. The frantic mother calls poison control and asks what she should do because the child has started vomiting blood. What is the nurse's immediate response? Ask the mother if the child is breathing by himself. An adolescent is admitted to the pediatric intensive care unit after suffering a seizure at school. She is alert on admission and tells the nurse that she has asthma and takes theophylline every day. She has a heart rate of 116 beats per minute with some shortness of breath. She also is complaining of nausea and vomiting. Which should the nurse suspect as the reason for the complaints that were gathered during the data collection process? The child might have a toxic theophylline level. The nurse reinforces preoperative teaching to a client who will wear an abdominal binder postoperatively following abdominal surgery. Which instruction should the nurse reinforce in the preoperative teaching plan? Sit up for coughing while splinting the incision. A client has sustained full-thickness circumferential burns of the trunk. Which should be the priority concern of the nurse? A client undergoing a computed tomography (CT) scan develops chest pain, wheezing, and stridor after injection of contrast media. Which type of shock is this client most likely exhibiting? Anaphylactic During the emergent phase after a major burn injury, which abnormalities should the nurse expect to note? The nurse observes the following rhythm on the cardiac monitor. Which action should the nurse take first? Refer to the figure. The nurse determines that which client is most likely to be a candidate for cardioversion? The nurse discovers an unresponsive, breathing newborn infant. To assess circulatory status, the nurse should palpate which arterial pulse area? Brachial The nurse is caring for a client who has bilateral vocal cord paralysis. The client begins to experience severe dyspnea; the nurse listens to the client's breath sounds and hears this sound. (Refer to audio.) Which intervention should the nurse take immediately? Notify the registered nurse. The nurse is reviewing the preoperative prescriptions of a client with a colon tumor who is scheduled for abdominal perineal resection. The nurse notes that the health care provider has prescribed neomycin sulfate (Mycifradin) for the client. Which is the rationale for prescribing this medication? To decrease the bacteria in the bowel The nurse is caring for a postoperative client who had a pelvic exenteration. The health care provider has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks which before administering the clear liquids? The nurse is monitoring a client with a diagnosis of gastric ulcer. Which finding would indicate perforation of the ulcer? A client with suspected opioid overdose has received a dose of nalmefene. The client subsequently becomes restless, starts to vomit, and complains of abdominal cramping. The blood pressure increases from 110/72 to 160/86 mm Hg. The nurse provides emotional support and reassurance while administering care to the client, knowing which statement is true? These are signs of opioid withdrawal. The nurse is assisting in caring for a client who is receiving a dose of nalmefene intravenously to treat opioid overdose. The nurse plans to have which supplies available as supportive equipment in case it is needed? The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients at which time interval? A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The licensed practical nurse (LPN) inspects the site and determines that the client has developed phlebitis. The LPN should plan to avoid which action in the care of this client? Prepare to start a new line in a proximal portion of the same vein. A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds that the client is complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased pulse rate. The intravenous The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which is the appropriate action by the nurse? Change the IV tubing. The nurse enters a client's room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is flushed and dyspneic. The nurse listens to the client's lung sounds and notes the presence of crackles in the lung bases. The client states that she was just going to ring the call bell for the nurse. The nurse determines that this client is most likely experiencing which complication of blood transfusion therapy? Fluid (circulatory) overload The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the client that it is important to immediately report which sign if it occurs? Backache A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? "Can you share with me what you've been told about your surgery?" The nurse is reinforcing instructions to a client about the use of an incentive spirometer in the postoperative period. The nurse should include which information in discussions with the client? The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which action in the care of this client at this time? The nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action should the nurse plan to take first? Recheck the vital signs in 15 minutes. The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to carefully monitor which parameter during the next hour? Urinary output of 20 mL/hr A client is admitted to the surgical unit postoperatively with a wound drain in place. Which nursing action should the nurse avoid in the care of the drain? Curl the drain tightly and tape it firmly to the body. When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to do which action in the initial care of this wound? The nurse is monitoring the status of the postoperative client. The nurse should become most concerned with which sign(s) that could indicate an evolving complication? The nurse is reinforcing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse should provide the client with which instruction regarding positioning in the postoperative period? Do not sleep on the left side. The emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin). Which should the nurse anticipate as the likely initial treatment? Weakness The nurse is assisting in admitting a child who arrived from the emergency department after treatment for acetaminophen (Tylenol) overdose. The nurse reviews the child's record and expects to note that the child received which for the acetaminophen overdose? Acetylcysteine A nursing student is assisting the clinic nurse with the administration of immunizations in the well-baby clinic. The student is asked to administer a measles, mumps, and rubella (MMR) vaccine to a child and prepares to administer the vaccine in which way? Subcutaneously in the upper arm The nurse has a prescription to give ear drops to a 2-year-old child. To administer the drops, the nurse should pull the pinna of the ear in which direction? Downward and backward A client who is receiving antineoplastic medication by the intravenous (IV) route complains of pain at the insertion site of the IV. The nurse inspects the site and finds the area is swollen and reddened. The nurse further observes that the solution is no longer infusing. The nurse immediately takes which priority nursing action? Notifies the registered nurse (RN) The nurse administering medications to a client notes a prescription to give a subcutaneous dose of heparin sodium. The nurse should perform which action to give this medication safely? Give the injection using a 25- to 27-gauge, ⅝-inch needle. Which intervention would be contraindicated in the postprocedure care of the client following a bone biopsy of the left arm? Place the left arm in a dependent position for 24 hours. The nurse is providing postprocedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should reinforce which client instruction? Report to the health care provider the development of fever or redness and heat at the site. A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which complication because of the history of diabetes? Separation of wound edges A client has sustained multiple fractures in the left leg and is in skeletal traction. The nurse has obtained an overhead trapeze for the client's use to aid in bed mobility. The nurse should monitor for which high-risk area for pressure and breakdown? Right heel The nurse is teaching a client about foods in the diet that could minimize the risk of osteoporosis. The nurse should encourage the client to increase intake of which food? Cheese A client has just had an application of a nonplaster (fiberglass) leg cast, and the nurse is reinforcing instructions for cast care at home. Which statement by the client indicates the need for further teaching? "I should use a hair dryer set to the hot setting to dry my cast if it gets wet." A client has just had skeletal traction applied following insertion of pins. The nurse should place highest priority on performing which action? Ensuring that the weights on the traction setup are hanging free The nurse is reinforcing discharge instructions for a client who underwent left total knee replacement (TKR) with insertion of a metal prosthesis. Which statement by the client indicates the need for further teaching? "I don't need to be worried if the shape of my knee changes." A client is experiencing an acute exacerbation of bursitis. The nurse encourages the client to avoid which least likely helpful measure until the current episode is resolved? Active intermittent range of motion A client in the clinical unit who is allergic to shellfish unknowingly ate a dish brought by a friend that had shellfish as an ingredient. The client quickly develops anaphylaxis. The nurse should focus on which intervention first until additional help arrives? Maintaining a patent airway The nurse on a telemetry unit checks a client's chart and notes that the potassium level is 6.3 mEq/L. Based on the laboratory result, which signs/symptoms should the nurse anticipate? Select all that apply. Anxiety Electrocardiogram (ECG) changes An adult client is admitted to the emergency department with acute extensive partial thickness burns to the lower extremities. The nurse anticipates the health care provider will initially prescribe which medications and route for pain control? Select all that apply. Morphine sulfate intravenously Hydromorphone (Dilaudid) intravenously A client who weighs 50 kg has arrived in the emergency department complaining of severe chest pain. The telemetry monitor shows an evolving anterior myocardial infarction (MI). The nurse anticipates that the health care provider will initially prescribe which treatments? Select all that apply. Oxygen 2 L, per nasal cannula Chewable aspirin 324 mg, oral Nitroglycerin 0.4 mg, sublingual Morphine sulfate 4 mg intravenously A client uses the call system to notify the nurse to say that "the IV hurts and my left hand is swollen." The nurse assesses the site and determines infiltration has occurred. In order of priority, which actions should the nurse take? Arrange the actions in the order they should be performed. All options must be used. Stop the infusion Remove the intravenous catheter Apply a compress to the site. Notify the registered nurse to start a new IV on the right extremity The nurse is caring for a client in the critical care unit. The nurse is reviewing the Critical Care Family Needs Inventory. The nurse knows that the most important issues of family members of critically ill clients include which factors? Select all that apply. Receiving assurance Receiving information Having support available Remaining near the client The nurse is caring for a client with a permanent pacemaker. The nurse knows that which three primary problems can occur when cardiac pacemakers malfunction? Select all that apply. Failure to sense Failure to capture Failure to pace or fire An adult client presents to the Emergency Department (ED) with complaints of substernal chest pain and is taken directly to a stretcher in the department. Which priority intervention should the nurse undertake? Obtain an electrocardiogram (ECG). The nurse is suctioning an endotracheal tube (ET) for an intensive care unit client who is being mechanically ventilated. Five minutes after suctioning, which primary outcomes should tell the nurse that the suctioning has been successful? Select all that apply. Clear lung sounds Increase in O2 saturation Heart rate on monitor within normal limits The nurse is caring for a cardiac client who has recently displayed this monitored rhythm. Which actions by the nurse are most appropriate? Refer to figure. Select all that apply Check all telemetry leads. Check blood pressure (BP). Obtain stat electrocardiogram (ECG). Assess client's level of consciousness (LOC). A comatose client received therapeutic hypothermia after a cardiac arrest. The nurse anticipates which primary complications associated with this treatment? Select all that apply. Infection Bleeding Metabolic and electrolyte disturbances A 50-year-old client with a history of cardiac disease has been admitted to the intensive care unit (ICU) with a diagnosis of acute alcohol withdrawal. Which initial client data should the nurse expect to find? Select all that apply. Insomnia Diaphoresis Tachycardia Increased serum total bilirubin The critical care nurse is caring for a client with a subclavian central line catheter. The nurse knows that a specific central-line bundle was developed to reduce the client's risk for developing a catheter-related bloodstream infection (CLABSI). The interventions include which essential actions? Select all that apply. Strict hand washing Optimal catheter site selection Strict sterile technique with maximal barrier precautions during placement A client with complaints of mild shortness of breath and weakness comes to the medical clinic. The nurse reviews the client's chart and immediately contacts the health care provider about which life-threatening finding? Refer to chart. Potassium level The nurse is caring for a client who is a victim of a major burn injury. Which are the names of the primary phases of burn care assessment? Select all that apply. Acute Resuscitative Rehabilitative A woman arrives at the emergency department complaining of abdominal pain of 4 on a scale of 1 to 10. She states that she thinks she is about 10 weeks pregnant. Her vital signs are pulse, 86 beats per minute; respirations,16 breaths per minute; and blood pressure,112/78 mm Hg. Which signs/symptoms should the nurse report to the health care provider immediately? Select all that apply. Pulse, 112 beats per minute Pain rating of 8 on a scale of 1 to 10 States "I feel like I am about to faint." The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload? Select all that apply. Distended neck veins Dry Cough The nurse is taking care of a client preoperatively. The client is NPO and tells the nurse that he takes detemir insulin (Levemir) and aspart insulin (NovoLog) at 0700 daily. The client's surgery is scheduled for 0900. Which is the best action for the nurse to take? Call the health care provider for clarification. The client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, what is the nurse's actions in order of priority? Arrange the actions in the order that they should be performed. All options must be used. Raise the head of the bed. Loosen tight clothing on the client. Check for bladder distention Contact the health care provider (HCP) Administer an antihypertensive medication Document the occurrence, treatment, and response. RESPIRATORY NCLEX QUESTIONS RESPIRATORY NCLEX A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action should the nurse take? Discontinue suctioning until the client is stabilized and monitor vital signs. The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? Select all that apply. 50 mL of drainage in the drainage-collection chamber The drainage system is maintained below the client's chest. The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate? The nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse should reinforce instructing the client to do which during this process? Perform Valsalva's maneuver. The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? Select all that apply. Be sure all connections remain airtight. Be sure all connections are taped and secure. Monitor closely for tubing that is kinked or obstructed by the weight of the client. The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method should be used to monitor the client for crepitus? The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse should provide the client with which information about this type of tube? Enables the client to speak The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position should the nurse instruct the client to assume? Sitting on the side of the bed, leaning on an overbed table The nurse is gathering data on a client with a diagnosis of tuberculosis (TB). The nurse should review the results of which diagnostic test to confirm this diagnosis? The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse reinforce? Select all that apply. The nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse should tell the client that the primary purpose of pursed lip breathing is which? Promote carbon dioxide elimination. The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action should the nurse take? The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client? Lateral position The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which? The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation? Shortness of breath The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection? A man who is an inspector for the U.S. Postal Service The nurse is reading the results of a Mantoux tuberculin skin test on a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. Which interpretation should the nurse make of these results? The nurse notes that a hospitalized client has experienced a positive reaction to the Mantoux tuberculin skin test. Which action by the nurse is the priority? A client being discharged from the hospital to home with a diagnosis of tuberculosis (TB) is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likely? The nurse is reinforcing discharge teaching with a client diagnosed with tuberculosis (TB) and has been on medication for 1½ weeks. The nurse knows that the client has understood the information if which statement is made? "I should not be contagious after 2 to 3 weeks of medication therapy." The nurse is caring for a client with emphysema receiving oxygen. The nurse should check the oxygen flow rate to ensure the client does not exceed how many L/min of oxygen? 2 The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply. A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect? Peripheral neuritis The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply. Dyspnea on exertion Presence of a productive cough Difficulty breathing while talking The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made? Coughing occurs with suctioning. The nurse is caring for an older client who is on bed rest. The nurse plans which intervention to prevent respiratory complications? A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. The nurse develops a response to the client's question, based on which understanding? A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom should the nurse expect the client to experience? The nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which item during periods of exposure to silica particles? Mask The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns from surgery? Obturator The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high- pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention? Suction the client. The nurse is preparing to obtain a sputum specimen from the client. Which nursing action is essential in obtaining a proper specimen? The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax? The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect the client to experience? The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse indicates that the client is performing the technique correctly? The nurse is assisting in collecting subjective and objective data from a client admitted to the hospital with tuberculosis (TB). The nurse should expect to note which finding? Complaints of night sweats The nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further teaching about its use if the client makes which statement? "After maximal inspiration, I will hold my breath for 10 seconds and then exhale." The nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, which conclusion should the nurse make? The chest tube is functioning as expected. The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. After immediately applying sterile gauze over the chest tube insertion site which should the nurse do next? A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry. The nurse performs which best action to ensure accurate readings on the oximeter? The nurse is told that an assigned client will have the chest tubes removed. The nurse plans to do which in preparation for the procedure? The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter? The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? Aspiration of gastric contents occurs when suctioning. A client has a chest tube that is attached to a chest drainage system. The client asks the nurse, "Can the tube come out faster if you turn the wall suction up higher?" The nurse's response is based on which fact with regard to turning up the wall suction? The nurse is preparing to perform nasotracheal suctioning on a client. The nurse places the client's bed in which position to effectively perform this procedure? Refer to figure. 1 The nurse is suctioning an adult client through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is 89%. Which action should the nurse implement? . The nurse is caring for a client who is being treated for a pneumothorax with a closed chest tube drainage system. When repositioning the client, the chest tube disconnects. Which nursing action would be immediate? Reattach the chest tube to the drainage system. The nurse is assisting a client with a closed chest tube drainage system to get out of bed to a chair. During the transfer, the chest tube gets caught in the leg of the chair and accidentally dislodges from the insertion site. Which action should the nurse implement? Cover the insertion site with sterile Vaseline gauze. The low-exhaled volume (low-pressure) alarm sounds on a ventilator. The nurse rushes to the client's room and checks the client to determine the cause of the alarm but is unable to do so. Which would be the next immediate nursing action? Ventilate the client with a resuscitation bag. The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action should the nurse implement? Check the amount of suction pressure being applied. The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response? A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention? The nurse checks a closed chest tube drainage system on a client who had a lobectomy of the left lung 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which should the nurse do first? A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. What is the nurse's immediate nursing action? Assess the client. A client arrives in the emergency department with an episode of status asthmaticus. What is the nurse's priority action? Place the client in high-Fowler's position. The nurse is checking the chest tube drainage system of a postoperative client who had a right upper lobectomy. The closed drainage system has 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water-seal chamber. One hour following the initial data collection, the nurse notes that the bubbling in the water-seal chamber is now constant, and the client appears dyspneic. Based on these findings, which action should the nurse do first? Inspect chest tube connections. A client with pneumonia is admitted to the hospital, and the health care provider writes prescriptions for the client. Which prescription should the nurse complete first? The nurse is monitoring the respiratory status of a client who has suffered a fractured rib. The nurse monitors the client and understands that which sign/symptom is unrelated to the rib fracture? The nurse is admitting a client to the nursing unit who is suspected of having tuberculosis (TB). The nurse plans to admit the client to which type of room? The nurse is collecting data from a client who is experiencing the typical signs/symptoms of tuberculosis (TB). The nurse should expect the client to report having symptoms of fatigue and cough that have been present for how long? Several weeks to months The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis? The nurse is collecting respiratory data from an adult client and is auscultating for normal breath sounds. The nurse should expect to hear bronchial breath sounds in which anatomical area? Refer to figure. 