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MED SURG hesi A&B 2 of 55 What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? a. Sexual activities may... be resumed upon return home b. Light housekeeping is permitted but avoid heavy lifting c. Use a metal eye shield on operative eye during the day d. Administer eye ointment before applying eye drops ANS:B 3 of 55 A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first? a. Obtain a sputum sample for culture b. Check his oxygen saturation level c. Administer an oral antipyretic d. Auscultate bilateral lung sound ANS:A 4 0f 55 An elder male client tells the nurse that he is loosing sleep because he has to get up several times at night to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? a. collect a urine specimen for culture analysis b. obtain a fingerstick blood glucose level c. palpate the bladder above the symphysis pubis d. review the client fluid intake ANS: C 5 of 55 An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? a. blood ph of 7.30 b. glucose of 350 mg /dl c. white blood cell count of 15000mm d. potassium of 2.5 meq/l ANS: D 6 of 55 A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cell. When notifying the healthcare provider what information should the nurse provide first using the SBAR communication process? a. explain specific reason for urgent notification b. preface the report by stating the clients name and admitting diagnosis c. communicate the pre-transfusion temperatures d. optain prn prescription for acetaminophen for fever 101f ANS: A 7 of 55 An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for discharge what important aspect regarding his medication therapy should the nurse explain? a. AZT therapy must be stopped when IV aerosol pentamine is being used. b. IV pentamine will be given until oral pentamine can be tolerated c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month d. Iv pentamine may offer protection to others aids related conditions such as kaposis sarcoma ANS:C 8 of 55 A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? a) a.collect a clean catch specimen b) b.palpate the suprapubic region c) c.instruct to wipe from front to back d) d.inquire about recent sexual activity ANS: A 9 of 55 A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? a) offer the client reassurance that this information indicates that the clients cancer cells are benign b) explain that these tissue cells often respond more effectively to radiation than to chemotherapy c) ask the client in the healthcare provider has giving her any information about the classification of her cancer d) help the client make plans to begin inmediate treatment since her cancer is likely to spread quickly ANS: C 10 of 55 A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first? a. monitor bp q45 minutes b. lower the head of the chair and elevate feet c. stop dialysis treatment d. administer 5%albumin IV ANS: C 11 of 55 A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage should be increase 900 units/hr. The nurse should program the infusion pump to deliver how many ml/hr? =9 12 of 55 The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this diagnosis? a. upper mid abdominal gnawing and burning pain b. severe abdominal cramps and diarrhea after eating spicy foods c. marked loss of weight and appetite over the last few months d. use of chewable and liquid antacids for indigestion ANS: A 13 of 55 The nurse is providing preoperative education for a jewish client schedule to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? a.the xenograft is taken from nonhuman sources b.grafting increases the risk for bacterial infection the burn heals the graft permanently attaches d.grafts are later removed by debriding procedure ANS: A 14 of 55 A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report? a. jaundice sclera b. intestinal cramping c. weakness and fatigue d. weight loss ANS: A 15 of 55 During a home visit the nurse assesses the skin of a client with eczema who reports than an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? a. an old friend with eczema came for visit b. recently received an influenza immunization c. corticosteroid cream was applied to eczema d. a grandson and his new dog recently visited ANS: D 16 of 55 When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching? a. select a protein rich food daily b. restrict sodium intake c. eat high potassium foods d. Avoid foods high in carbohydrate ANS: B 17 of 55 A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt? a. discontinue intravenous therapy b. Assess for abdominal distension and tenderness c. Obtain a prescription for a diet change d. Auscultate bowel sound in all four quadrants ANS: D 18 of 55 A client diagnose with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart? a. drive to the nearest emergency