NURSING MISC (NURMISC) (NURSING MISC (NURMISC Accumulative NCLEX- Respiratory, Neuro, GI, Ortho, Cardio , Endocrine and Integumentary

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NCLEX: Respiratory, Neuro, GI, Ortho Cardio GI, Endocrine, Integumentary Integumentary NCLEX A client with dermatitis has been prescribed a topical corticosteroid for use on the affected areas, and th... e nurse has reinforced instructions about the use of this medication. Which statement by the client indicates a need for further teaching? I will apply a bandage over the site after applying the medication. 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? I will apply the ointment once a day and cover it with a sterile dressing. 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? Triglyceride level 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? Warm compresses 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? Face 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? "I will massage the medication into the skin from my chin downward and apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application." 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? "The medication will permanently stain my skin." 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? Leave the cream on for 8 to 12 hours and then remove by washing. 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? Axilla 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? This medication can cause systemic effects. 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? 15 to 20 weeks 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? Informing the client this is normal. 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? Hyperventilation 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? Apply once a day and cover the wound with a sterile dressing. 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? Covering the sutilains application with a dry sterile dressing 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 superficial injury to tissue from the radiation. 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? Vitamin A 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? Axilla 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? Continue with the treatment because this is expected. 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? I should apply a very thin layer to my skin. 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? Apply to cleansed, debrided wounds as prescribed. 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? Massage the medication into the skin from the chin downward, and apply a second application in 24 hours, followed up with a cleansing bath 48 hours after the second application. 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? Tinnitus 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? Signifying leukopenia 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? Discontinue the prescribed antihistamine 2 days before the test. 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? Acne 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? Fill in the blank. a. 36% 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? a. It is highly metastatic. 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? a. An irregularly shaped lesion 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? a. "I need to avoid sun exposure before 10:00 AM and after 4:00 AM." 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? a. A white color of the skin, which is insensitive to touch 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? a. Partial-thickness skin loss of the epidermis 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? a. Silvery-white scaly lesions 8. Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? a. The return of distal pulses 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? a. Elevation above the level of the heart 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? a. Clustered skin vesicles 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? a. Blistering skin 12. A client asks the nurse about the causes of acne. The nurse should respond by making which statement to the client? a. "The exact cause of acne is not known." 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? a. Characteristic of a thrush infection 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? a. Elevating and immobilizing the affected leg 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 should never wear warm clothing over the newly healed skin area." 16. The nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder? a. An outdoor construction worker 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? a. "I will remove the dressing when I get home and wash the site with tap water." 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? a. Darken the room for the examination. 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? a. "I should use a dehumidifier, especially during the winter months." 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. "Take a shower immediately, and lather and rinse several times." 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? a. "It is a skin infection that involves the deeper skin layers and subcutaneous fat." 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? a. Warm compresses to the affected area 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? a. Culture of the lesion 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? a. Palms of the hands 26. The nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further teaching? a. "If the patch comes off, I need to reapply it." 27. The nurse prepares to assist in instructing a client about prevention of Lyme disease. Which should the nurse include in the instructions? a. It is caused by a tick carried by deer. 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? a. Neurological deficits 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? a. Inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable. 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? a. Punch biopsy of the cutaneous lesions 31. Which individual is least likely at risk for the development of Kaposi's sarcoma? a. An individual working in an environment in which exposure to asbestos is possible 32. 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? a. Red, shiny skin around the nail bed 33. 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? a. Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs 34. The nurse is checking her clients for skin breakdown. Which client should have the lowest priority for concern in the development of skin breakdown? a. A client with a lowered mental awareness status 35. 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. A superficial injury to tissue from the radiation 36. 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. Ensure that the solution is freshly prepared before use. 37. 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. "I will apply the ointment once a day and cover it with a sterile dressing." 38. 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. Stage II 39. 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. Covering the application with a warm, moist dressing and an occlusive outer wrap 40. Which individuals is least likely at risk for the development of psoriasis? a. A 32-year-old African American 41. 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. Elevated and immobilized 42. 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. "It is skin from another species." 43. 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. 36% 44. 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. Use the edge of a sterile surgical tool to scrape out the stinger. 45. 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. Venous circulation is being impaired. 46. 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. Normal saline 47. 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? a. 54% 48. 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. Monitor the client for signs of infection. 