1 The nurse is preparing to perform chest physiotherapy (CPT) on a client. Before determining the correct position in which to place the client, which information should the nurse ascertain? The lung areas involved A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client? Use a picture or word board. The nurse is caring for a restless client who keeps biting down on an orotracheal tube. The nurse uses which intervention to prevent the client from obstructing the airway with the teeth? Oral airway A client with active tuberculosis (TB) demonstrates less-than-expected interest in learning about the prescribed medication therapy. Which technique would the nurse ultimately need to employ in order to encourage participation? The nurse is collecting data on a client with chronic airflow limitation (CAL) and notes that the client has a "barrel chest." The nurse interprets that this client has which forms of CAL? Emphysema A client is at risk of developing a pulmonary embolism. The nurse monitors for which initial sign/ symptom? The nurse is assisting in caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse monitors the portable wound suction for which types of drainage expected in the immediate postoperative period? A client is admitted to the hospital with a diagnosis of carbon dioxide narcosis. In addition to respiratory failure, the nurse plans to monitor the client for which complication of this disorder? Increased intracranial pressure A client with acquired immunodeficiency syndrome (AIDS) has become infected with histoplasmosis. The nurse monitors the client for which signs and symptoms? Dyspnea A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. Which would be the appropriate nursing action? Notify the registered nurse. A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The nurse reviews the arterial blood gas reports for which results that are consistent with this disorder? Pao2 49 mm Hg, Paco2 52 mm Hg The nurse is assisting in caring for a postoperative client who had a pneumonectomy. The nurse monitors the client for which adverse signs and symptoms indicating acute pulmonary edema? Frothy sputum The nurse is assessing a client who has frequent episodes of asthma. Which assessment finding is most closely associated with asthma? The nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. Which action by the nursing student is incorrect, causing the clinical instructor to intervene? . A client with pneumonia is experiencing problems with ventilation as a result of accumulated respiratory secretions. The nurse determines that which accurately indicates effectiveness of the treatments prescribed for this problem? Arterial blood gases indicate a pH of 7.4, Po2 of 80 mm Hg, and Pco2 of 40 mm Hg. Which statement by the client indicates a need for further teaching regarding the reinforced home care instructions for acute sinusitis? A clinic nurse is reinforcing instructions to a client with a diagnosis of pharyngitis. Which intervention should the client be encouraged to perform? Avoid foods that are highly seasoned. A client arrives in the emergency department with a bloody nose. Which is the initial nursing action? The nurse is assisting in caring for a client with pneumonia who suddenly becomes restless. Arterial blood gases are drawn, and the results reveal a Pao2 of 60 mm Hg. The nurse reviews the plan of care for the client and determines that which priority problem potentially exists for this client? A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which arterial blood gas supports this diagnosis? The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. Based on this finding, the nurse makes which determination? The nurse is caring for a client following segmental resection of the upper lobe of the left lung. The nurse notes 700 mL of grossly bloody drainage in the chest tube drainage system during the first hour following surgery. Which statement represents the nurse's accurate interpretation of this finding? The nurse is assigned to assist in caring for a client with a chest tube drainage system. In planning for the client, the nurse makes certain that what equipment is available, in the event that the drainage system needs to be changed? Rubber-shod clamps A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. The licensed practical nurse should perform which action? The nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. Which observation by the nurse is inconsistent with the need for suctioning? The nurse is planning therapeutic interventions for a client who experienced a rib fracture 2 days earlier. The nurse understands that which intervention should be included? Select all that apply. Analgesics A client experiencing a pleural effusion had a thoracentesis. Analysis of the extracted fluid revealed a high red blood cell count. The nurse interprets that this result is consistent with which diagnosis? Trauma The nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which signs/symptoms support this diagnosis? Select all that apply. Early onset cough A client with arthritis of the hands and fingers is having difficulty using a metered-dose inhaler (MDI). The nurse suggests asking the health care provider for which prescription? Use of a spacer The nurse is collecting data on a client with chronic sinusitis. The nurse interprets that which client sign/symptom is unrelated to this problem? Severe evening headache A clinic nurse is assisting in caring for a client whose chief complaint is the presence of flulike symptoms. Which recommendation by the nurse is therapeutic? Select all that apply. Get plenty of rest. The nurse is caring for a client at home who has had a tracheostomy tube for several months. The nurse monitors the client for complications associated with the long-term tracheostomy and suspects tracheoesophageal fistula if which observation is noted for the client? The nurse is assisting in preparing a list of instructions for an adult client who is being discharged following a tonsillectomy. Which instructions should the nurse include in the list? Select all that apply. Avoid hot fluids. Avoid rough foods. Rest for the next 24 hours. The nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Which instructions should the nurse provide to the client? Select all that apply. Protect the stoma from water. The nurse is assisting a health care provider with the insertion of an endotracheal tube (ETT). The nurse should plan to ensure that which is done as a final measure to determine correct tube placement? Verify placement by a chest x-ray. The nurse reinforces instructing a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client? The client is breathing through the nose. A client with a diagnosis of lung cancer returns to the nursing unit after a left pneumonectomy. Which nursing actions should be done? Select all that apply. Administer humidified oxygen. Instruct on the use of the incentive spirometer. Monitor vital signs and pulse oximetry frequently. The nurse is observing a client with chronic obstructive pulmonary disease (COPD) performing the pursed-lip breathing technique. Which observation by the nurse would indicate accurate performance of this breathing technique? The nurse is preparing to assist a health care provider with the insertion of a chest tube. The nurse anticipates that which supplies will be required for the chest tube insertion site? Select all that apply. While assessing a client who is admitted to the hospital with a diagnosis of pleurisy, the nurse would note which characteristic symptom of this disorder? The nurse assessing a client diagnosed with laryngeal cancer would note which signs and symptoms? Select all that apply. Hemoptysis A sensation of a "lump" in the throat Hoarseness lasting more than 3 weeks A client is admitted to the nursing unit following a lobectomy. The nurse caring for the client notes that, in the first hour after admission, the chest tube drainage was 75 mL. During the second hour, the drainage dropped to 5 mL. Which finding does this indicate? . The nurse is reviewing the health care record of a client with a new onset of pleurisy. The nurse notes documentation that the client does not have a pleural friction rub, which was auscultated the previous day. How should this finding be interpreted? The nurse is monitoring a client following a motor vehicle crash. Which finding would indicate a need for chest tube placement? The nurse is planning care for a client whose oxygenation is being monitored by a pulse oximeter. Which intervention is important to ensure accurate monitoring of the client's oxygenation status? Instruct the client not to move the sensor. The nurse is assessing a client diagnosed with sinusitis. Which are signs and symptoms of sinusitis? Select all that apply. A client enters the urgent care center with epistaxis but no obvious facial injury. The nurse should take which action? Have the client sit down, lean forward, and apply pressure to the nose. A client with a nasal tumor is being admitted to the hospital. The nurse collects data about which primary symptom that the client is expected to exhibit? Nasal obstruction The nurse is caring for a client with laryngitis. Which interventions should the nurse implement? Select all that apply. The nurse is assisting a client, who underwent radical neck surgery, to get out of bed. How does the nurse provide support to this client, who is afraid to move the head? The nurse places a hand behind the client's head. A client with a suspected throat infection with Streptococcus needs to have a throat culture obtained. The nurse should take which action after obtaining the culture if the specimen cannot be delivered to the laboratory for at least an hour? Refrigerate the specimen. A client reports the chronic use of nasal sprays. The nurse reinforces instructions to this client about which piece of information related to chronic use of nasal sprays? The protective mechanism of the nose may be damaged. The nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which finding does the nurse expect to note during data collection? Chills and night sweats The nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse notes documentation of an airway problem because of thick respiratory secretions. The nurse should monitor for which item as the best indicator of an adequate respiratory status? Respiratory rate of 18 breaths per minute The nurse is listening to the client's breath sounds and hears musical whistling noises on inspiration and expiration scattered throughout the right lung fields. How should the nurse interpret these noises? Wheezes The nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator of the effectiveness of suctioning? Breath sounds are now clear. A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the health care provider whether this process should be delayed temporarily, based on administration of which medication to the client in the last hour? A hospitalized client is dyspneic and has been diagnosed with left pneumothorax by chest x-ray. Which sign or symptom observed by the nurse clearly indicates that the pneumothorax is rapidly worsening? A client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage. Which type of drainage is expected? Bloody The nurse is preparing a plan of care for the client who will be returning from surgery following a right lung wedge resection. Included in the plan of care is that in the postoperative period, the nurse should avoid which positioning? The nurse is monitoring a client for Biot's respirations. Which condition causes Biot's respirations? Which nursing actions would contribute to monitoring and maintaining a patent airway for the postoperative client? Select all that apply. Encouraging coughing and deep breathing Monitoring pulse oximetry readings frequently Encouraging the use of an incentive spirometer A postoperative client is using an incentive spirometer. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds, then exhales slowly. The client takes one breath and returns the incentive spirometer to the bedside. Based on this observation, which interpretation should the nurse make? The client should be repeating the sequence 10 to 20 times in each session. A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD) and has an arterial blood gas test done. Which results would the nurse expect to note? Po2 of 60 mm Hg and Pco2 of 50 mm Hg The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made? Coughing occurs with suctioning. A client with a respiratory disorder has anorexia secondary to fatigue and dyspnea while eating. The nurse determines that the client has followed the recommendations to improve intake if which action is taken? A client has undergone fluoroscopy-assisted aspiration biopsy of a lung lesion. The nurse determines that the client is experiencing complications from the procedure if the nurse makes which observation? The nurse has finished suctioning a client. The nurse should use which parameters to best determine the effectiveness of suctioning? Breath sounds are clear A client who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure if the nurse notes which sign/symptom? Breath sounds greater on the right than the left The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem? The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. The nurse analyzes this finding as indicative of which outcome? The system is functioning as expected. A client had thoracic surgery 2 days ago and has a chest tube in place connected to a closed chest tube system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines which? The nurse is reading the results of a tuberculin skin test for a client who has no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets the data as which result? Negative The nurse is working in a tuberculosis (TB) screening clinic. The nurse understands that which population is at highest risk for TB? Residents of a long-term care facility The nurse is collecting data on a client admitted to the hospital with suspected carbon monoxide poisoning and notes that the client behaves as if intoxicated. The nurse uses this data to make which interpretation? . A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation? The nurse is providing endotracheal suctioning to a client who is mechanically ventilated, when the client becomes restless and tachycardic. Which action should the nurse take? Monitor vital signs and discontinue attempts at suctioning until the client is stabilized. The nurse is discussing signs of severe airway obstruction with a group of nursing students. Which sign should the nurse emphasize as one that indicates severe airway obstruction? A client with chronic obstructive pulmonary disease (COPD) on bed rest is weaned from the ventilator before transferring to a medical unit. To adequately restore client strength before getting the client out of bed, which is the priority client activity for the nurse to incorporate in the plan of care? The nurse should plan to fill which chamber of the chest drainage unit to prevent atmospheric air from re-entering the pleural space? Refer to figure. 2 The nurse determines that which client is at greatest risk for development of acute respiratory distress syndrome (ARDS)? A client with pancreatitis and gram-negative sepsis The nurse is collecting data from a client with pneumonia. Chest auscultation over areas of consolidation reveals this breath sound. (Refer to audio.) The nurse should interpret this sound to be indicative of which breath sound? Bronchial breath sounds The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. (Refer to audio.) The nurse determines that these breath sounds usually are caused by which? In which area of the chest should the nurse expect to auscultate this breath sound? (Refer to audio.) The nurse is caring for a client who is suspected of having lung cancer. The nurse monitors the client for which most frequent early sign of lung cancer? A client who has had a radical neck dissection begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated? The nurse reads a client's tuberculin skin test as positive. The nurse notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse's response is based on the understanding that which statement is true for this client? The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which action as the best strategy to assist the client in coping with the disease? The nurse is caring for the client diagnosed with tuberculosis (TB). Which finding made by the nurse would be inconsistent with the usual clinical presentation of tuberculosis? High-grade fever A client diagnosed with tuberculosis (TB) is distressed over the loss of physical stamina and fatigue. The nurse should provide which explanation for these symptoms? Expected and the client should very gradually increase activity as tolerated A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which position for the procedure? Left side-lying with the head of the bed elevated at 45 degrees The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position because it will aggravate breathing? A client has undergone a right pneumonectomy. The nurse positioning this client following admission from the postanesthesia care unit avoids placing the client in which harmful position? The nurse is assisting a health care provider with the insertion of a wet-suction chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse plans to take which appropriate action? The nurse is caring for a client with a wet suction chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse should take which action? Immerse the end of the tube in sterile saline. A health care provider is about to remove a chest tube from a client. Once the dressing is removed and the sutures have been cut, the nurse assisting the health care provider asks the client to do which action? Perform the Valsalva maneuver. The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)? The nurse is assigned to assist in caring for a client who has a pneumothorax. The nurse notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. The nurse determines that this is indicative of which occurrence? A client who is postoperative with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed for which reason? A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could cause which difficulty? The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse should monitor the status of breath sounds in that area by placing the stethoscope in which location? Just under the left clavicle The nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure? A nursing student prepares to instruct a client to expectorate a sample of sputum that will be sent to the laboratory for Gram stain, culture, and sensitivity and describes the procedure to the licensed practical nurse (LPN), who is the primary nurse. The LPN corrects the student if which incorrect description is provided? The nurse is caring for the client who is at risk for lung cancer because of an extremely long history of heavy cigarette smoking. The nurse tells the client to report which frequent early symptom of lung cancer? The nurse is assisting in caring for a client with a tracheal tube attached to a ventilator when the high-pressure alarm sounds. The nurse checks the client and system for which most likely cause? . During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action? A client has a closed-chest tube drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. How does the nurse interpret this finding? The tube is patent. The nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder? Arterial Pao2 of 48 GI NCLEX 1. After a liver biopsy, the nurse should place the client in which position? A right side-lying position with a small pillow or folded towel under the puncture site 2. The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion? 3.5 3. The nurse is checking a client for the correct placement of a nasogastric (NG) tube. The nurse aspirates the client's stomach contents and checks its pH level. Which pH value indicates the correct placement of the tube? 4. A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. The LPN should reinforce instructing the client to perform which action? Take and hold a deep breath. 5. The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency? 6. The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. On review of the postoperative prescriptions, which should the nurse clarify? Irrigating the nasogastric (NG) tube 7. The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse include in client teaching to help prevent dumping syndrome? 8. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence? 9. The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to see documented in the record? Diarrhea 10. The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to note? Select all that apply. Encourage coughing and deep breathing. Administer anticholinergics, as prescribed. 11. It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing? 12. The nurse is reviewing the health care provider's prescriptions written for a client admitted with acute pancreatitis. Which health care provider prescription should the nurse verify if noted in the client's chart? 13. A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid? 14. The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred? Protruding and swollen 15. Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding? 16. The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa? 17. A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse tells the client to avoid which position that could aggravate the pain? Lying flat 18. The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse determines that the client understands the instructions given if the client states that which food item is acceptable to include in the diet? Turkey and lettuce sandwich 19. A client is admitted to the hospital with acute viral hepatitis. Which sign/symptom should the nurse expect to note based on this diagnosis? 