department b. take another NTG SL tablet and lie down until angina subsides c. call primary healthcare provider d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg ANS:D 18a. of 55 ------Esta es otra 18 que hay en fotos pero es diferente After taking orlistat (Xenical) for one week a femela client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. What action should the nurse take? a. obtain stool specimen to evaluate for occult blood and fat content b. instruct the client to increase her intake of saturated fats over the next week c. ask the client to describe her dietary intake history for the last several days d. advice the client to stop taking the drug and contact the healthcare provider ANS:C 19 of 55 Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide iodine (Betadine) solution. Which intervention should the nurse implement first? a. determine if the client has a history of diabetes b. assess airway patency and oxygen saturation c. review recent medication history and allergies d. obtain samples for complete blood count and cultures ANS: B 21 OF 55 A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a. low back pain and hypotension b. rhinitis and nasal stuffiness c. delayed painful rash with urticarial d. arthritic joint changes and chronic pain ANS: A 22 of 55 A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic symdrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the clients central venous catheter. When the clients respirations become labored and his lungs sound indicate crackles what action should the nurse take? a. collect a specimen for a white blood cell count and cultures b. determine the clients glycosylated hemoglobin (A1C) (POSSIBLE ANSWER) c. administer insulin IV push until the clients fluid volume is adjusted d. decrease infusion rate to address fluid overload ANS: D 22 of 55 ----- ESTA ES OTRA 22 QUE ESTABA EN FOTOS PERO ES DIFERENTE When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the clients upper back and the client denies pain. What action should the nurse take? a. Remove the patch and consult with the healthcare provider about the client pain resolution b. Place the patch on the clients shoulder and leave both patches in place for 12 hours c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch d. Apply a new patch in a different location after removing the original patch ANS: D 25 of 55 A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was 78/36.What action should the nurse implement? a. obtain blood pressure q5 minutes using duranap machine b. change the dilution of the nytroglycerin infusion c. reduce the rate of the nitroglycerin infusion d. begin dopamine infusion at 5mcg/kg per minute ANS: C 26 of 55 An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose? a. BUN creatinine specific gravity b. White blood count, hemoglobin hematocrit c. PH,PCO2, HC03 d. LDH OR LD, SGOT OR ALT, SGPT OR AST. ANS: D 27 OF 55 An elderly post operative female client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a nurse to administer the prescribed PRN medication naloxone? a. her respiratory rate is 7 breath/minute b. she indicates that she feels as if she cannot get enough air to breath c. she has intercostal retractions and bilateral wheezing is auscultated d. her pulse oximeter is 89% on room air ANS: A 28 of 55 Which assessment finding indicates to the nurse that the muscarinic agent bethanechol (Urecholine) is effective for a client diagnose with urinary retention? a. urinary output equal to intake b. no terminal urinary dribbling c. denies stress incontinence d. absence of xerostomia ANS: A 29 of 55 Following involvement in a motor vehicle collision, a middle aged adult client is admitted to the hospital with multiple facial fractures. The clients blood alcohol level is high on admission. Which PRN prescription should be administer if the clients begins to exhibit signs and symptoms of delirium tremens (DT s)? a. Lorazepam (Ativan) 2mg IM b. Chlorpromazine (thorazine) 50 mg IM c. Prochlorperazine (Compazine) 5 mg IM d. Hydromorphone (Dilaudid) 2 mg IM ANS: A 33 of 55 Which instructions should the nurse include in the teaching plan of a client who is taking the diuretic spironolactone (Aldactone)? a. call the healthcare provider f you develop gynecomastia b. Take the medication in the morning c. Avoid caffeine and smoking d. Increase your consumption of bananas and oranges ANS: B 34 of 55 A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client to take the glucagon? a. after meals to increase endogenous insulin secretion b. after insulin administration to prevent hypoglycemia c. when recognized signs of severe hypoglycemia occur d. when unable to eat during sick days ANS: C 35 of 55 A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? a. describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider b. explain the need for using lead shields for 2 to 3 weeks after the treatment c. describe the signs of goiter because this is a common side effects of radioactive iodine d. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately ANS: A 36 OF 55 A female client is being treated for tuberculosis with rifampin (rifadin) Which statement indicates that futher teaching is needed? d- I will take my usual contraceptive for birth control ESTA PREGUNTA ESTABA ESCRITA EN LAS hOJAS DE FOTOS 38 of 55 A client is discharged with a prescription for warfarin ( Coumadin). What discharge instructions should the nurse emphasize to the client? a. take a multi vitamin supplement daily b. use an astringent for superficial bleeding c. avoid going barefoot especially outside d. include large amounts of spinach in the diet ANS: C 39 of 55 In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone intranasally which serum lab test is most important for the nurse to monitor? a. osmolality b. calcium c. platelets d. glucose ANS: A 40 OF 55 After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with a severe migraine headache the nurse should explain that relief can be expected within what time frame? a. 2 hours b. 5 minutes c. 1 hour d. 15 minutes ANS: D 41 of 55 A client with hypertension who has been taking labetalol for two weeks, reports a five pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to obtain? a. capillary refill b. body temperature c. muscle strength d. breath sounds ANS: D 43 of 55 A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What explanation should the nurse provide? a. The eye drops slow pupil response to accommodate for darkness b. The drops increase the fluid in the eyes and cloud the visual field c. The drug can cause lens to become more opaque d. The medication causes pupils to dilate which reduces night vision ANS: A 44 of 55 A client who is taking and oral dose of tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? a. toasted wheat bread and jelly b. cheese and crakers c. cold cereal with skim milk d. fruit flavored yogurt ANS: A 45 of 55 The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which physiologic action? a. Facilitates transport of glucose into the cell b. Increases intracellular receptor site sensitivity c. Stimulates function of beta cells in the pancreas d. Delays carbohydrates digestion and absorption ANS: A 46 of 55 The health care provider prescribe a medication for an older adult client who is complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should question which prescription? a. Eszoplicone (Lunesta)10 mg orally at bed time b. Zolpidem 10 mg orally at bed time c. Temazepan orally at bed time d. Ramelteon orally at bedtime ANS: A 47 of 55 A male client reports to the nurse that he is experiencing GI distress from high dose of a corticosteroid and is planning to stop taking the medication. In response to the clients statement what nursing action is most important for the nurse to take? a. Encourage the client to take medication with food to decrease GI distress b. Advice the client that the medication should be stopped gradually rather than abruptly. c. Review the clients dosing schedule to ensure he is taking the prescribed amount d. Assess the client for other indication of adverse effects of corticosteroid ANS: B 48 of 55 Fifteen minutes after receiving sulfa athenozole . A male client report a burning sensation over his abdomen chest and groin. Which intervention is most important for the nurse to implement? a. Auscultate lung sounds for wheezing b. Review the clients list if drugs allergies c. Add sulfamethinozole to clients allergies d. Check neurological vital signs ANS: B 49 of 55 Antibiotic resistant organism are a major infection control problems. To help minimize the emergence of resistant bacteria what instruction should the nurse provide to the clients? a. stop taking prescribed antibiotics when symptoms decrease b. avoid using antibiotics when suffering from colds or the flu c. ask the healthcare provider to prescribe the newest antibiotic when needed d. request a prescription for first time vancomysin for a sore throat ANS: B 50 of 55 A client with symptoms of influenza that started the previous day ask the clinic nurse about taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse provide? a. Advise the client once symptoms occur is too late to receive an influenza vaccination b. Refer the client to the healthcare provider at the clinic to obtain a medication prescription c. Explain to the client that antibiotics are not useful in treating viral infections such as influenza d. Instruct the client that over the counter medications are sufficient to manage influenza symptoms ANS: B 51 of 55 Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2 grams using an infusion pump to deliver the dose in one