49. 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. "My clothes can be laundered with other household members' clothes." 50. 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. White skin that is insensitive to touch 51. Which clients are at risk for developing skin breakdown? Select all that apply. a. A client who is underweight b. A client diagnosed with heart failure c. A client diagnosed with spinal cord injury 52. 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. Administer an opioid analgesic last taken 6 hours ago. 53. 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. "I need to stop taking my antihistamine 2 days before I come to the clinic for the test." 54. 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. Apply cold compresses to the affected area. 55. 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. 56. 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. Appearance 57. 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. Chicken breast, broccoli, strawberries, milk 58. 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. Another species 59. 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. Stage 2 pressure ulcer 60. 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. Ambulation three times daily 61. 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. a. 19% 62. 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. Bull's-eye rash 63. A client with jaundice is complaining of pruritus. Which strategy should the nurse institute to help control the problem and prevent injury? a. Pat the skin dry after bathing. 64. 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. Weeping of the skin 65. 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. Slight because the local anesthetic may burn or sting 66. 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. Discontinue the prescribed antihistamine 2 days before the test. 67. 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. 22.5% 68. 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. Elevated hematocrit levels 69. 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. Using astringents to clean the skin 70. 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. Warm compresses 71. 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. Being in the sun for prolonged periods between 10:00 AM and 3:00 PM 72. 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 73. 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. 74. 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. Dressing if present 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 75. 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 76. 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 77. 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? Answer: 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? Answer: High-Fowler's position 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? Answer: 3.5 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? Answer: 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? Answer: 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? Answer: 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? Answer: Limit the fluids taken with meals. 8. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence? Answer: Sweating and pallor 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? Answer: 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. Answer: 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? Answer: Hepatitis A 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? Answer: Position the client supine and flat. 13. A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid? Answer: Lying recumbent after meals 14. The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred? Answer: 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? Answer: Evaluate absorption of the last 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? Answer: Use diluted mouthwash and water to rinse the mouth after brushing teeth. 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? Answer: 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? Answer: 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? Answer: Fatigue 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? Answer: Hepatitis B vaccine 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? Answer: Increase intake of fluids. 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? Answer: 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? Answer: Offer small, frequent meals. 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? Answer: Personal history of ulcerative colitis or gastrointestinal (GI) polyps 25. A client has undergone esophagogastroduodenoscopy (EGD). The nurse places highest priority on which action as part of the client's care plan? Answer: Checking for return of a gag reflex 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? Answer: "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? Answer: Low fiber 28. A client has asymptomatic diverticular disease. Which type of diet should the nurse anticipate being prescribed? Answer: High-fiber diet 29. The nurse is caring for a client suspected of having appendicitis. Which should the nurse anticipate will be prescribed for this client? Answer: No oral intake of liquids or food 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? Answer: "I should resume a full activity level within 1 week." 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? Answer: 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? Answer: Hematemesis 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? Answer: Document the finding in the client's record. 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? Answer: 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? Answer: The aspirate from the tube has a pH of 7.45. 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? Answer: The pH of the aspirate is 5. 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? Answer: Remain with the client and be silent 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? Answer: Learn measures such as biofeedback or progressive relaxation 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? Answer: "I need to add 0.5 ounce of mineral oil to my daily diet." 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. Answer: Ask a member of the local ostomy club to visit with the client before discharge. Ask the enterostomal nurse specialist 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? Answer: "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? Answer: 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? Answer: 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? Answer: Acetaminophen (Tylenol) 45. A nurse planning care for a client with hepatitis plans to meet the client's safety needs by performing which action? Answer: Monitoring prothrombin and partial thromboplastin values 46. The nurse is collecting admission data on the client with hepatitis. Which finding would be a direct result of this client's condition? Answer: Drowsiness 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? Answer: 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? Answer: "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? Answer: "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? Answer: 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? Answer: "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? Answer: 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? Answer: 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? Answer: Provide frequent oral and nasal care on a regular basis. 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? Answer: History of chronic obstructive pulmonary disease with weight loss 56. The nurse should include which information when reinforcing home care instructions for a client who has peptic ulcer disease? Answer: Learn to use stress reduction techniques. 57. The nurse is reinforcing dietary instructions for a client with peptic ulcer disease. Which action does the nurse encourage the client to do? Answer: Eat anything as long as it does not aggravate or cause pain. 