20. Which infection control method should be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure? 21. client is admitted to the hospital with viral hepatitis and is complaining of a loss of appetite. In order to provide adequate nutrition, which action does the nurse encourage the client to take? 22. The nurse is caring for a client with acute pancreatitis and a history of alcoholism and is monitoring the client for complications. Which data should be indicative of paralytic ileus? Inability to pass flatus 23. A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention should be appropriate? 24. The nurse is participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse plans to include which risk factor for colorectal cancer in the material? 25. A client has undergone esophagogastroduodenoscopy (EGD). The nurse places highest priority on which action as part of the client's care plan? 26. The nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement made by the client supports the diagnosis of gastric ulcer? "My pain comes shortly after I eat, maybe a half hour or so later." 27. A client has been diagnosed with acute gastroenteritis. Which diet should the nurse anticipate to be prescribed for the client? 28. A client has asymptomatic diverticular disease. Which type of diet should the nurse anticipate being prescribed? 29. The nurse is caring for a client suspected of having appendicitis. Which should the nurse anticipate will be prescribed for this client? 30. The nurse has given the client with hepatitis instructions about postdischarge management during convalescence. The nurse determines that the client needs further teaching if the client makes which statement? 31. The nurse is assigned to care for a client who had a Sengstaken-Blakemore tube inserted when more conservative treatment failed to alleviate the condition. The nurse should suspect that the client has which diagnosis? Esophageal varices 32. The nurse has been caring for a client with a Sengstaken-Blakemore tube. The health care provider arrives on the nursing unit and deflates the esophageal balloon. Following deflation of the balloon, the nurse should monitor the client closely for which? 33. A health care provider places a Miller-Abbott tube in a client who has a bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next? 34. The nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which history is least likely associated with this disease? History of the use of acetaminophen (Tylenol) for pain and discomfort 35. A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which finding would indicate adequate location of the tube? 36. The nurse is caring for a client with a nasogastric tube. Which observation is most reliable in determining that the tube is correctly placed? 37. A client is admitted to the hospital with a bowel obstruction secondary to a recurrent malignancy, and the health care provider plans to insert a Miller- Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, "I don't want to hear about that. Just let the doctor do it." Based on the client's statement, which is the nurse's best action? 38. The nurse is assisting in planning stress management strategies for the client with irritable bowel syndrome. Which suggestion should the nurse give to the client? 39. A calcium supplement is prescribed for a client with hypoparathyroidism in the management of hypocalcemia. The client arrives at the clinic for a follow- up visit and complains of chronic constipation, and the nurse reinforces instructions to the client about measures to alleviate the constipation. Which comment by the client would indicate a need for further teaching? 40. A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures are most likely to promote coping? Select all that apply. to consult with the client before discharge. Ask the client to begin doing one part of the ostomy care and increase tasks daily. 41. Which statement by the spouse of a client with end-stage liver failure indicates the need for further teaching by the multidisciplinary team regarding the management of pain? "This opioid will cause very deep sleep, which is what my husband needs." 42. After the deflation of the balloon of a client's Sengstaken-Blakemore tube, the nurse monitors the client closely for which esophageal complication? Hemorrhage 43. The nurse is collecting data on a client admitted to the hospital with hepatitis. Which data indicate that the client may have liver damage? Pruritus 44. The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of liver disease. Which medication prescription should the nurse question? Acetaminophen (Tylenol) 45. A nurse planning care for a client with hepatitis plans to meet the client's safety needs by performing which action? 46. The nurse is collecting admission data on the client with hepatitis. Which finding would be a direct result of this client's condition? 47. The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. Which data noted in the record indicate poor absorption of dietary fats? Steatorrhea 48. A client is admitted to an acute care facility with complications of celiac disease. Which question should be helpful initially in obtaining information for the nursing care plan? "What is your understanding of celiac disease?" 49. A client is seen in the ambulatory care office for a routine examination. Which statement by the client would be important for the nurse to follow up? "I just lost a family member to gastrointestinal cancer." 50. A client with a possible hiatal hernia complains of difficulty swallowing. Which other sign/symptom is associated with a hiatal hernia? Heartburn and regurgitation 51. The nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent recurrence of symptoms. Which statement should be included in the teaching? "Avoid lying down for an hour after eating." 52. The nurse documents that a client with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which action? Eating low-fat or nonfat foods 53. Treatment measures have been implemented for a client with bleeding esophageal varices and have been unsuccessful. The health care provider states that a Sengstaken-Blakemore tube will be used to control the resulting hemorrhage. The nurse prepares for insertion via which route? Nasogastric 54. The nurse is caring for a client with a Sengstaken-Blakemore tube. To prevent ulceration and necrosis of oral and nasal mucosa, the nurse should plan to perform which action? 55. A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. Which data would further support this diagnosis? 56. The nurse should include which information when reinforcing home care instructions for a client who has peptic ulcer disease? 57. The nurse is reinforcing dietary instructions for a client with peptic ulcer disease. Which action does the nurse encourage the client to do? 58. The nurse has been reinforcing dietary teaching for a client with gastroesophageal reflux disease (GERD) who has a routine follow-up visit. Which behavior is the best indicator of a successful outcome for this client? 59. A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which items concerning ongoing self-management should the nurse reinforce to the client? Select all that apply. 60. The nurse who is reinforcing instructions to a client following gastric resection should include which suggestions? Select all that apply. 61. The nurse reinforces instructions to a client following a gastrectomy about the signs and symptoms of pernicious anemia, knowing what information? Regular monthly injections of vitamin B12 will prevent this complication. 62. The nurse who is assisting in the care of a client within the first 24 hours following a total gastrectomy for gastric cancer should avoid which intervention? Irrigating the nasogastric (NG) tube 63. The nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to absorb food. While carrying out this function, the nurse recalls that absorption is defined as which? The transfer of digested food molecules from the GI tract into the bloodstream 64. A health care provider asks the nurse to obtain a Salem Sump tube for gastric intubation. The nurse should correctly select which tube from the unit storage area? 65. The nurse has assisted in the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse plans to set the suction to which pressure? 66. A client has had a partial gastrectomy and the nurse is reinforcing discharge instructions. The nurse should tell the client about the need for which? Select all that apply. Iron supplements Calcium supplements Vitamin B12 injections 67. A client in the emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply. Milk of magnesia 68. The nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse should place the client in which position during and after the feedings? 69. The nurse is reinforcing discharge instructions to a client who has had a total gastrectomy. The nurse tells the client about the importance of returning to the health care clinic as scheduled for which priority assessment? Vitamin B12 and folic acid studies 70. The nurse assigned to care for a client with cirrhosis reviews the medical record and notes that the client has difficulty maintaining an effective breathing pattern due to pressure on the diaphragm. The nurse plans care knowing that which client position will best assist in facilitating breathing? 71. A client arrives at the emergency department and complains of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the health care provider's prescriptions. Which prescription should the nurse question if written on the health care provider's prescription form? Administration of an opioid analgesic 72. The nurse is caring for a client with a nasogastric (NG) tube and tests the pH of the aspirate to determine correct placement. The nurse notes that the pH is 5. Which information does this indicate? 73. A generally healthy 63-year-old man is seen in the health care provider's office for a routine examination. Which statement made by the client is important for the nurse to follow up on? "Everyone in my immediate family has died from gastrointestinal cancer." 74. A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse should gather further information about the presence of which sign or symptom? 75. The nurse is teaching a client who is newly diagnosed with a hiatal hernia about measures to prevent recurrence of symptoms. The nurse should make which accurate statement to the client? "Be sure to sleep with your head elevated in bed." 76. The nurse is reinforcing discharge instructions to a client with a hiatal hernia. Which should the nurse include in the teaching session? Select all that apply. Wait at least 1 hour after meals to perform chores. Be sure to elevate the head of the bed during sleep. 77. The nurse is reinforcing instructions to a client about insertion of a Sengstaken-Blakemore tube. Which statement by the client indicates an understanding of the teaching? 78. The nurse is assisting in caring for a client with a Sengstaken-Blakemore tube. Which article should the nurse place at the bedside? Scissors 79. A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting, and a gastric ulcer is suspected. The nurse should gather which additional supportive data from the client for this diagnosis? History of alcohol use, smoking, and weight loss 80. The nurse should include which instruction in a teaching plan for a client who has peptic ulcer disease? Learn to use stress reduction techniques. 81. The nurse is reinforcing dietary instructions for a client with peptic ulcer disease. Which statement made by the client indicates a need for further teaching? I will eat a bland diet only 82. A client has undergone subtotal gastrectomy and the nurse is preparing the client for discharge. Which item should be included when reinforcing instructions to the client about ongoing self-management? Smaller, more frequent meals should be eaten 83. The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse should include which instruction? Take actions to prevent dumping syndrome. 84. The nurse provides information to a client following a gastrectomy who is now diagnosed with pernicious anemia. Which instructions about pernicious anemia should the nurse reinforce? Select all that apply. . Use additional lightweight blankets as needed. Check blood serum vitamin B12 levels every 1 to 2 years. 85. The nurse is caring for a client within the first 24 hours following a total gastrectomy for gastric cancer. During this time frame, on which intervention should the nurse focus? Maintaining a patent nasogastric (NG) tube 86. The nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to digest food. Which processes are involved in the complete digestive process? Select all that apply. 87. A licensed practical nurse (LPN) is helping a registered nurse (RN) conduct an abdominal assessment. The LPN assists the client into which position? 88. A health care provider asks the nurse to obtain a Salem Sump tube for gastric intubation. The nurse selects which tube from the unit storage area? Tube with a lumen and an air vent 89. The nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression. Which settings will the health care provider prescribe? Select all that apply. Low Intermittent 90. The nurse is working with a client diagnosed with anorexia nervosa. The nurse plans care, focusing on which as the primary problem? 91. A client has been diagnosed with chronic gastritis and has been told that there is too little intrinsic factor being produced. The nurse tells the client that which therapy will be prescribed to treat the problem? 92. The nurse is caring for a client in the emergency department who has right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescription? 93. The nurse is performing an abdominal assessment on a client. The nurse interprets that which finding is abnormal and should be reported to the registered nurse (RN) or health care provider? 94. The nurse is interpreting the laboratory results of a client who has a history of chronic ulcerative colitis. Which result indicates a complication of ulcerative colitis? Hemoglobin 10.2 g/dL 95. A client diagnosed with pernicious anemia asks the nurse what caused the deficiency. The nurse replies that it is likely a result of which condition that is part of the client's health history? Hemigastrectomy 96. The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning and all connections are snug. The tube is secured properly and does not appear to have been dislodged. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. The nurse analyzes this problem as which? Channels of gastric secretions may be bypassing the holes in the tube; turning the 97. The nurse is preparing to administer a soapsuds enema to a client. Into which position does the nurse place the client to administer the enema? Refer to figure. 3 98. A postgastrectomy client is at high risk for hyperglycemia related to uncontrolled gastric emptying of fluid and food into the small intestine (dumping syndrome). Because of this risk, the nurse plans to monitor which data? 99. The nurse is caring for a client with pneumonia with a history of bleeding esophageal varices. Based on this information, the nurse plans care, knowing that which could result in a potential complication? 100. A client is admitted to the hospital with a diagnosis of acute pancreatitis. The nurse plans care, knowing that which problem occurs with this disorder? Alteration in comfort related to abdominal pain 101. A postgastrectomy client who is being discharged from the hospital tells the nurse, "I hope my stomach problems are over. I need to get back to work right away. I've missed a lot of work, and I'm really behind. If I don't get my act together, I may lose my job." Based on the client's statement, the nurse determines that at this time, it is appropriate to discuss which topic? Reducing stressors in life 102. The nurse gathers data from a client admitted to the hospital with gastroesophageal reflux disease (GERD) who is scheduled for a Nissen fundoplication. Based on an understanding of this disease, the nurse determines that the client may be at risk for which complication? 103. The nurse analyzes the results of laboratory studies performed on a client with peptic ulcer disease (PUD). Which laboratory value would indicate a complication associated with the disease? 104. The nurse is admitting a client to the hospital for the treatment of dehydration. The client reports nausea, vomiting, diarrhea, and cramping for the past week. The nurse asks the client about medications he is taking. The client denies taking prescription medications but states he has been taking some herbs given to him by his cousin. The nurse alerts the health care provider when the client states he has been taking which herb? Senna 105. The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed the nasogastric tube to be discontinued. To determine the client's readiness for discontinuation of the nasogastric tube, which measure should the nurse check? 106. A sexually active 20-year-old client has developed viral hepatitis. Which statement made by the client would indicate a need for teaching? 107. A client is admitted to the hospital with severe jaundice and is having diagnostic testing. Because the client has no complaints of fatigue, the client is encouraged to ambulate in the hall to maintain muscle strength. The client paces around the room but will not enter the hall. Which problem most likely is the reason for the client's reluctance to walk in the hall? 108. A client with viral hepatitis states to the nurse, "I am so yellow." The nurse should take which action? Assist the client in expressing feelings 109. The nurse is reviewing the medication record of a client with acute gastritis. Which medication noted on the client's record should the nurse question? 110. A client with peptic ulcer disease is scheduled for a pyloroplasty, and the client asks the nurse about the procedure. The nurse bases the response on which information? 111. A client with a peptic ulcer is scheduled for a vagotomy, and the client asks the nurse about the purpose of this procedure. The nurse tells the client that a vagotomy serves which purpose? 112. The nurse is instructing a client who had a herniorrhaphy about how to reduce postoperative swelling following the procedure. Which should the nurse suggest to the client to prevent swelling? 113. The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. Which is the appropriate nursing action? Stop the irrigation temporarily. 114. A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse should time the medication so that each dose is taken at which time? 115. A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. To aid the client in symptom management, the nurse suggests which diet? A low-fiber diet 116. A client is resuming a diet after partial gastrectomy. To minimize complications, the nurse should tell the client to avoid which practice? Drinking liquids with meals 117. The nurse has assisted the health care provider with a liver biopsy, which was done at the bedside. Upon completion of the procedure, the nurse assists the client into which position? 118. A licensed practical nurse (LPN) is assisting in the insertion of a nasogastric (NG) tube for an adult client. The LPN helps determine the correct length to insert the tube by performing which measurement? 119. A postoperative client has regained bowel sounds and is ready to start a clear liquid diet. The nurse is told that the health care provider has written a prescription to remove the nasogastric (NG) tube. The nurse assists in the procedure and asks the client to do which during tube removal? 120. The nurse has a prescription to give 30 mL of an antacid to a client through a nasogastric (NG) tube that is connected to wall suction. The nurse should do which action to perform this procedure correctly? 121. The nurse is caring for a client with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times? 122. The nurse will be providing postprocedure care to a client who has undergone esophagogastroduodenoscopy (EGD). The nurse should plan to do which action first? Monitor for return of the gag reflex. 123. A health care provider asks the licensed practical nurse (LPN) to reinforce preprocedure instructions to a client who will undergo a barium swallow (esophagography) in a few days. The LPN should include which instruction in this discussion? 124. The nurse notes that the medical record of a client with cirrhosis states that the client has asterixis. To verify this information the nurse should take which action? 125. A health care provider is about to perform a paracentesis on a client with abdominal ascites. The nurse should assist the client to assume which position? Upright 126. A client is receiving bolus feedings via a nasogastric tube. The nurse plans to place the client's head of the bed (HOB) in which optimal position once the feeding is completed? Elevated 30 to 45 degrees with the client in the right lateral position for 60 minutes 127. A client receiving a high cleansing enema complains of pain and cramping. The nurse should take which corrective action? 128. The nurse is getting a client who underwent umbilical hernia repair ready for discharge. The nurse tells the client that it is important to continue to do which action after discharge? 129. A client presents to the urgent care center with complaints of abdominal pain. Suddenly the client vomits bright red blood. The nurse takes which immediate action? 130. The nurse is reinforcing medication instructions to a client with peptic ulcer disease. Which represents correct information given by the nurse? of stomach acid. 131. A client with acute pancreatitis is experiencing severe pain. After noting an absence of an analgesic prescription on the health care provider prescription sheet, the nurse should suggest contacting the health care provider to request a prescription for which medication? 132. An acutely ill looking client arrives at the emergency department. The client complains of "the worst pain I ever felt in my belly. I can't get comfortable." The client is quiet but with each movement the client cries out in pain. The nurse suspects the client has peritonitis. Which data should the nurse collect to assist in validating this suspicion? Select all that apply. hiccups. Inspect the client's mucous membranes. 133. A client arrives at the emergency department complaining of severe abdominal pain and is placed on NPO status. During a quick assessment the nurse observes that the client has both Cullen's sign and Grey Turner's sign and pancreatitis is suspected. The nurse should perform the following actions/prescriptions in which priority order? Arrange the actions in the order they should be performed. All options must be used. Obtain vital signs and draw blood for laboratory analysis. pain medication. Hydrate the client with intravenous fluids. Place a nasogastric tube. Client is NPO (nothing by mouth). Inquire about when pain occurs and previous history including medications and alcohol. 