hour, the client reports feeling nauseated. What action should the nurse implement? a. stop medication infusion and notify the healthcare provider of the adverse effect b. increase the rate of the infusion to complete the dose of the medication more rapidly c. continue the infusion and administer a prn antiemetic prescription d. reasurre the client that the nausea is not related to the iv infusion ANS: C 52 of 55 The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimers disease as an intervention for which client problem? a. fluid volume excess b. disturbed though processes c. chronic pain d. tered breathing patterns ANS: B 53 of 55 To prevent deep vein thrombosis following knee replacement surgery, an adult male client is receiving enoxaparin (Lovenox) subcutaneously daily. Which laboratory finding requires immediate action by the nurse? a. blood urea nitrogen (BUN) 20mg/dl or 7.1 mmol/L (SI) b. Hematocrit 45% c. Serum creatinine 1.0 mg/dl or 88.4 mol/L (SI) d. Platelet count of 100,000/mm3 or 100x10??/ L (SI) ANS: D 54 of 55 A client with type 2 diabetes mellitus is managed with metformin (Glucophage), an oral hypoglycemic agent. The primary health care provider prescribes ad additional medication injected exenatide (byetta). Which information is most important for the nurse to teach this client? a. Administer subcutaneously after meals b. Consume additional sources of potassium c. Notify the healthcare provider if anorexia occurs d. Watch for signs of jitteriness or diaphoresis ANS: B 55 of 55 A client is who is diagnose with schizophrenia receives a prescription for a atypical antipsychotic drug aripipazole (Abilify). Which assessment should the nurse perform to monitor for an adrenergic receptor antagonist side effect that commonly occurs atypical antipsychotic agents? a. observe the client hallucinatory behaviors b obtain the client fingerstick glucose levels c. measure the clients lying and standing blood pressure d. determine the clients abnormal involuntary movements scale (AIMS) ANS: B   PART BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 1. A client with eczema is using an OTC topical product with urea 10% OTC (Aqua Care Cream) to the affected skin areas. Which finding reflects the expected therapeutic response. Hydration of affected dry skin areas Healing with a return to normal skin appearance Reduced pain in eczematous areas Decreased weeping of ulcerations in affected area 2. A male client with a primary lung cancer was told by his healthcare provider that he now has a secondary tumor. After the healthcare provider leaves, the client asks the nurse what "secondary tumor" means. What response would be best for the nurse to provide. Tell me why you are concerned about this term? Your original cancer has spread to another location You need to remain hopeful, treatment can still be effective Let me call your health care provider back to explain the meaning of secondary tumors. 3. The UAP reports to the nurse that a client who was admitted with abdominal pain has just had a large black tarry stool. What intervention should the nurse implement first. Test the stool for occult blood Obtain consent for a blood transfusion Review history for gastrointestinal bleeding Notify the rapid response team 4. Which action is most important for the nurse to implement to reduce the risk for DVT in a post op client. Change the client’s IV access site in the next 72 h Assist the client in turning from side to side q 2h Advise the client to perform leg exercises regularly Encourage frequent cough and deep breathing exercises 5. A male tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement. Assess for perineal itching, erythema, and excoriation Obtain a specimen of urethral drainage for culture Observe the perineal area for a chancroid-like lesion Identify all sexual partners in the last four days 6. The nurse is planning care for a pt with CKD who is a resident at a long term care facility. The pt is anuric and has hemodialysis 3x per week. Which intervention should the nurse include in the pt's plan of care? plan meals that include dark leafy veg use adult briefs to prevent skin breakdown monitor for signs of bleeding record strict urinary output 7. A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110 mmol/L or SI), hematocrit of 34% and microcytic and hypochromic red blood cells. Based on the findings, which dinner selection should the nurse suggest for the patient? Beef steak with steam broccoli and orange slices Cheese pasta and a lettuce and tomato salad Broil white fish with a baked sweet potato Grill shrimp and seasoned rice with asparagus salad. 