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? Answer: A decrease in sour eructation 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. Answer: Eat smaller and more frequent meals. Drink fluids between meals not with them. 60. The nurse who is reinforcing instructions to a client following gastric resection should include which suggestions? Select all that apply. Answer: Eat small frequent meals Take action to prevent dumping syndrome 61. The nurse reinforces instructions to a client following a gastrectomy about the signs and symptoms of pernicious anemia, knowing what information? Answer: 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? Answer: 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? Answer: 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? Answer: A tube with a larger lumen and an air vent 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? Answer: Low and intermittent 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. Answer: 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. Answer: Milk of magnesia Heat pad to the abdomen 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? Answer: Fowler's 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? Answer: 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? Answer: Semi-Fowler's 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? Answer: 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? Answer: Placement of the NG tube is accurate. 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? Answer: "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? Answer: Difficulty swallowing 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? Answer: "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. Answer: It is advisable to stop smoking cigarettes. 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? Answer: The tube will be inserted through my nose to my stomach. 78. The nurse is assisting in caring for a client with a Sengstaken-Blakemore tube. Which article should the nurse place at the bedside? Answer: 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? Answer: 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? Answer: 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? Answer: 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? Answer: 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? Answer: 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. Answer: Provide meticulous and frequent oral hygiene. 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? Answer: 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. Answer: Chemical Absorption Mechanical Active transport 87. A licensed practical nurse (LPN) is helping a registered nurse (RN) conduct an abdominal assessment. The LPN assists the client into which position? Answer: Supine with the head raised slightly and the knees slightly flexed 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? Answer: 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. Answer: 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? Answer: Impaired nutritional status 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? Answer: Vitamin B12 injections 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? Answer: Milk of magnesia 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? Answer: Pulsation between the umbilicus and pubis 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? Answer: 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? Answer: 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? Answer: Channels of gastric secretions may be bypassing the holes in the tube; turning the client will promote stomach emptying. 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. Answer: 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? Answer: Postprandial blood glucose readings 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? Answer: Vigorous coughing 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? Answer: 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? Answer: 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? Answer: Aspiration 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? Answer: Hemoglobin 10.2 g/dL 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? Answer: 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? Answer: Presence of bowel sounds in all four quadrants 106. A sexually active 20-year-old client has developed viral hepatitis. Which statement made by the client would indicate a need for teaching? Answer: "I can never drink alcohol again." 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? Answer: Feeling self-conscious about appearance 108. A client with viral hepatitis states to the nurse, "I am so yellow." The nurse should take which action? Answer: 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? Answer: Ibuprofen (Motrin) 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? Answer: A pyloroplasty involves an incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum. 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? Answer: Reduces the stimulation of acid secretions 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? Answer: Elevate the scrotum. 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? Answer: 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? Answer: 30 minutes before meals 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? Answer: 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? Answer: 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? Answer: Right side-lying with a small pillow or towel under the puncture site 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? Answer: From the tip of the client's nose to the earlobe and then down to the xiphoid process 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? Answer: Take a breath and hold it until the tube is out. 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? Answer: Clamp the NG tube for 30 minutes following administration of the medication. 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? Answer: A pair of scissors 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? Answer: 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? Answer: Remove all metal and jewelry before the test. 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? Answer: Ask the client to extend the arms. 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? Answer: 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? Answer: 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? Answer: Clamp the tubing for 30 seconds and restart the flow at a slower rate. 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? Answer: Avoid coughing. 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? Answer: Takes the client's vital signs. 130. The nurse is reinforcing medication instructions to a client with peptic ulcer disease. Which represents correct information given by the nurse? Answer: Cimetidine (Tagamet) results in decreased secretion 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? Answer: Hydromorphone (Dilaudid) 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. Answer: Inspect the abdomen for rigidity. Check for the presence of 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. Answer: Obtain vital signs and draw blood for laboratory analysis. 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. 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. Answer: Oliguria Restlessness Abdominal pain Unexplained tachycardia 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. Answer: Avoid potentially hepatotoxic over-the-counter drugs. 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? 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? Transfusion reaction 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? The blood will be held, and the health care provider will be notified 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? Infiltration 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 [Show More]

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