134. A morbidly obese client, 3 days postoperative gastric bypass surgery, comes to the clinic complaining of pain. The nurse suspects that the client has an anastomotic leak requiring hospitalization. Which findings validate this suspicion? Select all that apply. Oliguria Restlessness 135. The nurse is reinforcing instructions to a client and his family about alcohol abuse and chronic cirrhosis. The nurse knows to include which essential elements in the discharge teaching guide? Select all that apply. of complications and when to seek prompt medical attention. Explain that cirrhosis of the liver is a chronic illness and the importance of continuous health care. Avoid spicy and rough foods and activities that increase portal pressure such as straining at stool, coughing, sneezing and vomiting. Cardio NCLEX 1. The nurse is assigned to assist with caring for a client after cardiac catheterization. The nurse should plan to maintain bed rest for this client in which position? - 2. A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL and a serum creatinine level of 2.2 mg/dL has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which? - Acute surgery. The nurse plans to do which to enable the client to best tolerate the ambulation? - Premedicate the client with an analgesic before ambulating. 3. A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which first? - Check the client status and lead placement. 4. The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply. - Administering oxygen - - Administering morphine sulfate intravenously 5. The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? - Status of airway 6. The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? - Limiting movement and abduction of the right arm 7. A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is which? - Pulmonary embolism 8. A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next? - 9. The nurse has reinforced instructions to the client with Raynaud's disease about self- management of the disease process. The nurse determines that the client needs further teaching if the client states which? - 10. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? - Crackles 11. The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition? - 12. The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which? - Normal, caused by increased blood flow through the leg 13. A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The nurse responds that this procedure may stimulate which? - 14. A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection? - 15. A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? - The boot has been applied too tightly. 16. A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the nurse best describe this type of anginal pain? - Variant angina 17. The nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? - 18. An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which description best describes the client's response? - 19. A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure? - 20. A client is scheduled for a dipyridamole thallium scan. The nurse should check to make sure that the client has not consumed which substance before the procedure? - 21. An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a noncardiac problem? - "Does the pain get worse when you breathe in?" 22. A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? -Bathroom privileges and self-care activities 23. The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use? -Surgical tourniquet 24. A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated? - 25. A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client? - 26. The nurse is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? - 27. The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply. - Be careful not to injure the legs or feet. - Walk each day to increase circulation to the legs. - Cut down on the amount of fats consumed in the diet. 28. A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse should become concerned with which fibrinogen level? - 90 mg/dL 29. A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The nurse should take which action first? - Assist the client to sit or lie down. 30. The nurse notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action? - 31. A client brings the following medications to the clinic for a yearly physical. The nurse realizes which medication has been prescribed to treat heart failure? - 32. assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? - Restricting the client's potassium intake 33. A client has an inoperable abdominal aortic aneurysm (AAA). Which measure should the nurse anticipate reinforcing when teaching the client? - 34. The nurse finds a client tensing while lying in bed staring at the cardiac monitor. Which is the nurse's best response when the client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!"? - "Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works?" 35. In order to assess the dorsalis pedis pulse of a client diagnosed with arterial vascular disease, the nurse palpates which anatomical location? Refer to 36. The nurse is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition? - 37. A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question should the nurse ask the client first? - 38. The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk? - Marking the location of the pedal pulses on the right leg 39. When preparing a client for a pericardiocentesis, which position does the nurse place the client in? - 40. For a client diagnosed with pulmonary edema, the nurse establishes a goal to have the client participate in activities that reduce cardiac workload. Which client activities will contribute to achieving this goal? - Using a bedside commode for stools 41. The nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse should perform which action? - 42. The nurse has reinforced home care instructions to a client who had a permanent pacemaker inserted. Which educational outcome has the greatest impact on the client's long-term cardiac health? - The ability to take an accurate pulse in either the wrist or neck 43. The clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client's apical pulse and places the stethoscope in which position? - At the midclavicular line at the fifth left intercostal space 44. The nurse is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L. The client asks the nurse why the oxygen is necessary. The nurse bases the response on which information? - Deficient oxygenation to heart cells results in angina pectoris pain. 45. The licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)? - Respirations and blood pressure 46. A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions? - "I need to adhere to my dietary restrictions." 47. The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu? - Lemonade 48. The nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question? - 49. The nurse has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? - "I should routinely use polyunsaturated oils in my diet." 50. The nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia? - 51. The nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia? - ST-segment depression 52. While the nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only the nurse. I want my doctor." Which response by the nurse should be therapeutic? - "So you're saying that you want to talk to your health care provider?" 53. The nurse reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information? - " 54. A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. The nurse interprets that the client is experiencing which type of angina? - Stable 55. The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statement by the client indicates a need for further teaching? - 56. The nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. The nurse plans to reinforce which information about this type of angina when teaching the client? - Prinzmetal's angina is generally treated with calcium channel blocking agents. 57. The nurse working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse? - The pain has not been unrelieved by rest and nitroglycerin tablets. 58. The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to the client to try to motivate the client to quit smoking? - "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." 59. A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as ongoing prescribed medications. The nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect? - Weight gain of 2 to 3 pounds in a few days 60. A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving if which breath sounds are noted? - 61. A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted? - 62. The nurse is providing discharge teaching for a post–myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement? - 63. The nurse determines that a client with coronary artery disease (CAD) needs further teaching about disease management if the client makes which statement? - 64. An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action? - . 65. The nurse is planning adaptations needed for activities of daily living for a client with cardiac disease. The nurse should incorporate which instruction in discussion with the client? - Take in adequate daily fiber to prevent straining during a bowel movement. 66. An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse calls the health care provider to verify a prescription for which medication that the client was taking before admission? - 67. Acetylsalicylic acid (aspirin) is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA). When the nurse takes the aspirin to the client, the client asks the nurse about its purpose. What is the purpose of the aspirin? - 68. The nurse is caring for a client with coronary artery disease, and a topical nitrate is prescribed for the client. Why is acetaminophen (Tylenol) usually prescribed to be taken before the administration of the topical nitrate? - 69. The nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention should be included in the postprocedure plan of care? - 70. The nurse is reinforcing dietary instructions to a client with heart failure (HF). The nurse determines that the client understands the instructions if the client states that which food item will be avoided? - Catsup 71. A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain and Raynaud's disease is diagnosed. Which factor would precipitate these episodes? - 72. A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems? - 73. The nurse is beginning to ambulate a client with activity intolerance caused by bacterial endocarditis. The nurse determines that the client is best tolerating ambulation if which parameter is noted? - Blood pressure that increases from 114/82 to 118/86 mm Hg 74. The nurse is assisting a hospitalized client who is newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu. The nurse encourages the client to select which meal? - Fresh strawberries, steamed vegetables, and baked fish 75. A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. The nurse should take which action? - Have the client stop and lie back down in bed. 76. The nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The nurse should place highest priority on making sure that which is available at the bedside? - Oxygen tubing and flowmeter 77. The nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which statement? - 78. A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). Which statement indicates an initial understanding of lifestyle alterations? - 79. The nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. Which should the nurse do next? - Explore with the client the sources of stress in life. 80. A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action? - 81. A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client? - 82. The nurse is reinforcing instructions to a client with angina pectoris about measures to reduce recurrence of chest pain. The nurse should stress to the client the importance of taking which measure? - Avoiding exposure to either very hot or very cold weather 83. The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which intervention to effectively accomplish this goal? - Provide a quiet and low-stimulus environment. 84. A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse should perform which intervention to care for this client in a holistic manner? - 85. The nurse carries out a standard prescription for a stat electrocardiogram (ECG) on a client who has an episode of chest pain. The nurse should take which action next? - Give sublingual nitroglycerin (Nitrostat) per the health care provider's prescriptions. 86. A client admitted to the hospital with a diagnosis of myocardial infarction (MI) tells the nurse that the pain likely resulted from the fried chicken sandwich that the client had for lunch. The nurse's response is based on which fact? - 87. The nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). Which are characteristics of a therapeutic environment? - Low stimulus, low stress 88. A client who experienced a myocardial infarction (MI) tells the nurse that he is fearful about not being able to return to a normal life. Which action by the nurse is therapeutic at this time? - Explore the specific concerns with the client. 89. A client complaining of chest pain has an as-needed (PRN) prescription for sublingual nitroglycerin (Nitrostat). Before administering the medication to the client, the nurse should first check which? - 90. A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." Which is an appropriate nursing response? - "You are concerned about losing your leg?" 91. The nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. The nurse should tell the client to do which? - 92. A client is admitted to the hospital with possible rheumatic heart disease. The nurse collects data from the client and checks the client for which signs/symptoms? - 93. A client with infective endocarditis is at risk for heart failure. The nurse monitors the client for which signs and symptoms of heart failure? - Lung crackles, peripheral edema, and weight gain 94. A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects the health care provider to write a prescription for the client to remain on bed rest. In which position should the bed be positioned? - 95. The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder? - 96. A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates understanding of this stress reduction measure? - "The best thing about this is that I can use it anywhere, anytime." 97. A client, who is 36 hours post–myocardial infarction, has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation is made? - The preactivity pulse rate is 86 beats per minute; the postactivity pulse rate is 94 beats per minute. 98. The nurse is planning a dietary menu for a client with heart failure being treated with digoxin (Lanoxin) and furosemide (Lasix). Which would be the best dinner choice from the daily menu? - 99. A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which symptoms? - 100. The nurse is caring for a client diagnosed with Buerger's disease. Which finding should the nurse determine is a potential complication associated with this disease? - 101. The nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for coronary artery disease (CAD). The nurse should determine the teaching is successful if the client states that which weight loss goal is safe? - 102. The nurse has reinforced instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. The nurse understands further teaching is needed if a family member makes which statement? - "A daily half-mile–long brisk walk generally helps people bounce back more quickly and provides more of a sense of control." 103. The nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as indicative of which finding? - 104. The nurse has completed counseling about smoking cessation with a client with coronary artery disease (CAD). The nurse determines that the client has understood the material best if the client makes which statement? - "A smoker has twice the risk of having a heart attack as a nonsmoker." 105. The nurse has given simple instructions on preventing some of the complications of bed rest to a client who experienced a myocardial infarction. The nurse should intervene if the client was performing which of these contraindicated activities? - Isometric exercises of the arms and legs 106. A client with a diagnosis of heart failure (HF) is preparing for discharge to home from the hospital. Which condition indicates the client is ready for discharge to home? - . 107. A client admitted to the hospital with coronary artery (CAD) disease complains of dyspnea at rest. The nurse determines that which would be of most help to the client? - Elevating the head of the bed to at least 45 degrees 108. The nurse is evaluating the effects of care for the client with deep vein thrombosis. Which limb observations should the nurse note as indicating the least success in meeting the outcome criteria for this problem? - 109. A client is at risk for complications of heart failure. Which is the nurse's priority for early detection of the most likely cause of complications with this client? - Evaluating total body fluid 110. A female client complains of an "odd, left-sided, twinge-like pain" along the anterior axillary line and states she has had this feeling for the past 3 days. Which is the initial action? - Determine if the pain is cardiac in origin. 111. A client's blood pressure is 100/78 mm Hg; the client has tachycardia and is cool and pale. The nurse assists the client to which position to promote tissue oxygenation and alleviate hypoxia? - Semi-Fowler's 112. The nurse notes this rhythm on the client's cardiac monitor. The nurse next reports that the client is experiencing which heart rhythm? Refer to figure. - 113. The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse institute when providing care for the client? - . 114. The nurse is using a stethoscope to listen to the client's heart and hears this sound. (Refer to audio.) To assist in identifying the sound, the nurse should take which initial and best action? - Palpate the carotid pulse for a pulsation. 115. The nurse is caring for a client who has a malignant lung neoplasm and has developed cardiopulmonary complications. On auscultation, the nurse hears these breath sounds over the left lower sternal border (over the apical area) and interprets the sounds as which? (Refer to audio.) - 116. The nurse is auscultating a client's heart sounds and hears these sounds. (Refer to audio.) The nurse identifies these as being produced during which phase of the cardiac cycle? - Passive filling phase of ventricles 117. A hypertensive client who has been taking metoprolol (Lopressor) has been prescribed to decrease the dose of the medication. The client asks the nurse why this must be done over a period of 1 to 2 weeks. In formulating a response, the nurse incorporates the understanding that abrupt withdrawal could affect the client in which way? - Precipitate rebound hypertension 118. A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation? - The ulcer has a brownish or "brawny" appearance. 119. A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed, the nurse places a sign above the bed stating that the client should remain on bed rest and in which position? -With the head of the bed elevated no more than 15 degrees 120. A client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned, knowing that this level could lead to which complication? - 121. A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active? - 122. The nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development? - Hypokalemia 123. A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN should assist the RN by placing the bed in which position for the reading? - 124. The nurse is assisting a client who will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. The nurse takes which action to assist the client? - 125. A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which typical characteristic? - Deep and painful 126. The nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which food items from the dietary menu? - Baked haddock, steamed broccoli, herbed rice, sliced strawberries 127. The nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse should reinforce with the client the importance of complying with which measure to prevent a recurrence? - Weigh self every morning before breakfast. 128. The nurse is assisting in the care of a client diagnosed with rheumatic heart disease. The nurse should reinforce instructions to the client to notify the dentist before dental procedures for which reason? - 129. A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next? - 130. The health care provider is discharging a client with a diagnosis of chronic heart failure. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. - Obtain annual influenza vaccination. - - Report a weight gain of 3 or more pounds in a week. 131. The nurse is preparing for a health fair about tobacco use and the development of coronary heart disease. Which information should the nurse include? Select all that apply. - Nicotine decreases oxygen to the heart. - Hypnosis may be helpful to stop smoking. - Avoid exposure to environmental tobacco smoke. 132. The nurse is caring for a client with a new onset of atrial fibrillation. Which prescribed treatments should the nurse expect? Select all that apply. - Digoxin (Lanoxin) - 133. A client with hyperlipidemia is seen in the clinic for a follow-up visit. Which dietary modifications should the nurse include to lower the risk of coronary heart disease? Select all that apply. - Use liquid vegetable oil. - - Remove skin from poultry. 134. The nurse is caring for a client with left-sided heart failure. Which clinical signs are most important for the nurse to communicate to the health care provider? Select all that apply. - Pink-tinged frothy sputum - Increase in respiratory rate - Auscultation of crackles throughout the lungs 135. The nurse is admitting a client with acute pericarditis who reports chest pain. When planning the client's care, which position should the nurse encourage the client to assume to alleviate the chest pain? Select all that apply. - 136. The health care provider is discharging a client with a diagnosis of primary hypertension. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. - Monitor the blood pressure at home. - Restrict sodium intake as prescribed. - Eye examinations with an ophthalmoscope should be routine. - Follow-up appointments for blood pressure checks are important. 137. The nurse is caring for a client in the cardiac care unit with heart disease. The nurse knows that the direction of blood flows through the heart and lungs in which order? Please arrange the blood flow in the direction of flow. All options must be used. - Blood flows to the right atrium from the superior and inferior vena cavae. - Blood flows from the right atrium to the right ventricle via the tricuspid valve. - Blood flows from the right ventricle to the lungs for oxygenation. - Blood flows from the lungs to the left atrium. - Blood flows from the left atrium via the mitral valve to the left ventricle. - Blood flows from the left ventricle to the aorta and then to the systemic circulation. Neurology NCLEX 1. The nurse is reinforcing home-care instructions to a client and family regarding care after cataract removal from the right eye. Which statement made by the client indicates an understanding of the instructions? "I should not sleep on my right side." 2. The nurse is assisting with caring for a client after a craniotomy. Which is the best position for the client to be placed? 