8. Tthe nurse is preparing a client for a bronchoscopy. While obtaining consent, the client complaints of thirst and admits to drinking a small amount of orange juice two hours ago. What action should the nurse take? Offer the client ice chip. Administer and antiemetic. Delay procedure for 6 hours. Increase intravenous flow rate. 9. A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement? Advise the client to apply plastic wrap over the ointment to promote healing Instruct the client to continue the ointment until all erythema is relieved Explain that the client needs to complete all prescribed doses of the medication. Schedule an appointment for the client to see the healthcare provider. 10. The nurse learns in changes of shift report that x-ray report for newly admitted client indicates consolidation in the left lower lung. What action should the nurse take? Administer a PRN dose of a bronchodilator. Complete an assessment of respiratory status Demonstrate use of incentive spirometer. Prepare a client for chest tube insertion. 11. The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care A plan meal that include dark leafy vegetables B Use adult briefs to prevent skin breakdown C Monitor for signs of blending D records strict urinary output 12. Following an ileal conduit urinary diversion, a male client voices several complaint. Which complaint indicates to the nurse that he is experiencing a complication? A bright red moist ostomy site. Amber colored urine coming out of the stoma. A small amount of bleeding at the stoma site. A dark purplish colored stoma. 13. A male client is admitted to the emergency department with vomiting of dark brown, foul-smelling emesis. He reports he had surgical repair of a recurrent inguinal hernia one week ago and complains of intense abdominal pain. After assessing that his bowel sounds are hyperactive, which prescription should the nurse implement first. Place an indwelling urinary catheter and attach a bedside drainage Give a prescribed analgesic for temperature above 101 F. Insert a nasogastric tube (NTG) and attach to low intermittent suction. Send the client to x-ray for a flat plate of the abdomen. 14. The nurse is monitoring capillary glucose, q4 hours, of a adult woman admitted with diabetic ketoacidosis. Two hours after receiving 10 units of regular insulin for a glucose level of 255 mg/dL, the client is perspiring and complaining of shakiness. What interventions should the nurse implement . Administer an additional dose of insulin. Obtain another capillary glucose level. Reevaluate client symptoms in an hour. Give the client 8 ounces of orange juice. 15. The nurse is planning care for an older adult male who experienced a cerebrovascular accident several weeks ago. Because of his expressive aphasia, the client often becomes frustrated with the nursing staff. Which intervention should the nurse implement? Speak slowly to the client. Ask the client samples questions. Teach the client use of basic sign language. Encourage client in use of picture charts. 16. A client with an arterial ischemic leg ulcer is being discharged from the hospital. Which instruction is most important for the nurse to include in this client’s discharge teaching plan? Wear shoes and socks while awake. Keep legs elevated as much as possible. Inspect feet daily for skin breakdown. Trim toenails straight across. 17. The chest x-ray for a client who is admitted for pneumonia shows pleural effusion with decreased air flow in the entire left upper lobe. What breath sounds that verify the x-ray finding should the nurse document after auscultation of the left upper lobe. Low pitched, sonorous rhonchi Diminished breath sounds. Pleural friction rub. Crackles or course rales. 18. Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers? Oatmeal raisin and fruit with skin Chicken, rice and wheat products. Potatoes, low fat breads, and applesauce. Lean beef, salads and bake potatoes. 19. Which food is most important for the nurse to encourage a male client with ostemalacia to include in this daily diet? A)- Red meats and eggs. B)- Fortified milk and cereals. C)- Citrus fruit D)- Green leafy vegetables. 20. A male client with esophageal varices who has been NPO since admission to the intensive care unit is requesting something to eat. He has not had a bleeding episode in three days, and he has a prescription for diet as tolerated. Which snack is best for the nurse to provide the client? A)- Soda crackers, milk and a cup of yogurt. B)- Clear liquid broth, hot tea, and ice cream. C)- Ginger ale, strawberry gelatin, and a clear soup. D)- Luke warm broth, iced tea, and a lemon popsicle. 21. A client who has a history of long standing back pain treated with methadone (Dolophine), is admitted to the surgical unit following urological surgery. What modifications in the plan of care should the nurse make for this client’s pain management during the postoperative period? Maintain client’s methadone, and medicate surgical pain based on pain rating. Use minimal parenteral opioids for surgical pain, in addition to oral methadone. Make no changes in standard pain management for this surgery and hold methadone. Consult with surgeon about increasing methadone in lieu of parenteral opioids. 