3. The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to Figures. A 4. The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially? 5. Which intervention should be implemented for the older client with presbycusis who has a hearing loss? . 6. The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply. To avoid activities that require bending over To place an eye shield on the surgical eye at bedtime 7. The nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care? Eye medications will need to be administered for the rest of your life. 8. The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record? A sense of a curtain falling across the field of vision 9. The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment? Complaints of a burst of black spots or floaters 10. A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position should the nurse prepare to position the client? On bed rest in a semi-Fowler's position 11. A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action? Apply ice to the affected eye. 12. A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure? Irrigating the eye with sterile normal saline 13. The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action? Report the finding to the registered nurse (RN). 14. The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique? 15. The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication? 16. A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed? 17. The nurse notes that the health care provider has documented a diagnosis of presbycusis on the client's chart. The nurse understands that this condition is accurately described as which? 18. A client with Ménière's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist in controlling the vertigo? Avoid sudden head movements. 19. The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client? 20. A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma? 21. Betaxolol hydrochloride (Betoptic) eyedrops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication? Monitoring blood pressure 22. The nurse assists to prepare the client for ear irrigation as prescribed by the health care provider. Which action should the nurse plan to take? 23. In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse administers the eyedrops knowing that the purpose of this medication is which? Dilate the pupil of the operative eye. 24. The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which? Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 25. The client is receiving an eyedrop and an eye ointment to the right eye. Which action should the nurse take? 26. The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question? Atropine sulfate (Isopto Atropine) 27. The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply. Wash hands. Put on gloves. . 28. A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint? 29. Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity? 30. A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which? "The medication causes the pupil to constrict and will lower the pressure in the eye." 31. A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply. Pad the bed's side rails. Place an airway at the bedside. the bedside. 32. The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising? Increasing temperature, decreasing pulse, decreasing respirations, increasing BP 33. The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse? 34. The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity? 35. The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria? 36. The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time? The health care provider reviews the x-ray results. 37. The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom? 38. The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively? 39. The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client? 40. The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? ." 41. The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted? Severe, throbbing headache 42. The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action? Limiting bladder catheterization to once every 12 hours 43. The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take? Raise the head of the bed and remove the noxious stimulus. 44. The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply. Face the client when talking. Speak slowly and maintain eye contact. 45. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which items into the client's room? 46. The nurse is attempting to communicate with a hearing-impaired client. Which strategy by the nurse would be least helpful when talking to this client? Smiling continuously during conversation 47. The nurse is reviewing the record of a client with mastoiditis. The nurse should expect to note which documented characteristic regarding the results of the otoscopic examination? Red, dull, thick, and immobile tympanic membrane 48. A client is diagnosed with a disorder involving the inner ear. The nurse caring for the client understands that which is the most common client complaint associated with a disorder involving the inner ear? Tinnitus 49. The nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. The nurse should expect to note documentation of which early symptom of this disorder? Ringing in the ears 50. The nurse provides discharge instructions to the client who was hospitalized for an acute attack of Ménière's disease. Which statement made by the client indicates a need for further teaching? 51. The nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching? "I should turn the hearing aid off after removing it from my ear." 52. Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test and determines that the intraocular pressure is normal if which result is noted? 15 mm Hg 53. The nurse is assisting in developing a plan of care for the client scheduled for cataract surgery. The nurse makes suggestions regarding the plan, knowing that which problem is specifically associated with this type of surgery? Sensory perceptual alteration 54. The nurse is reviewing the health record of a client diagnosed with a cataract. The initial sign/symptom that the nurse should expect to note in the early stages of cataract formation is which? Blurred vision 55. The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position? On the nonoperative side 56. During the early postoperative stage, the cataract extraction client complains of nausea and severe eye pain over the operative site. Which action should the nurse implement? Report the client's complaints. 57. The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which finding should be an early indication that the level of consciousness (LOC) is deteriorating? Drowsiness 58. The nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item should be included as part of the precautions? Maintaining the head of the bed at 15 degrees 59. The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated? Restrain the client's limbs. 60. The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client? Within the client's reach, on the left side 61. The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which? Remind the client to turn the head to scan the lost visual field. 62. A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has experienced which precipitating factor? Omitted doses of medication 63. A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse should plan which approach as therapeutic in assisting the client to cope with the disease? Encourage and praise perseverance in exercising and performing ADL. 64. The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client made which statement? "I will try to eat my food either very warm or very cold." 65. A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety? Provide a clear path for ambulation without obstacles. 66. The nurse reinforces home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further teaching? "I need to remove the eye dressing as soon as I get home and place a warm pack on my eye." 67. The nurse provides dietary instructions to a client with Ménière's disease. The nurse tells the client that which food or fluid item is acceptable to consume? Sugar-free Jell-O 68. The nurse is caring for a client who will be undergoing surgical treatment for Ménière's disease. The nurse plans care based on which expected outcome? The surgery relieves pressure from accumulation of inner ear fluid in the endolymphatic sac. 69. A clinic nurse notes that following several eye examinations the health care provider has documented a diagnosis of legal blindness in the client's chart. Which should the nurse expect to note documented as the result of the Snellen chart test? 20/200 vision 70. The nurse is assigned to administer the prescribed eye drops for a client preparing for cataract surgery. Which type of eye drops should the nurse expect to be prescribed? A mydriatic medication 71. A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions? "I will wear my eye shield at night and my glasses during the day." 72. A client with glaucoma asks the nurse if complete vision will return. The nurse should make which response to the client? "Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan." 73. A client with retinal detachment is admitted to the outpatient nursing unit in preparation for a scleral buckling procedure. Which prescription should the nurse anticipate? Placing an eye patch over the client's affected eye 74. The nurse should check for vision loss in a client with which condition? Diabetes mellitus 75. The nurse is assisting the health care provider with performing a Weber tuning fork test on a client. What does this test assess for? Hearing loss 76. The nurse is providing discharge instructions for a client who has had a fenestration procedure for the treatment of otosclerosis. Which statement by the client indicates an understanding of the instructions? "I will take stool softeners as prescribed by my doctor." 77. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve should identify a complication specifically associated with this surgery? Cranial nerve VII, facial nerve 78. The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? Bloody or clear drainage from the auditory canal 79. The nurse is assigned to care for a client with a diagnosis of Ménière's disease. Which part of the ear is affected with Ménière's disease? Inner ear 80. Surgery has been recommended for the client with otosclerosis. The client tells the nurse that she would prefer not to have surgery and asks the nurse about alternative methods to improve hearing. The nurse should make which appropriate response to the client? "A hearing aid may improve your hearing." 81. The nurse is caring for a client hospitalized with an acute attack from Ménière's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which response should the nurse make to the client regarding the hearing loss? "The attack leaves a hearing loss in the involved ear." 82. The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of an acute attack of Ménière's disease. Which prescription noted on the client's chart should the nurse question? The administration of a vasoconstrictor 83. A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse reinforces instructions to the client regarding home care following the procedure. Which statement by the client indicates a need for further teaching? "I need to avoid air travel for at least 6 months." 84. The nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which should be included on the list of instructions prepared for the client? "You need to avoid air travel." 85. A myringotomy is performed on a client in the ambulatory care center. The ambulatory care nurse calls the client 24 hours after the procedure to evaluate the status of the client. The client reports to the nurse that a small amount of brownish drainage has been coming from the ear. Which instruction should the nurse provide to the client? "Continue to monitor the drainage because this is normal and may occur for 24 to 48 hours following the surgery." 86. A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? Walker 87. The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client? Encouraging multiple visitors at one time 88. A client with a neurological impairment experiences urinary incontinence. Which nursing action should help the client adapt to this alteration? Establishing a toileting schedule 89. The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems? Allergy to pollen 90. A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which action by the family? Encouraging the client to stand unassisted on the leg 91. The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which should the nurse check before the procedure? Allergy to iodine or shellfish 92. A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which finding noted in the client history indicates that the client may be ineligible for this diagnostic procedure? Prosthetic valve replacement 93. A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse should provide reassurance to the client about the procedure? "Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure." 94. The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client? Explaining equipment and procedures on an ongoing basis 95. The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should avoid which action during this procedure? Making sure not to suction for longer than 30 seconds 96. The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which complication of hypothermia blanket use? Skin breakdown 97. The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center which is located in which part of the brain? Hypothalamus 98. A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client makes which statement? "I can resume a full activity level immediately." 99. The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How should the nurse interpret the client's situation? It is possible the client can hear the family. 100. The nurse is providing care to a client with increased intracranial pressure (ICP). Which approaches would be beneficial in controlling the client's ICP from an environmental viewpoint? Select all that apply. Reducing environmental noise Maintaining a calm atmosphere Allowing the client uninterrupted time for sleep 101. The nurse is preparing to give the postcraniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate and not "something stronger." The nurse should formulate a response based on which understanding of codeine? Codeine does not alter respirations or mask neurological signs as do other opioids. 102. The nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further teaching? "I will not hear sounds clearly unless they are loud." 103. The nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance? Indicates that facial puffiness will be a permanent problem 104. A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. Which is the best response by the nurse? Acknowledge the client's anger and continue to encourage participation in care. 105. A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this? Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable. 106. A client who is paraplegic after spinal cord injury has been taught muscle- strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity? Doing active range of motion to finger joints 107. A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will do which? Wear the patch continuously, alternating eyes each day. 108. The nurse is planning care for a client in spinal shock. Which action would be least helpful in minimizing the effects of vasodilation below the level of the injury? Moving the client quickly as one unit 109. The nursing instructor asks a nursing student about the points to document if the client has had a seizure. The instructor determines that the student needs to research seizures and related documentation points if the student states which assessment is important? Client's diet in the 2 hours preceding seizure activity 110. The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measure should the nurse avoid in planning for the client's safety? Putting a padded tongue blade at the head of the bed 111. The nurse has given medication instructions to the client receiving phenytoin (Dilantin). The nurse determines that the client understands the instructions if the client makes which comment? "Good oral hygiene is needed, including brushing and flossing." 112. A client with a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the should nurse avoid which action? Giving the client thin liquids 113. The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client? Completing the sentences that the client cannot finish 114. A client receives a dose of edrophonium (Enlon). The client shows improvement in muscle strength for a period of time following the injection. The nurse should interpret this finding as indicative of which disease process? Myasthenia gravis 115. A client with myasthenia gravis is having difficulty speaking. The client's speech is dysarthric and has a nasal tone. The nurse should use which communication strategies when working with this client? Select all that apply. Listening attentively Asking yes and no questions when able Using a communication board when necessary Repeating what the client said to verify the message 116. The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by which activity? Taking medications on time to maintain therapeutic blood levels 117. The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statements? "Going to the beach will be a nice, relaxing form of activity." 118. A client with Parkinson's disease is experiencing a parkinsonian crisis. The nurse should immediately place the client where? In a quiet, dim room with respiratory and cardiac support available 119. The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will perform which activity? Rock back and forth to start movement with bradykinesia. 120. An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets that a negative value of which is consistent with normal findings? Red blood cells 121. The nurse is collecting data on a client with a diagnosis of meningitis and notes that the client is assuming this posture. (Refer to figure.) The nurse contacts the health care provider and reports that the client is exhibiting which? Opisthotonos 122. An older gentleman is brought to the emergency department by a neighbor who heard him talking and wandering in the street at 3 am. The nurse should first determine which about the client? Whether this is a change in his usual level of orientation 123. An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client's daughter. The daughter states that this is the first time that the client experienced confusion. The nurse determines from this piece of information that which is unlikely to be the cause of the client's disorientation? Alzheimer's disease 124. A resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." An appropriate response by the nurse is which? "I'm glad you told me that. Let's have a cup of coffee and you can tell me about your father." 125. The nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which information? Masklike facies is a component of Parkinson's disease. 126. The nurse is communicating with a client who is hard of hearing in both ears. To facilitate communication with this client, the nurse should perform which? Lower the voice pitch and face the client when speaking. 127. The nurse overhears the term sundowning used to describe the behavior of a client newly admitted to the nursing unit during the previous evening shift. Of which diagnosis is sundowning a symptom? Alzheimer's disease 128. The nurse has reinforced discharge instructions to the client who has had ocular surgery of the right eye. The nurse determines that the client needs further teaching if the client states which? "I will call the health care provider if a temperature of 99° F is present." 129. A client with glaucoma has suffered significant eye damage before diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client makes which statement? "There is no difficulty driving at dusk." 130. A client in the emergency department is diagnosed with Bell's palsy. The nurse collecting data on this client expects to note which observation? A lag in closing the bottom eyelid 131. An adult client with suspected meningitis has undergone lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis of a bacterial infection. The nurse checks for which value indicating a bacterial infection of the CSF? Decreased glucose level 132. A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which question will elicit information regarding the signs/symptoms associated with this disorder? "Have you had difficulty with peripheral vision?" 133. The nurse is preparing to reinforce instructions to a client with glaucoma regarding the prescribed treatment measures for the disorder. The nurse prepares the instructions based on which treatment goal? Maintaining intraocular pressure at a reduced level 134. The nurse in the outpatient unit is preparing a client who is scheduled for a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which instructions should the nurse reinforce to the client? "You may return to work 1 or 2 days following the procedure." 135. The nurse reinforces instructions to a client with glaucoma regarding measures that will prevent an increase in intraocular pressure in the eyes. Which statement by the client indicates a need for further teaching? "I can tie my shoelaces by bending over slowly." 136. A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestation associated with this disorder should the nurse expect to be documented in the client's record? Painless, progressive loss of vision 137. Prescriptive glasses are prescribed for a client with bilateral aphakia, and the nurse reinforces instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for further teaching? "The prescriptive glasses will correct my visual field of sight." 138. A client is brought to the ambulatory care department by the spouse one day following a cataract extraction procedure. A diagnosis of hyphema is made, which occurred as a result of the surgical procedure. The nurse reinforces instructions to the client and spouse regarding the treatment for the complication and makes which statement? "Maintain bed rest and patching of both eyes." 139. The nurse is reinforcing preoperative instructions to a client scheduled for cataract surgery and prepares a written list of instructions for the client. Which statement by the client indicates a need for further teaching? "I can drink any liquids that I want to on the morning of the surgery." 140. The nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse should expect the client to report which symptom? Blurred central vision 141. The nurse is reinforcing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which instruction should the nurse include in the teaching plan for the client? Apply a warm compress for 15 minutes four times daily. 142. The nurse in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse should take which action? Notify the registered nurse. 143. A client arrives at the emergency department after experiencing a traumatic blow to the eye and a hyphema is diagnosed. In which position should the nurse place the client? In semi-Fowler's position 144. A client who was hit in the eye with a baseball bat sustains a contusion of the eyeball. The emergency department nurse implements which immediate action? Applies ice to the affected eye 145. A client arrives in the emergency department with an eye injury caused by metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse plan to assist with first? Irrigate the eye with sterile saline. 146. A client arrives in the emergency department with a chemical eye injury. The nurse immediately performs which action? Irrigates the eye with copious amounts of sterile normal saline 147. The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan? Administering medications that will dilate the pupil 148. The nurse is providing discharge instructions to a client following a keratoplasty. Which statement by the client indicates the need for further teaching? "Sutures are removed in 2 weeks." 149. The nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse should take which action? Notify the registered nurse. 150. The nurse is monitoring a client with a head injury and notes that the client is assuming the posture shown in the figure. What is the client exhibiting that would require the nurse to notify the registered nurse immediately? Refer to the figure. Decorticate posturing 151. The nurse is inserting soft contact lenses into the eyes of a client. Which direction does the nurse tell the client to look? Straight ahead 152. The nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs further teaching regarding the eye drop application of pilocarpine hydrochloride (Isopto Carpine)? Select all that apply. "I should apply the eye drops directly over my family member's pupil." "I have to contact the prescriber if my family member develops a small pupil." "I need to wipe off the tip of the eye drop bottle with a tissue between administrations." 153. The nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle crash. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation? Extension of the extremities and pronation of the arms 154. The nurse is caring for a client diagnosed with Bell's palsy 1 week ago. Which data would indicate a potential complication associated with Bell's palsy? Excessive tearing 155. The nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data should focus on which characteristic of this disease? Recent memory loss 156. The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply. Bowel sounds are absent. The client's abdomen is distended. Respiratory excursion is diminished. Accessory muscles of respiration are areflexic. 157. The nurse is ambulating a client with a known seizure disorder. The client says, "I'm seeing those flashing lights again," then loses consciousness and develops a clonic-tonic seizure. Which would be the nurse's initial action? Assist the client to the floor. 158. The nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement? "I can't swallow very well today." 159. The nurse is providing client teaching regarding glaucoma. Which instructions are important to include in the teaching plan? Select all that apply. Follow a low-sodium, minimal-caffeine diet with plenty of fiber. Be sure to report halos of light or increased eye pain to your health care provider. 160. A client arrives at the emergency department following a blow to the eye from a softball. Which intervention should be implemented by the nurse initially? Apply ice to the affected eye. 161. While at home, the nurse receives a telephone call from a neighbor, who reports that while accidentally breaking a mirror, a piece of glass flew into her eye. Which is the appropriate initial nursing action after observing that the large glass shard is protruding from the neighbor's eye? Secure a paper cup over the affected eye. 162. A client arrives at the emergency department following an eye injury in which an acid used to clean the brick on the fireplace splashed into the eye. Which question should the nurse ask initially? "Did you flush the eye following the injury?" 163. The nurse is caring for a client following enucleation. Which postsurgical observation requires immediate attention by the nurse? Bright red drainage on the dressing 164. Which instruction is appropriate for the nurse to provide to a client who reports via telephone that he is certain an insect has flown into his ear because he can hear it "buzzing"? Use a flashlight to coax the insect out of the ear. 165. Which statement by the nurse indicates an understanding of the diagnosis of presbycusis? "It is a sensorineural type of hearing loss that occurs with aging." 166. The nurse determines that the client diagnosed with Ménière's disease understands the reinforced dietary instructions when the client states that which food will be avoided in the diet? Hot dogs 167. The nurse is assisting in developing a plan of care for a client following the surgical removal of an acoustic neuroma. Which assessment will be included in the plan of care for this specific intervention? Assessment of cranial nerve VII (facial) 168. A client is being discharged from the ambulatory care unit following cataract removal. Which instruction from the discharge teaching plan should the nurse reinforce? Take acetaminophen (Tylenol) if any discomfort occurs. 169. The nurse is reinforcing instructions to a client following a cataract extraction on the right eye. Which statement by the client indicates a need for further teaching? "I need to wear an eye shield all the time." 170. When the nurse documents the results of a Snellen vision test as 20/80 vision, the client asks the nurse to describe what these numbers mean. Which statement is the appropriate response? "You can read at a distance of 20 feet what a client with normal vision can read at 80 feet." 171. Which information will the nurse reinforce to the client scheduled for a lumbar puncture? An informed consent will be required. 172. The nurse is reinforcing instructions to a client taking divalproex sodium (Depakote). The nurse tells the client to return to the clinic for follow-up laboratory studies related to which test? Liver function studies 173. Which data collection finding supports the possible diagnosis of Bell's palsy? Speech or chewing difficulties accompanied by facial droop 174. The nurse reviews the health care provider's treatment plan for a client with Guillain-Barré syndrome. Which prescription noted in the client's record should the nurse question? Clear liquid diet 175. A client has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which action to determine whether the client is ready to begin sitting up? Compares the client's pulse and blood pressure when both flat and sitting 176. A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client? Monitoring the respiratory rate 177. A client with myasthenia gravis is experiencing prolonged periods of weakness. The health care provider prescribes a test dose of edrophonium (Enlon) and the client becomes weaker. The nurse interprets this outcome as indicative of which result? Cholinergic crisis 178. The nurse is assisting in gathering data on cranial nerve XII of a client who sustained a brain attack (stroke). The nurse understands that the client should be asked to perform which action? Extend the tongue. 179. The nurse is assisting to perform a Romberg test on a client being seen in the clinic. The nurse performs this test to make which determination? The ability of the vestibular apparatus in the inner ear 180. A perforated eardrum is suspected in a client who was hit in the ear with a basketball. Which documented observation concerning an otoscopic examination supports this suspicion? A round or oval darkened area on the eardrum 181. The nurse is assisting in performing a confrontation test on a client seen in the clinic. The nurse understands that this test is performed to check which client ability? The ability to demonstrate effective peripheral vision 182. The nurse in a health care clinic is assisting to test the client for accommodation. The nurse should ask the client to perform which initial action? Focus on a distant object. 183. The nurse is reviewing the medical record of a client diagnosed with amyotrophic lateral sclerosis (ALS). Which initial sign/symptom of this disorder supports this diagnosis? Mild clumsiness 184. The nurse is assisting in caring for a client with a supratentorial lesion. The nurse monitors which criterion as the critical index of central nervous system (CNS) dysfunction? Level of consciousness 185. The nurse caring for a client following a craniotomy monitors for signs of increased intracranial pressure (ICP). Which indicates an early sign of increased ICP? Confusion 186. Acetazolamide is prescribed for a client with a diagnosis of a supratentorial lesion. The nurse monitors the client for effectiveness of this medication, knowing which is its primary action? Decrease cerebrospinal fluid production 187. Which sign/symptom is observed in the clonic phase of a seizure? Extension spasms of the body 188. The nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply. Suction machine Oxygen administration Padding for the side rails Prescribed diazepam (Valium) 189. The nurse is preparing for the admission of a client with a diagnosis of early stage Alzheimer's disease. The nurse assists in developing a plan of care, knowing that which is a characteristic of early Alzheimer's disease? Forgetfulness 190. The clinic nurse is reviewing the medical record of a client scheduled to be seen in the clinic. The nurse notes that the client is prescribed selegiline hydrochloride (Eldepryl). The nurse understands that this medication is prescribed for which diagnosis? Parkinson's disease 191. The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. Which documented early symptom supports this diagnosis? Vertigo 192. The nurse is assisting in caring for a client with a suspected diagnosis of meningitis. The nurse reinforces to the client information regarding which diagnostic test that is commonly used to confirm this diagnosis? Lumbar puncture 193. The nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. Which diagnostic test should be prescribed to confirm this diagnosis? Brain biopsy 194. The nurse is caring for a client with a diagnosis of multiple sclerosis who has been prescribed oxybutynin (Ditropan). The nurse evaluates the effectiveness of the medication by asking the client which question? "Are you getting up at night to urinate?" 195. The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. Which sign/symptom is considered a primary symptom of this syndrome? Development of muscle weakness 196. A thymectomy via a median sternotomy approach is performed on a client with a diagnosis of myasthenia gravis. The nurse has assisted in developing a plan of care for the client and includes which nursing action in the plan? Monitor the chest tube drainage. 197. The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric brain attack (stroke). The nurse notes that the client is alert and oriented to time and place. Based on these findings, the nurse makes which determination? The client may have perceptual and spatial disabilities. 198. The nurse is preparing to care for a client with a diagnosis of brain attack (stroke). The nurse notes in the client's record that the client has anosognosia. The nurse plans care, knowing which is a characteristic of anosognosia? The client neglects the affected side. 199. The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse incorporates communication strategies in the plan of care, knowing that the client's speech should fit which characterization? Associated with poor comprehension 200. The nurse is caring for a client with a diagnosis of brain attack (stroke) with anosognosia. To meet the needs of the client with this deficit, which action does the nurse plan? Increase the client's awareness of the affected side. 201. The nurse is caring for a client who sustained a spinal cord injury. While administering morning care, the client developed signs and symptoms of autonomic dysreflexia. Which is the initial nursing action? Elevate the head of the bed. 202. Prescriptive eyeglasses are prescribed for a client with bilateral aphakia. When reinforcing teaching instructions regarding the eyeglasses, the nurse determines the need for further teaching when the client makes which statement? "My peripheral vision will not be distorted." 203. The nurse has reinforced instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further teaching? "No eating or drinking for at least 18 hours before the surgery." 204. The nurse in the recovery room area is preparing to care for a client following cataract extraction of the right eye. Which position does the nurse prepare to place the client? On the left side with the head of the bed elevated 205. A client who sustained an eye injury arrives at the emergency department. Which is the initial nursing action? Obtain a history regarding the cause of the injury. 206. A client arrives at the emergency department for treatment of an injury to the eye after being hit by a baseball bat. On data collection, the nurse notes that the eye is bleeding. Which nursing action is appropriate? Cover the eye with cold, sterile saline gauze. 207. A client arrives in the emergency department following an eye injury from a chemical solution. Which is the initial nursing action? Test the eye pH with litmus paper. 208. The nurse is reviewing the preoperative prescriptions of a client scheduled for a keratoplasty. Which prescriptions noted in the client's chart should the nurse question? Administer medication to dilate the affected pupil. 209. The nurse has reinforced instructions to a client following a right keratoplasty. Which statement by the client indicates a need for further teaching? "In 1 week, I'll return to have the sutures removed." 210. The nurse caring for a client in the postoperative period following an enucleation notes bloody staining on the surgical eye dressing. Which is the appropriate nursing action? Contact the health care provider. 211. A client reporting recent right eye discomfort is diagnosed with chalazion of the right eye. The nurse reinforces instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures? "I should apply warm packs to my eye." 212. The nurse is reinforcing home care instructions to a client who has a hordeolum (sty) of the right eye. Which statement by the client indicates an understanding of the instructions? "I should apply antibiotic ointment as prescribed." 213. The nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse observes the presence of nystagmus. The nurse should document the findings of this test as indicative of which result? Normal 214. The nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the client complains of vertigo. The nurse documents the findings of this test as indicative of which result? Normal 215. The nurse is assisting a health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the nurse notes that nystagmus does not occur. The nurse should document the findings of this test as indicative of which result? Positive 216. A caloric test is prescribed for a client suspected of having a disease of the labyrinth. The nurse obtains which essential item in preparation for this test? An otoscope 217. A nursing instructor asks a student about cochlear implants. The student understands that which clients are candidates for such a procedure? Select all that apply. A client who has a profound hearing loss in both ears A client who has received no benefit from conventional hearing aids 218. A female client with myasthenia gravis comes to the health care provider's office for a scheduled office visit. The client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. Which is the appropriate nursing response? "Have you thought about sharing your feelings with your husband?" 219. The nurse assigned to care for a hearing-impaired client should use which approach to communication in order to enhance communication and preserve the client's self-esteem? Select all that apply. Speaking slowly and clearly Standing directly in front of the client while speaking Turning down the volume on the radio or TV when talking 220. The nurse is reinforcing discharge instructions to a client going home after same- day eye surgery. During the postoperative period, the nurse stresses that the client may safely perform which activity? Watch television. 221. The nurse is reinforcing discharge instructions to a client who has had ocular surgery of the left eye. Which statement by the client indicates a need for further teaching? "I need to call the doctor if I develop any fever." 222. A client who had previously undergone cataract surgery tells the nurse that she has begun seeing flashing lights and floaters in the eye. Based on the client's history, the nurse interprets that the client is at risk for which? Detached retina 223. A client diagnosed with primary open-angle glaucoma has been prescribed pilocarpine ophthalmic drops. When the client asks the nurse how this medication lowers intraocular pressure, which information does the nurse tell the client? The medication increases the outflow of aqueous humor. 224. The nurse interprets that a client diagnosed with glaucoma needs information about the expected effects of this condition when the client makes which statement? "Taking my daily walk right around dusk each evening has proven to be so enjoyable." 225. The nurse is preparing to instill an otic solution into the adult client's right ear. The nurse should include which action while performing this procedure? Select all that apply. Pulling the auricle of the right ear upward Pulling the auricle of the right ear backward Warming the solution to room temperature Placing the client in a left side-lying position 226. A client has a diagnosis of presbycusis. The nurse interprets that which behavior indicates that the client has successfully adapted to this disorder? Agrees to use a prescribed hearing aid, especially when home alone 227. Immediately following cataract repair, the client's affected conjunctiva and eyelids are edematous. Which statement by the nurse accurately characterizes these findings for the client? "The edema is normal and should subside within 3 days." 228. A client who has undergone cataract removal without an intraocular lens implant is visibly upset because his vision is still blurry. Which action should the nurse perform to provide realistic reassurance to this client? Explain that vision will improve with adjustment to aphakic lenses. 229. A client with a history of ear problems telephones the ambulatory care nurse to cancel an appointment because he will be away on business. The client mentions that he will be flying during this trip. The nurse advises the client to engage in which activity to prevent barotrauma during takeoff and landing? Select all that apply. Chewing gum Yawning occasionally Swallowing a few times Sucking on a piece of hard candy 230. A client has had same-day surgery to insert a ventilating tube in the tympanic membrane. The nurse reinforces to the client to be sure to perform which action until the postoperative assessment by the health care provider? Use a shower cap to protect the ears if taking a shower. 231. An adult client with a history of ear infections reports a right earache accompanied by a sensation of fullness. The client also reports nausea and has a temperature of 100.6° F. The nurse questions the client about which aspect of the client's history? Whether the client has had a recent upper respiratory infection (URI) 232. A client is recovering at home after suffering a brain attack (stroke) 2 weeks ago. A home caregiver tells the home health nurse that the client has some difficulty swallowing food and fluids. Which nursing action would be appropriate? Observe the client feeding himself or herself. 233. When reinforcing information to a client regarding how to appropriately care for a new hearing aid, the nurse should provide the client with which instruction? To check the battery regularly to ensure that it is working before use 234. A client susceptible to motion sickness asks the nurse about the use of medication to prevent an occurrence. The nurse plans to incorporate into the discussion that the medication works effectively if which guideline is followed? Taking the medication 1 hour before a triggering event. 235. The nurse is collecting data from a client who has a history of untreated cataracts. The nurse checks the client for which associated manifestation? Difficulty with driving a car at night 236. A client has been diagnosed with open-angle glaucoma and asks the nurse to repeat the health care provider's explanation of the disorder. The nurse should offer the client which explanation? The pressure increases within the eye from excess fluid or blocking of drainage. 237. The nurse is reinforcing education to a client who has just obtained a hearing aid about its use and maintenance. The nurse tells the client that it is helpful to follow which practice? Keep an extra battery readily available. 238. A client has sought treatment in the ambulatory care clinic after an insect has become trapped in the external ear canal. The nurse prepares to assist the health care provider to instill which acceptable solutions into the ear to remove the insect? Select all that apply. Lidocaine Mineral oil Ether solution 239. The nurse is collecting neurological data on a poststroke adult client. Which technique should the nurse perform to adequately check proprioception? Hold the sides of the client's great toe, and while moving it, ask what position it is in. 240. After a routine eye examination, a client has been told there are refractive errors in both eyes. The nurse explains to the client that this problem is primarily treated with which intervention? Prescription of corrective lenses 241. The nurse is reinforcing discharge teaching to a client following right eye cataract surgery. The nurse determines that the client needs further teaching about ways to avoid strain on the operative eye when the client makes which statements? Select all that apply. "I can lie on my right side." "I will wear my eye shield only during the daytime." 242. The nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply. Monitor the client's ability to void. Maintain the client in a flat position. Monitor the client's ability to move the extremities. Inspect the puncture site for swelling, redness, and drainage. 243. A client with Parkinson's disease "freezes" while ambulating, increasing the risk for falls. Which suggestion should the nurse include in the client's plan of care to alleviate this problem? Consciously think about walking over imaginary lines on the floor. 244. The nurse is assisting in checking for Tinel's sign in a client suspected of having carpal tunnel syndrome (CTS). Which technique should the nurse expect to be used to elicit this sign? Percuss the medial nerve at the wrist as it enters the carpal tunnel, and monitor for tingling sensations. 245. The nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which assessment will provide the nurse with the best information about recovery from the spinal shock? Reflexes 246. The nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. The nurse understands that an early sign of rupture is which? A decline in the level of consciousness 247. The nurse is caring for a client with a head injury and is monitoring the client for signs of increased intracranial pressure (ICP). Which sign if noted in the client should the nurse report immediately? The client vomits. 