22. A male client with laryngectomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube. Which action is most important for the nurse to take? Place knots all hotties laterally to prevent irritation and pressure. Remove ties to secure a disposable soft foam dollar with Velcro. Leave the old one to place until the new ones are secure Secure tracheostomy ties by making knots close to the tube. 23. during spring break, a young adult present at the urgent care clinic and report a stiff neck, fever for the past 6 hours, and headaches. Which intervention is more important for the nurse to implement? Initiate insolation precautions. Prepare for a lumbar puncture. Administer an antipyretic Draw blood culture. 24. A client with hypothyroidism report difficulty falling asleep because of feeling of depression which action should the nurse implement? Encourage increased exercise and activity during the day. Review most recent thyroid function test results. Withhold next scheduled dose of levothyroxine. Request a PRN sedative hypnotic to help with insomnia. 25. A client receives a prescription for warfarin (Coumadin) 2 mg IM daily. The pharmacy delivers a vial. The instruction reads, reconstitute with 2.7 ml of sterile water for injection to yield 2 mg/ml. How many ml should the nurse administer? (Enter the numerical value only).R/ 2.5 1 ml 26. After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. What assessment should the nurse complete first? Measure abdominal girth. Observe for flushing. Auscultate breath sounds. Obtain current vitals signs. 27. An older adult woman is seen in the clinic 3 months following her diagnosis of types 2 diabetes mellitus (DM) She tells the nurse that she has had a difficult time keeping her blood sugar in control. The nurse reviews the client s current fingerstick and daily log of blood glucose levels. Which intervention is most important for the nurse to implement? Collect a voided urine specimen for ketones analysis. Ask the client to recall her last 3 days of food intake. Compare current weight with weight 3 months ago. Review the client glycosylated hemoglobin (A1C) level. 28. Two day following a nephrectomy, the client reports abdominal pressure and nausea. Which intervention should the nurse implement? Ambulate client in hallway. Auscultate bowels sounds. Measure hourly urine output. Palpate the abdomen. 29. an adult female client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate (Feosol) 325mg PO daily. Which laboratory values should the nurse monitor? Neutrophils and eosinophils. Serum iron and ferritin. Platelet count and hematocrit Serum electrolytes. 30. To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what intervention should the nurse implement? (Select all apply) Perform chest physiotherapy. Initiate passive range of motor exercises. Establish a regular bladder routine. Encourage use of incentive spirometer. Teach the client breathing exercises. 31. The nurse is evaluating a male client s understanding of diet teaching about the DASH (Dietary Approaches to stop hypertension) eating plan. Which behavior indicate that the client is adhering to the eating plan? Enjoys fat free yogurt an occasional snack food. Carefully cleans and peels all fresh fruit and vegetables. Uses only lactose free dairy products. No longer includes grains in his daily diet. 32. The nurse is taking a client’s blood pressure and observe carpal spams after the sphygmomanometer cuff is inflated. What action should the nurse implement next? Administer a prescribed PRN anti-anxiety agent? Notify the health care provider of the findings Asses the client’s recent serum calcium level Prepare to implement seizure precautions 33. A male client is recovering from an episode of urinary tract calculi. During discharge teaching the client asks about the dietary restrictions he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation? Low sodium soup. Tea and hot chocolate. Citrus fruit juice. Over all fluid intake. 34. During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond? Document the client understanding of teaching Review the client previous surgical history Ask for a demonstration of these exercises Explain that coughing should be avoided. 35. A client with chronic obstructive pulmonary disease (COPD) is somnolent and having periods of apnea. The client oxygen saturations 88% while receiving humidified oxygen at 6L/nasal cannula(NC). Which intervención should the nurse implementa? Complete a neurological assessment. Adjust the oxygen flow rate 21/ NC. Administer a narcotic reversal agent. Change oxygen to 40% per face mask. 36. A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care? Continuous cardiac monitoring. Perform passive range of motion. Evaluate level of consciousness. Assess lung sounds c/4 hours. 