248. The nurse is caring for a client with a spinal cord injury. High-top sneakers on the client's feet will prevent the occurrence of which? Foot drop 249. A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching? "I will bend at the waist, keeping the halo vest straight to pick up items." 250. The nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma. Which intervention does the nurse document in the plan as the priority nursing intervention for this client? Monitor urine output. 251. The nurse is reinforcing discharge instructions to a client who has undergone transsphenoidal surgery for a pituitary adenoma. Which statement by the client indicates the client understands the discharge instructions? "I need to call the doctor if I develop frequent swallowing or postnasal drip." 252. The nurse is collecting admission data on a client with Parkinson's disease. The nurse asks the client to stand with the feet together and the arms at the side and then to close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on this finding, the nurse documents which in the client's record? Positive Romberg's test 253. A nursing student is collecting data on a client recently diagnosed with meningitis. The student expects to note which signs and symptoms? Select all that apply. Tachycardia Photophobia Red, macular rash Positive Kernig's sign 254. The nurse is reinforcing discharge instructions to a client following right eye cataract surgery about ways to avoid strain on the operative eye. The nurse determines that the client needs further teaching if the client makes which statement? "I can lie on my right side." 255. The nurse is caring for a client with acute otitis media. The nurse plans care knowing which treatment for this problem is likely to be included? Myringotomy 256. The nurse is assisting in preparing a teaching plan for a client with Ménière's disease. The nurse places highest priority on teaching the client information related to which information? Safety 257. The nurse is reviewing the results of an eye examination on a client. Which tests can detect glaucoma? Select all that apply. Tonometry Visual field check 258. A client is suspected of having a diagnosis of Guillain-Barré syndrome (GBS). Which findings would support a diagnosis of Guillain-Barré syndrome? Select all that apply. Visual and hearing disturbances Ascending symmetrical muscle weakness 259. The nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which measure should the nurse include in the plan of care? Place an eye patch over the affected eye. 260. The nurse is reinforcing home care instructions to a client following a fenestration procedure for the treatment of otosclerosis. Which instruction should the nurse give the client? Increase fluids and take a stool softener daily. 261. The nurse is reviewing the health care record of a client suspected of having mastoiditis. Which finding does the nurse expect to note if this disorder is present? Swelling behind the ear 262. A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The nursing instructor asks the student to describe the types of medication that will likely be prescribed for the client to treat the eye disorder. Which drug classification will facilitate the outflow of aqueous humor? Cholinergic miotic agents 263. A nursing student is preparing to assist with an ear irrigation on an assigned client who has a buildup of cerumen in the left ear. The nursing instructor asks the student about the procedure for the irrigation. The student nurse should perform the procedure in which correct order? Arrange the actions in the order that they should be used. All options must be used. Warm the prescribed solution to body temperature (95° F to 105° F). Have the client sit up holding an emesis basin under the ear to be irrigated with a drape under the basin. Straighten the external canal of an adult by pulling the auricle up and back. Select an irrigating syringe or bulb syringe with a tip that is smaller than the canal. Direct the solution toward the top of the canal in a steady stream, not toward the eardrum. 264. A clinic nurse is reinforcing home care instructions to a client with a diagnosis of glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma? "I need to take my eye drops for the rest of my life." 265. The nurse is observing an unlicensed assistive personnel (UAP) talk to a client who is hearing impaired. The nurse should intervene if which action is performed by the UAP during communication with the client? The UAP speaks directly into the impaired ear. 266. A clinic nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching? "I should turn the hearing aid off after removing it from my ear." 267. The nurse is collecting data on a client diagnosed with Parkinson's disease. Which finding indicates a serious complication of this disorder? Congested cough and coarse rhonchi heard during auscultation 268. The nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping excessively. Which method is the best way for the nurse to explore issues with the client regarding these behaviors? Have the client express the feelings in writing. 269. A client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) protein is 750 mg/dL. The nurse analyzes these results as which? Higher than normal, supporting the diagnosis of Guillain-Barré 270. A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which finding is indicative of this complication? The client complains of a headache, and the blood pressure is elevated. 271. The nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which sign is indicative of this complication of a spinal cord injury? Areflexia below the level of injury 272. A client with tetraplegia complains bitterly about the nurse's slow response to the call light and the rigidity of the therapy schedule. Which interpretation of this behavior should serve as a basis for planning nursing care? The client is reacting to loss of control. 273. A client with Parkinson's disease is developing dementia. Which action should the nurse plan to assist the client in maintaining self-care abilities? Break down activities into small steps. 274. The nurse is caring for a client that is comatose and notes in the client's chart that the client is exhibiting decerebrate posturing. The nurse understands that which definition describes decerebrate posturing? The extension of the extremities and pronation of the arms 275. A client recovering from a craniotomy complains of a "runny nose." Based on the interpretation of the client's complaint, which action should the nurse take? Notify the registered nurse. 276. The nurse is planning care for a client with Bell's palsy. Which measure should be included in the plan? Instill artificial tears and wear a patch over the affected eye at night. 277. A client with Guillain-Barré syndrome has been asking many questions about the condition, and the nursing staff feels that the client is very discouraged about her condition. It is important for the nurse to include which information in discussions with the client? Generally, a vast number of people recover from this condition. 278. The nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. This conclusion is based on which findings? Select all that apply. Drainage from ear Bruising around the eyes Pink-tinged drainage from the nose 279. The nurse notes that the client's eyes are reddened, and the client states that an eye infection has been diagnosed. The nurse interprets that the client is most likely referring to infection of which structure that provides a protective covering for the eye? Conjunctiva 280. The client has undergone funduscopic examination of the eye. The documented results indicate that the blood vessels are without tortuosity, narrowing, pulsation, or nicking. The nurse interprets that this report indicates which finding? Normal retinal examination 281. The nurse notes that the client's physical examination record states the client's eyes moved normally through the six cardinal fields of gaze. The nurse makes which interpretation? The client has normal ocular movements. 282. The nurse assesses that a client with glaucoma has vision that is lost because of obstruction of aqueous humor flow by the trabecular meshwork. The nurse interprets that this client is suffering from which disorder? Primary open-angle glaucoma 283. The nurse is listening to a health care provider explain the results of an eye examination to a client. The health care provider states that the client has glaucoma resulting from a congenitally narrow anterior chamber angle, which has suddenly become blocked by the base of the iris. The nurse interprets that the health care provider is describing which type of glaucoma? Angle-closure glaucoma 284. A client is experiencing double vision, or diplopia. The nurse interprets that this client is experiencing a loss of which normal function of the eye? Binocular vision 285. After an eye examination, a client has been diagnosed with acute angle-closure glaucoma. The nurse collecting data from the client asks the client about an accompanying history of which sign/symptom? Eye pain 286. A client is experiencing blockage of the eustachian tubes. The nurse teaches the client that which activities by the client may forcibly open the eustachian tube? Performing the Valsalva maneuver 287. The nursing student is developing information for use in a clinical conference about hearing disorders. In the presentation, the student plans to include the statement that the ear is housed in which bones of the skull? Temporal 288. Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply. Monitor for hemorrhage. Administer eye medications. Maintain the eye patch or shield. Assist with activities of daily living. Educate regarding symptoms of retinal detachment. 289. A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic study (studies) to determine the cause of the complaints? Select all that apply. Cerebral angiography Lumbar puncture (LP) Computed tomography 290. When the nurse taps at the level of the client's facial nerve, the following response is noted. How should the nurse document this finding on the client record? Refer to figure. Positive Chvostek's sign 291. The nurse is collecting neurological data on an unconscious client. On application of a central noxious stimulus, the nurse observes this response. How should the nurse document this response on the client's record? Refer to figure. Client demonstrated decerebrate posturing. 292. The nurse suspects neurogenic shock in a client with complete transection of the spinal cord at the T3 (thoracic 3) level if which clinical symptoms are observed? Hypotension and bradycardia 293. The nurse is told in report that a client has a positive Chvostek's sign. Which other data should the nurse expect to find on data collection? Select all that apply. Tetany Diarrhea Possible seizure activity Positive Trousseau's sign 294. A client with glaucoma and an acute exacerbation of chronic obstructive pulmonary disease (COPD) has a new prescription to receive carteolol HCl (Ocupress) eye drops. Which action by the nurse is most appropriate? Withhold the dose and notify the registered nurse. 295. The nurse determines that motor function of which cranial nerve is intact if the client can perform this action? Refer to figure. Facial 296. A client complains of pain in the lower back and pain and spasms in the hamstrings when the nurse attempts to extend the client's leg. How should the nurse record this finding on the client's medical record? Refer to figure. Positive Kernig's sign 297. A client with a stroke (brain attack) is experiencing residual dysphagia. The nurse should remove which food items that arrived on the client's meal tray from the dietary department? Peas 298. The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to do which action? Wrap a plastic bag filled with ice with a pillowcase and place it on the eye. 299. The nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse reviews the client's plan of care, expecting to note that the client should be maintained in which position? Semi-Fowler's position 300. A client is about to undergo a lumbar puncture (LP). The nurse tells the client that which position will be used during the procedure? Side-lying with the legs pulled up and the head bent down onto the chest 301. The nurse is speaking with a client with a hearing impairment. The nurse refrains from doing which least likely helpful action when communicating with this client? Using many exaggerated hand gestures while talking 302. The nurse is gathering data from a client with a history of untreated cataracts. The nurse asks the client about the presence of which sign of a cataract? Difficulty with driving at night and blurred vision 303. The nurse is assisting a client who has just been given a hearing aid to wear for the first time. When reinforcing client teaching, the nurse should include which instruction? "The hearing aid should not be worn if an ear infection is present." 304. The nurse is attempting to inspect the lacrimal apparatus of a client's eye. Because of its anatomical location the nurse should do which action? Retract the upper eyelid and ask the client to look down. 305. A client has been newly diagnosed with glaucoma. As part of the discharge instructions, the nurse should plan to reinforce which information? The need for lifelong medication therapy 306. A client is diagnosed with hyphema after experiencing a traumatic blow to the eye. The nurse explains to the client that which activity limitation needs to be implemented following this type of injury? Bed rest with the head in semi-Fowler's position 307. A client arrives in the emergency department with an eye injury resulting from metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse take first? Irrigate the eye with sterile saline. 308. A client has been diagnosed with glaucoma. The nurse who is teaching the client principles of self-care should encourage the client to limit or refrain from which usual activity on a repeated basis? Picking objects up off the floor 309. The nurse is explaining how sound is conducted from the middle ear to the inner ear in teaching a client who is experiencing hearing loss. The nurse plans to use a diagram that illustrates how which bones connects to the cochlea at the oval window? Stapes 310. The nurse is developing a poster to use in teaching clients about the prevention of hearing loss. The nurse should diagram which structure as part of the inner ear? Cochlea 311. An adult client has increased fluid in the middle ear, which is causing vertigo. The nurse checks this client for which associated signs and symptoms of this condition? Nausea and vomiting 312. The nurse has been assigned to a client with a hearing impairment. To enhance nurse-client communication, the nurse should plan to communicate with the client by speaking in which manner? In a normal tone while facing the client 313. The nurse is reviewing the medication list for an assigned client. Which medication is the only one on the client's prescription sheet that does not have an ototoxic effect? Acetaminophen (Tylenol) 314. A client has just undergone lumbar puncture (LP). The nurse assists the client into which optimal position? Prone, with a pillow under the abdomen 315. A client with Bell's palsy exhibits facial asymmetry and cannot close the eye completely on one side. The client is also drooling and has loss of tearing in one eye. The nurse documents that the client displays symptoms of involvement of which cranial nerves (CNs)? CN VII 316. The nurse is caring for the client with a head injury secondary to a motor vehicle crash. The nurse observes the client's status regularly, monitoring closely for which change in vital signs that could indicate increased intracranial pressure? Decreasing pulse, decreasing respirations, increasing BP 317. A client who sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8-hour shift was 3300 mL, and 2800 mL for the shift before that. The findings have been reported to the health care provider, and the nurse anticipates a prescription for which medication? Desmopressin (DDAVP) 318. A client who suffered a cervical spine injury had Crutchfield tongs applied in the emergency department. The nurse should avoid which action in the care of the client? Removing the weights when repositioning the client 319. The nurse is reinforcing instructions to the client who has just been fitted for a halo vest. Which statement by the client indicates the need for further teaching? "I will avoid driving at night because the vest limits the ability to turn the head." 320. A client with spinal cord injury has experienced more than one episode of autonomic dysreflexia. The nurse should avoid which action that could trigger an episode of this complication? Allowing the client's bladder to become distended 321. The nurse is assisting in admitting a client who experienced seizure activity in the emergency department. The nurse avoids which action when managing this client's environment? Keeping the bed position raised to the nurse's waist level 322. The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The health care provider gives a test dose of edrophonium (Enlon). The nurse recalls that the client should have which reaction if the client has this disease? An increase in muscle strength within 1 to 3 minutes 323. A client with myasthenia gravis becomes increasingly weaker. The health care provider injects a dose of edrophonium (Enlon) to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if the client is in cholinergic crisis? A temporary worsening of the condition 324. Which symptoms would validate the diagnosis of a cluster headache? Select all that apply. A runny nose Burning sensation in the eye Tearing on the affected eye 325. A client, who frequently experiences hearing loss due to built-up cerumen in the ears, asks the nurse about ways to deal with the problem including irrigating the ears. Which information is correct for the nurse to include in the teaching plan? Select all that apply. Irrigate the ear canal with lukewarm tap water around 98° F. The ear irrigation should be stopped if the client becomes dizzy or nauseous. Instill drops of mineral oil and hydrogen peroxide for several days to soften dried cerumen before irrigation. 326. The nurse administers meclizine hydrochloride (Antivert) to a client diagnosed with an attack of Ménière's disease. Which observations demonstrate to the nurse that the medication is effective? Select all that apply. Decrease in nausea Decrease in vertigo 327. The nurse is reinforcing discharge instructions to a client who just underwent a myringotomy with placement of a polyethylene tube in the left ear. Which statement by the client indicates a need for further teaching? Select all that apply. "I may wash my hair tomorrow." "I will irrigate the ear with gentle pressure." "I can expect to feel pressure inside the ear." In which area of the chest should the nurse expect to auscultate this breath sound? (Refer to audio.) 1. The nurse is collecting data regarding a client after a thyroidectomy and notes that the client has developed hoarseness and a weak voice. Which nursing action is appropriate? 2. The nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan of care? Apply a moisturizing lotion to dry feet, but not between the toes. 3. The nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement made by the client indicates the need for further teaching? " 4. A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which teaching information should the nurse reinforce upon discharge? Rotate the insulin injection sites systematically. 5. The nurse reinforces teaching with a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops? Shakiness 6. When the nurse is reinforcing instructions to a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective? 7. The nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. Which statement made by the client would indicate hyperglycemia and thus warrant health care provider notification? 8. The nurse is reinforcing instructions with a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize? 9. The nurse is reinforcing discharge teaching with a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood? "I can eat foods that contain potassium." 10. The nurse educator is asking the nursing student to recall the signs/symptoms of hypothyroidism. The nurse educator determines that the student understands this disorder if which are included in the student's response? Select all that apply. 11. The nurse is caring for a postoperative parathyroidectomy client. Which would require the nurse's immediate attention? 12. The nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs. Which further information should the nurse obtain from the client during data collection? Plan for injection rotation 13. A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates a correct understanding of Humulin N insulin and exercise? 14. The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? 15. A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is reinforcing instructions to the client regarding the program. Which should the nurse include in the instructions? Take a blood glucose test before exercising. 16. The nurse should expect to note which interventions in the plan of care for a client with hypothyroidism? Select all that apply. Instruct the client about thyroid replacement therapy. 17. Which client complaint should alert the nurse to a possible hypoglycemic reaction? Tremors and double vision 18. Which nursing action would be appropriate to implement when a client has a diagnosis of pheochromocytoma? Monitor the client's blood pressure. 19. The nurse is caring for a client with pheochromocytoma. The client is scheduled for an adrenalectomy. During the preoperative period, the priority nursing action should be to monitor which criterion? Vital signs 20. The nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. Which is the appropriate choice for this client to meet nutritional needs? 21. The nurse is caring for a client with pheochromocytoma. Which data are indicative of a potential complication associated with this disorder? Congestion heard on auscultation of the lungs 22. The nurse is caring for a client after a thyroidectomy and monitoring for signs of thyroid storm. The nurse determines that which sign/symptom is indicative that a thyroid storm may be occurring? 23. When caring for a client who is having clear drainage from his nares after transsphenoidal hypophysectomy, which action by the nurse is essential? 24. After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse understands that which signs/symptoms are indicative of this disorder? Excessive thirst and urine output 25. Which signs/symptoms should the nurse expect to note when collecting data on a client with Addison's disease? Hypotension and vomiting 26. Which measure should the nurse anticipate being included in the plan of care for a client who has been diagnosed with Graves' disease? 27. The nurse is preparing to reinforce instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which diet should be prescribed for this client? 