37. Two days after an abscess of the chin was drained, the client returns to the clinic with fever Chills, and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with povidone-iodine (betadine) solution. Which intervention should the nurse implement first? a. Obtain samples for complete blood count and cultures. b. Assess airway patency and oxygen saturation c. Determine in the client has a history of diabetes d. Review recent medication history and allergies 38. The Health Care Provider prescribes an IV solution of regular insulin (Humulin) 100 units in 250 ml of 0.45% saline to infuse at 12 units/hour. The nurse should program the infusion pump to deliver how many ml/hours. (Enter numeric value only) 30 ml/h 39. After 3 days of persistent epigastric pain, a female client presents to the clinic she has been taking oral antacids without relief. Her vital signs are HR 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96% and blood pressure 116/70. The nurse obtains a 12-lead ECG. Which assessment finding is most critical? ST elevation in three leads 40. The clinic nurse is reviewing strategies for blood glucose monitoring with a client who is newly diagnosed with diabetes mellitus. In helping the client select a blood glucose meter, which client assessments should the nurse complete. a. Deep tendon reflexes and skin color. B. Capillary refill time and radial pulse volume. C. Skin elasticity and hand grip strength. D. Manual dexterity and visual acuity. 41. An older adult man who is legally blind in both eyes and is taking diuretics requests assistance to the bathroom. Which intervention should the nurse implement? A. Apply an external urinary catheter. B. Use adults’ briefs during period of diuresis C. Provide the client with a urinal. D. Assist the client to the bathroom 42. After teaching a female client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Elimination of which food choices by the client indicates teaching is successful A. Citrus fruit and melon with salt substitute. B. Pasta with herbal butter and no meat sauce C. Whole milk and daily ice cream servings D. Canned vegetables and salt dispenser on the table 43. The nurse applies an automatic external defibrillator (AED) to a client who collapse din an exam room at a community clinic. What action should the nurse take next. A. Assess the client’s oxygen saturation B. Determine the defibrillator reading C. Measure the client’s blood pressure. D. Bring a crash cart to the exam room. 44. A homeless adult male with a history of chronic alcoholism is admitted with signs of hepatic encephalopathy. Two days after receiving a prescription for lactulose, the client has three diarrhea stools within 4 hours. Which intervention is most important for the nurse include in the client's plan of care? a. Provide meticulous perineal care with a skin barrier. B. Record the client’s 24-hour dietary intake for one week. C. Encourage the client to attend an alcoholic anonymous. D. Review the client’s serum ammonia levels weekly possible. 45. A male client with an external fixation device for a fractured left femur is complaining of left foot pain. Which intervention should the nurse implement first? A. Administer PRN pain medication B. Auscultate blood pressure. C. Assess peripheral pulses D. Observe the leg for swelling. 46. A client with acute renal injury (AKI) who weighs 50 kg and has a potassium level of 6.7 mEq/L is admitted to the hospital. Which prescribed medication should the nurse administer A. Calcium acetate (Phos-Lo) one tablet PO B. Sodium polystyrene (Kayexalate) 15 grams PO C. Epoetin alfa, recombinant (Epogen) 2,500 units SUB. D. Seyelamer (RenaGel) one tablet PO. 47. What goal has the highest priority when planning nursing care for a client with acute sinusitis a. Reports improved of taste and smell. b. expresses knowledge of causative factors. c. demonstrates return of normal voice. d. expresses relief of pain. 48. A client is recovering from a transurethral prostatectomy. Which activity should be limited until after the first postoperative visit with his healthcare provider? A. Kegel exercises B. Eating high-fiber foods C. Walking around the house D. Driving a car. 49. The nurse is assessing a client who is one day post parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider, the nurse should prepare for which procedure. A. Tracheostomy placemen B. Pacemaker placement C. Nasogastric tube insertion D. Central Line insertion 50. Two days following abdominal surgery a client begins to complain of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first? A. Encourage the client to ambulate B. Offer ice chips or warm liquids C. Assess the client’s temperature D. Auscultate the client’s abdomen 51. A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. It is most important for the nurse to emphasize the need to observe for changes in which characteristic. Elasticity of the skin Pigmentation of the skin Muscle aches and pain Appearance of any mole 52. A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider? Low back pain and hypotension Rhinitis and nasal stuffiness Delayed painful rash with urticaria Arthritic joint changes and chronic pain 53. The nurse plans to administer naloxone (Narcan) 1mg .the label of the 10 ml vial indicates that the drug concentration is 0.4 mg/mL how many ml should the nurse administer R/ 2.5 Ml 54. Which nursing problem has the highest priority when planning care for a client whit ostemalacia? Altered tissue perfusion Risk of infection Rick for injury Sleep pattern disturbance 55. The nurse is providing preoperative educationfor a Jewish client schedule to receive a xenograft to promote burn healing .Which information should the nurse provide this client? The xenograft is taken from nonhuman sources 56. A client with pheochromocytoma reports the onset of a severe headache The nurse observe that the client is very diaphoretic. Which assessment data should the nurse obtain next? Blood pressure 57. A client develops subcutaneous emphysema following a thoracotomy. To evaluate the progression of subcutaneous emphysema,which assements should the nurse make select all that apply Measure the oxygen saturation Palpate skin around the chest tube Auscultate breath sounds bilaterally Assess for deviation of the sternum Observe appearance of the neck 58. The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. what action would be best for the nurse to take? A Obtain a specimen of the drainage for culture B Maintain the current IV antibiotic schedule C Milk the tube to remove any clots D - Schedule a portable chest X ray per PRN protocol 59. Which action is most important for the nurse to implant to reduce the risk for deep vein thrombosis in a postoperative client? A change the client IV access site at least 72 h B assist the client in turning from side to side q 2h C Advise the client to perform leg exercise regular 60. An adult female whit multiple sclerosis (MS) fell while walking to the bathroom. On transfer to the intensive care unit ,she is confused and has projectile vomiting twice Which intervention should the nurse implemented first? A administer a PRN ANTIEMETEC as prescribed B Determine client last dose of corticosteroids C Determine neurological baseline prior to the fall D Complete head -to toe neurological assessment 61. A Fame client whit chronic syndrome of inappropriate ant – diuretic hormone (SIADH) report to the nurse that she is constantly thirsty. What action should the nurse take ? Encourage the client to use hard candy frequently to help relieve her thirst 62. The nurse is assessing a group of older adults. What factor in a male clients history puts him at greatest risk for developing colon cancer? A -smoker cigarette B- Eats a high fat diet C- Has intestinal polyps D- Is excessively exposed to sunlight 63. The nurse should include which information in the teaching plan for a client recently diagnosed whit primary open -angle glaucoma? SELECT ALL THE APPLY A -Limit salt intake to reduce increased intraocular pressure (iop) B -Regular eye examine are necessary tomonitor IOP and visual field C -Daily eye medication is instilled to lower intraocular pressure D -expect vision loss to progress Fromm central vision to peripheral vision E -Vigorous exercise such as jogging or running should be avoided 64. A client with stage IV bone cancer is admitted to the hospital for pain control the client verbalizes continuous severe pain 8 on a 1 to 10 scale which intervention should the nurse implement A – Alternate IV AND IM analgesic medication B – Admitter opioid and no opioid medication simultaneously C -Educate client on signs and symptoms of narcotic dependency D Give maximum dosage when score when score reaches 10 65. The nurse completes the admission assessment of female client whit systemic lupus erythematosus Which finding requires the most immediate follow -up assessment by the nurse ? Fatigue Joint pain Alopecia Hematuria 66. What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? Light housekeeping is permitted. but avoid heavy lifting 67. A client who has been takin finasteride (proscar) an enzyme ( 5 alpha reductase) inhibitor used to shrink the gland , is admitted because of continuing begin prostatic hypertrophy(BPH0 symptoms when planning care which nursing problem should the nurse plan to address first? disturbed sleep patters Urinary retention Chronic pain Risk for infection [Show More]

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