28. The nurse is caring for a client with a diagnosis of hypoparathyroidism. The nurse reviews the client's laboratory results and notes that the calcium level is extremely low. The nurse should expect to note which sign/symptom on data collection? Positive Trousseau's sign 29. The nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which specific signs of this complication should be included on the list? Increased thirst 30. The nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed, and the pulse and respiratory rate are elevated from the client's baseline. Which action should the nurse implement? Check the client's capillary blood glucose. 31. A client with type 1 diabetes mellitus takes NPH insulin every morning and checks the blood glucose level four times per day. The client tells the nurse that yesterday the late afternoon blood glucose was 60 mg/dL and that she "felt funny." Which statement by the client indicates an understanding of this occurrence? "I forgot to take my usual mid-afternoon snack yesterday." 32. The nurse is reinforcing instructions to a client with diabetes mellitus about blood glucose monitoring and monitoring for signs of hypoglycemia. The nurse should teach the client that which result is a sign of hypoglycemia? 33. The nurse caring for a client scheduled for a transsphenoidal hypophysectomy to remove a tumor in the pituitary gland assists in developing a plan of care for the client. The nurse suggests including which specific information in the preoperative teaching plan? Toothbrushing will not be permitted for at least 2 weeks following surgery. 34. Following hypophysectomy, a client complains of being very thirsty and having to urinate frequently. Which is the initial 35. The nurse is reviewing a health care provider's prescriptions for a client with newly diagnosed, untreated hypothyroidism. Which medication prescribed for the client should the nurse question and verify? 36. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar state (HHS) is made. The nurse who is assisting with care for the client obtains which item in preparation for the treatment of this syndrome? 37. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which finding should the nurse expect to note as confirming this diagnosis? 38. A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial serum glucose level was 950 mg/dL. Intravenous (IV) insulin was started along with rehydration with IV normal saline. The serum glucose level is now 240 mg/dL. The nurse who is assisting in caring for the client obtains which item, anticipating a health care provider's prescription? 39. A client with diabetes mellitus is being discharged following treatment for hyperglycemic hyperosmolar state (HHS) precipitated by acute illness. The client states to the nurse, "I will call the doctor next time I can't eat for more than a day or so." The nurse plans care, understanding that which statement accurately reflects this client's level of knowledge? 40. A health care provider has prescribed propylthiouracil (PTU) for a client with hyperthyroidism, and the nurse assists in developing a plan of care for the client. Which nursing measure would be included in the plan regarding this medication? 41. The nurse is assisting in preparing a care plan for a client with diabetes mellitus who has hyperglycemia. The nurse should focus on which potential problem for this client? 42. The nurse is assigned to care for a client at home who has a diagnosis of type 1 diabetes mellitus. When the nurse arrives to care for the client, the client tells the nurse that she has been vomiting and has diarrhea. Which additional statement by the client indicates a need for further teaching? 43. The nurse is assigned to assist in caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). Which is the priority nursing action for this client who is in the acute phase? 44. A client with type 2 diabetes mellitus has a blood glucose of more than 600 mg/dL and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the health care provider's documentation and would expect to note which 45. The nurse has collected data on a client with diabetes mellitus. Findings include a fasting blood glucose of 130 mg/dL, temperature 101° F, pulse of 88 beats per minute, respirations of 22 breaths per minute, and a blood pressure of 118/78 mm Hg. Which finding would be of concern to the nurse? 46. The nurse is collecting data from a client newly diagnosed with diabetes mellitus regarding the client's learning readiness. Which client behavior indicates to the nurse that the client is not ready to learn? The client complains of fatigue whenever the nurse plans a teaching session 47. A client with diabetes mellitus visits the health care clinic. The client previously had been well controlled with glyburide (DiaBeta), but recently, the fasting blood glucose has been running 180 to 200 mg/dL. Which medication, if added to the client's regimen, may be contributing to the hyperglycemia? 48. The nurse in an outpatient diabetes clinic is assisting in caring for a client on insulin pump therapy. Which statement by the client indicates that a need for teaching regarding insulin pump therapy 49. A client with Graves' disease has exophthalmos and is experiencing photophobia. Which intervention would best assist the client with this problem? Obtaining dark glasses for the client 50. The nurse caring for a client who has had a subtotal thyroidectomy reviews the plan of care and determines which problem is the priority for this client in the immediate postoperative period? 51. A comatose client with an admitting diagnosis of diabetic ketoacidosis (DKA) has a blood glucose value of 368 mg/dL, arterial pH of 7.2, arterial bicarbonate of 14 mEq/L, and is positive for serum ketones. The diagnosis is supported by which noted data? 52. The nurse is collecting data on a client admitted to the hospital with a diagnosis of myxedema. Which data collection technique would provide data necessary to support the admitting diagnosis? Inspection of facial features 53. A client with Cushing's disease is being admitted to the hospital after a stab wound to the abdomen. The nurse plans care and places highest priority on which potential problem? 54. The nurse has reinforced instructions about measuring blood glucose levels to a client newly diagnosed with diabetes mellitus. The nurse determines that the client understands the procedure when making which most accurate statement? I should check my blood glucose level before eating each meal, regardless of how much I eat." 55. The nurse is reinforcing dietary instructions to a client newly diagnosed with diabetes mellitus. The nurse accurately instructs the client with which statement? It is best to eat meals at approximately the same time each day. 56. A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the nurse that after giving the injection, the insulin seems to leak through the skin. The nurse can appropriately determine the problem by asking the client which? 57. The nurse is reinforcing instructions to a client newly diagnosed with diabetes mellitus regarding insulin administration. The health care provider has prescribed a mixture of NPH and regular insulin. The nurse should stress that which is the first step? Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin. 58. The nurse is reviewing the prescriptions of a client diagnosed with diabetes mellitus who was admitted because of an infected foot ulcer. Which health care provider's prescription supports the treatment of this condition? An increased amount of NPH daily insulin 59. The nurse is assisting in preparing a plan of care for the client with diabetes mellitus and plans to reinforce the client's understanding regarding the signs/symptoms of hypoglycemia. Which signs/symptoms should the nurse review? Elevated pulse; shakiness; and cool, clammy skin 60. The nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply. Monitoring daily weight, 61. A nursing student notes in the medical record that a client with Cushing's syndrome is experiencing body image disturbances. The need for additional education regarding this problem is identified when the nursing student suggests which nursing intervention? Evaluating the client's understanding that the body changes need to be dealt with 62. The nurse is caring for a client following an adrenalectomy and is monitoring for signs of adrenal insufficiency. Which are signs and symptoms related to adrenal insufficiency? Select all that apply. FEVER, WEAKNESS, HYPTOENSION, MENTAL STATUS CHANGE 63. The nurse is reinforcing home care instructions to a client with a diagnosis of Cushing's 64. The nurse is reviewing a plan of care for a client with Addison's disease. The nurse notes that the client is at risk for dehydration and suggests nursing interventions that will prevent this occurrence. Which nursing intervention is an appropriate component of the plan of care? Select all that apply • Monitoring intake and output, • Monitoring for changes in mental status, • Encouraging fluid intake of at least 3000 mL/day 65. The nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. Which health care provider's prescription noted on the record indicates the need for clarification? 66. The nurse reviews a plan of care for a postoperative client following a thyroidectomy and notes that the client is at risk for breathing difficulty. Which nursing intervention should the nurse include in the plan of care? 67. The nurse is monitoring a client following a thyroidectomy for signs/symptoms of hypocalcemia. Which sign/symptom noted in the client indicates the presence of hypocalcemia? 68. The nurse is caring for a client following a thyroidectomy. The client tells the nurse that she is concerned because of voice hoarseness. The client asks the nurse whether the hoarseness will subside. Which statement by the nurse regarding the hoarseness is accurate? The hoarseness is normal and will gradually subside. 69. The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs and symptoms noted in the client should alert the nurse to the presence of this crisis? Select all that apply. Fever, Sweating, Agitation 70. Which client is at risk for developing thyrotoxicosis? 71. The nurse is caring for a client diagnosed with hyperparathyroidism who is prescribed furosemide (Lasix). The nurse reinforces dietary instructions to the client. Which is an appropriate instruction? 72. The nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further teaching? Select all that apply. "I need to limit playing football to only the weekends." "I should exercise in the evening to encourage a good sleep pattern." 73. The nurse has reinforced dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse instructs the client to include which item in the diet? 74. The nurse has reinforced home care measures to a client diagnosed with diabetes mellitus regarding exercise and insulin ? "I should perform my exercise at peak insulin time." 75. The nurse is caring for a client newly diagnosed with diabetes mellitus. The client asks the nurse whether eating at a restaurant will affect the diabetic control and whether this is allowed. Which nursing response is appropriate? " 76. A client who is managing diabetes mellitus with insulin injections asks the nurse for information about any necessary changes in her diet to avoid hyperinsulinism. Which diet would be appropriate for the client? Small frequent meals with protein, fat, and carbohydrates at each meal 77. A client has an endocrine system dysfunction of the pancreas. The nurse anticipates that the client will exhibit impaired secretion of which substance? 78. The nurse is reinforcing discharge instructions to a client who had a unilateral adrenalectomy. Which information should be a component of the instructions? 79. The nurse is caring for a client experiencing thyroid storm. Which should be a priority concern for this client? Potential for cardiac disturbances 80. The nurse is collecting data on a client with hyperparathyroidism. Which question would elicit accurate information about this condition from the client? "Are you experiencing pain in your joints?" 81. A client is in metabolic acidosis caused by diabetic ketoacidosis (DKA). The nurse prepares for the administration of which medication as a primary treatment for this problem? 82. The nurse is caring for a postoperative adrenalectomy client. Which finding does the nurse specifically monitor for in this client? 83. The nurse is caring for a client with a diagnosis of myasthenia gravis. The health care provider plans to perform an edrophonium (Enlon) test on the client to determine the presence of cholinergic crisis. In addition to planning care for the client during this testing, which equipment will the nurse ensure is at the bedside? 84. A client with myxedema has changes in intellectual function such as impaired memory, decreased attention span, and lethargy. The client's husband is upset and shares his concerns with the nurse. Which statement by the nurse is helpful to the client's 85. A client with hypoparathyroidism has hypocalcemia. The nurse avoids giving the client the prescribed vitamin and calcium supplement with which liquid? 86. A client is diagnosed with hyperparathyroidism. The nurse teaching the client about dietary alterations to manage the disorder tells the client to limit which food in the diet? 87. The nurse participating in a free health screening at the local mall obtains a random blood glucose level of 200 mg/dL on an otherwise healthy client. The nurse tells the client to do Call the health care provider to have the value rechecked as soon as possible. 88. The nurse is instructing a client with Addison's disease about a newly prescribed medication, fludrocortisone acetate (Florinef). Which statement by the client indicates a need for further teaching? 89. The nurse reviews the nursing care plan of an older client with diabetic neuropathy of the lower extremities as a result of type 2 diabetes mellitus. The nurse plans care, knowing that which problem has the highest priority for this client? The possibility of injury as a result of decreased sensation in the legs and feet 90. An older client with a history of hyperparathyroidism and severe osteoporosis is hospitalized. The nurse caring for the client plans to address which problem first? The possibility of injury 91. A client has been diagnosed with hypoparathyroidism. Which food groups should be included in the diet? 92. A hospitalized client is newly diagnosed with diabetes mellitus. The client must take both NPH and Regular insulin for glucose control. The nurse develops a teaching plan to help the client meet which outcome as a first step in managing the disease? Adjust insulin according to capillary blood glucose levels. 93. A client newly diagnosed with diabetes mellitus takes NPH insulin every day at 7:00 AM. The nurse has taught the client how to recognize the signs of hypoglycemia. The nurse determines that the client understands the information presented if the client watches for which signs and symptoms in the late afternoon? 94. A client newly diagnosed with diabetes mellitus is having difficulty learning the technique of blood glucose measurement. The nurse should teach the client to do which action to perform the procedure properly? Let the arm hang dependently and milk the digit. 95. The nurse is planning to instruct a client with diabetes mellitus who has hypertension about "sick day management." Which beverage does the nurse avoid putting on a list of easily consumed carbohydrate-containing beverages for use when the client cannot tolerate food orally? 96. The nurse is monitoring the results of periodic serum laboratory studies drawn on a client with diabetic ketoacidosis (DKA) receiving an insulin infusion. The nurse determines that which value needs to be reported? Potassium 3.1 mEq/L 97. The wife of a client with diabetes mellitus who takes insulin calls the nurse in a health care provider's office about her husband. She states that her husband is sleepy and that his skin is warm and flushed. She adds that his breathing is faster than normal and his pulse rate seems fast. Which action should the nurse tell the wife to do first? 98. A client recently diagnosed with diabetes mellitus requiring insulin tells the clinic nurse that he is traveling by air throughout the next week. The client asks the nurse for any suggestions about managing the disorder while traveling. Which action should the nurse tell the client to do? Keep snacks in carry-on luggage to prevent hypoglycemia during the flight. 99. A client scheduled for a thyroidectomy says to the nurse, "I am so scared to get cut in my neck." Based on the client's statement, the nurse determines that the client is experiencing which problem? 100. The nurse is caring for a client with Addison's disease. The nurse checks the client's vital signs and determines that the client has orthostatic hypotension. The nurse determines that this finding relates to which factor? A 101. Which nursing measure would be effective in preventing complications in a client with Addison's disease? Monitoring the blood glucose 102. The nurse is collecting data on a client with a diagnosis of hypothyroidism. Which of these behaviors, if present in the client's history, should the nurse determine as being likely related to the symptoms of this disorder? Depression 103. While collecting data on a client being prepared for an adrenalectomy, the nurse obtains a temperature reading of 100.8° F. The nurse analyzes this temperature reading as which? A finding that needs to be reported immediately 104. The anticipated intended effect of fludrocortisone acetate (Florinef) for the 105. The nurse is caring for a client with hypothyroidism who is overweight. Which food items should the nurse suggest to include in the plan? Skim milk, apples, whole-grain bread, and cereal 106. A client has a blood glucose level drawn for suspected hyperglycemia. After interviewing the client, the nurse determines that the client ate lunch approximately 2 hours before the blood specimen was drawn. The laboratory reports the blood glucose to be 180 mg/dL, and the nurse analyzes this result as indicative of which interpretation? 107. In planning nutrition for the client with hypoparathyroidism, which diet would be appropriate? 108. The nurse is caring for a client with type 1 diabetes mellitus who is hyperglycemic. Which problem should the nurse consider first, when planning care for this client 109. A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse should most closely monitor which assessment in the preoperative period? 110. The nurse working on an endocrine nursing unit understands that which correct concept is used in planning care? Clients who have hyperparathyroidism should be protected against falls 111. Glucagon hydrochloride injection would most likely be prescribed for which disorder? 112. The nurse is caring for a child with a diagnosis of diabetes insipidus. The nurse anticipates that the health care provider will prescribe which medications? 113. When caring for a client diagnosed with pheochromocytoma, which information should the nurse know when assisting with planning care? Excessive catecholamines are released. 114. A client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that surgery is the best thing to do." Which response by the nurse is appropriate? 115. A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which response by the nurse is appropriate? "Usually, these physical changes slowly improve following treatment." 116. A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. Which intervention would be appropriate to decrease the client's anxiety 117. The nurse is collecting data from a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the medication regimen? " 118. The nurse is collecting data from a client who is being admitted to the hospital for a diagnostic workup for primary hyperparathyroidism. The nurse understands that which client complaint would be characteristic of this disorder? 119. The nurse is preparing to discharge a client who has had a parathyroidectomy. When reinforcing instructions to the client about the prescribed oral calcium supplement, which information should the nurse include? Take the calcium 30 to 60 minutes following a meal. 120. A client is brought to the emergency department with suspected diabetic ketoacidosis (DKA). Which finding should the nurse note as being consistent with this diagnosis? 121. A client is admitted with a diagnosis of pheochromocytoma. The nurse should monitor which parameter to detect the most common sign of pheochromocytoma? Blood pressure elevation 122. During data collection on a postoperative client who has undergone hypophysectomy, the client complains of thirst and frequent urination. Knowing the expected complication of this surgery, the nurse should check which parameter next? 123. A client with diabetes mellitus is scheduled to have a fasting blood glucose level determined in the morning. The nurse tells the client not to eat or drink after midnight. When the client asks for further information, the nurse clarifies by stating that which should be acceptable to take before the test? Water 124. A client with a pituitary tumor will undergo transsphenoidal hypophysectomy. The nurse reinforces which information in the preoperative teaching plan for the client? Blowing the nose following surgery is prohibited. 125. A client who returned to the nursing unit 8 hours ago after hypophysectomy has clear drainage saturating the nasal dressing. The nurse should take which action? 126. A client with newly diagnosed Cushing's syndrome expresses concern about personal appearance, specifically about the "buffalo hump" that has developed at the base of the neck. When counseling the client about this symptom, the nurse should incorporate which knowledge? It 127. A client has just been admitted with a diagnosis of myxedema coma. If all of the following interventions were prescribed, the nurse should place highest priority on completing which action first? Administering oxygen 128. The nurse has just supervised a newly diagnosed diabetes mellitus client self-inject NPH insulin at 7:30 ᴀᴍ. The nurse reviews the time frames for peak insulin action with the client, telling the client to be especially watchful for a hypoglycemic reaction between which time frame? 129. The nurse is discussing foot care with a diabetic client and the spouse. The nurse includes which instruction during this informational session? 130. The nurse has provided diabetic teaching with the family of a client newly diagnosed with diabetes. The nurse determines that the family understands the reason for having glucagon on hand for emergency home use if the family indicates that the purpose of the medication is to treat which condition? 131. After receiving furosemide (Lasix) 40 mg slow intravenous push for chest pain related to shortness of breath and generalized edema, the client responds poorly. The client has no relief of the chest pain, shortness of breath, or edema and only minimal urine output (less than 40 mL of urine). The health care provider is notified, and after reviewing the chart, suspects the client has syndrome of inappropriate antidiuretic hormone (SIADH). Which findings would lead to this specific diagnosis? Refer to chart. [Show More]

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