NURSING Med Surg 2 / SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX THREE / {Received Score 100%} / Download To Score An A (LATEST)

Document Content and Description Below

1) The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and symptoms should the nurse look for? ✓ Lesions with well-defined geometric margins 2) The nurse is ... providing home care instructions to the client who just had surgery for squamous cell carcinoma. The nurse provides follow-up teaching and explains to the client to watch for which characteristics of this type of skin carcinoma? ✓ Firm, nodular lesion topped with a crust or with a central area of ulceration 3) The nurse is teaching the client about risk factors for skin cancer. Which statements by the client indicate that teaching was successful? Select all that apply. ✓ "I have to avoid excessive exposure to sunlight." ✓ "I am at higher risk for skin cancer because my mother had one." 4) The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment on which structures? Select all that apply. ✓ Lips ✓ Conjunctiva ✓ Mucous membranes 5) The nurse is providing teaching to a client who will undergo chemotherapy for cancer, and alopecia is expected from the chemotherapeutic agent. Which statement made by the client indicates a need for further teaching? ✓ "I can't believe my hair loss will be permanent." 6) The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body. Which finding suggests that an escharotomy may be necessary? ✓ High pressure alarm keeps sounding on the ventilator 7) A client with chloasma is extremely stressed about the change in her facial appearance. Which integumentary change observed by the nurse is consistent with this problem? ✓ Blotchy brown macules across the cheeks and forehead 8) The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition? ✓ Hypertrophy of collagen fibers 9) The nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record? Refer to figure. View Figure ✓ Stage IV pressure ulcer 10) A client recently diagnosed with chronic kidney disease requiring hemodialysis has an arteriovenous fistula for access. The client asks the nurse what complications can occur with the access site. What complications should the nurse inform the client about? Select all that apply. ✓ Hepatitis ✓ Infection 11) The nurse has completed discharge teaching for a client who was admitted for reticular skin lesions. Which statement by the client indicates understanding of the discharge instructions? ✓ "I need to assess my skin for lesions that appear net-like." 12) A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible for this finding? Select all that apply. ✓ Fever ✓ Vasodilation ✓ Inflammation ✓ Excessively high environmental temperature 13) An older client's physical examination reveals the presence of a fiery star-shaped marking with a circular, solid center. The nurse recognizes that these findings, which are caused by capillary radiations extending from the central arterial body, are representative of which lesions? ✓ Spider angioma 14) An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area? ✓ Greater trochanter 15) In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem? ✓ Altered body image 16) The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse should plan to assess which part of the integumentary system first? ✓ Nails 17) A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term? ✓ Ecchymosis 18) A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound? ✓ Autograft 19) The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions? ✓ "You will need to wear dark eye goggles during the treatment." 20) The nurse in the surgical care center will be assisting the health care provider to perform a punch biopsy of a client's skin lesion. Which interventions should be included in the preprocedure plan of care? Select all that apply. ✓ Obtain an informed consent. ✓ Prepare to apply direct pressure to the biopsy site after the procedure. ✓ Tell the client that a small piece of tissue will be removed for examination. 21) The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The nurse develops the plan based on which characteristics associated with acne? Select all that apply. ✓ The exact cause of acne is unknown. ✓ Acne requires active treatment for control until it resolves. ✓ Oily skin and a genetic predisposition may be contributing factors for acne. ✓ The types of lesions in acne include comedones (open and closed), pustules, papules, and nodules. 22) The nurse is reviewing the health care records of clients scheduled to be seen at a health care clinic. The nurse determines that which client is at the greatest risk for development of an integumentary disorder? ✓ An outdoor construction worker 23) A client scheduled for a skin biopsy is concerned and asks the nurse how painful the procedure is. Which statement is the appropriate response by the nurse? ✓ "The local anesthetic may cause a burning or stinging sensation." 24) The nurse is preparing a client for punch biopsy. What should the nurse do to prepare for this procedure? ✓ Ensure that the consent form has been signed. 25) The nurse prepares to assist a health care provider who is examining a client's skin with a Wood's light. Which step should the nurse include in the plan for this procedure? ✓ Darken the room for the examination. 26) The nurse prepares to treat a client with frostbite of the toes. Which action should the nurse anticipate will be prescribed for this condition? ✓ Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs 27) The presence of which finding leads the home health nurse to suspect infestation of a client with scabies? ✓ Multiple straight or wavy, threadlike lines beneath the skin 28) The nurse suspects herpes zoster (shingles) when which assessment finding is noted? ✓ Clustered skin vesicles 29) Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instruction? ✓ "The UV light treatments are given on consecutive days." 30) The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply. ✓ Antibiotic therapy ✓ Warm compresses to the affected area 31) Which individuals are most likely to be at risk for development of psoriasis? Select all that apply. ✓ A woman experiencing menopause ✓ A client with a family history of the disorder ✓ An individual who has experienced a significant amount of emotional distress 32) A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? ✓ 9600 mL of lactated Ringer's solution 33) The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? ✓ Heart rate of 95 beats/minute 34) The nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client? ✓ Oral mucosa 35) The nurse is caring for a client who has vesicles filled with purulent fluid on the face and upper extremities. On the basis of these findings, the nurse should tell the client that the vesicles are consistent with which condition? ✓ Acne 36) The nurse is performing assessment of the client who is admitted with left leg cellulitis. What does the nurse anticipate finding on the assessment of the left lower extremity? ✓ Erythema 37) A client complains of chronic pruritus. Which diagnosis should the nurse expect to note documented in the client's medical record that would support this client's complaint? ✓ Chronic kidney disease 38) A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which disorder? ✓ Systemic lupus erythematosus (SLE) 39) The nurse notes that an older adult has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. How should the nurse document these lesions in the medical record? ✓ Appears to have cherry angiomas on trunk and thighs 40) The nurse is teaching a client about changes in body image related to chronic obstructive pulmonary disease (COPD). Which statement by the client would indicate that teaching was successful? ✓ "My nails may become clubbed." 41) The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about prevention of pressure ulcers while the client has limited mobility. Which statement by the client indicates the need for further teaching? ✓ "I can sit in my favorite chair all day." 42) The nurse is caring for a client with a diabetic ulcer. What discharge instructions should the nurse provide to the client? Select all that apply. ✓ Use a mild soap when washing the feet. ✓ Use lanolin on the feet to prevent dryness. ✓ Exercise the feet daily by walking and flexing at the ankle. 43) An older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply. ✓ Heels ✓ Elbows ✓ Sacrum ✓ Back of the head 44) An adult client trapped in a burning house has 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, what percentage does the nurse determine the extent of the burn injury to be? Fill in the blank. ✓ Correct Answer: 22.5 % 45) A hospitalized client is diagnosed with scabies. The health care provider (HCP) recommended that the client and the client's roommate be treated with lindane. Which finding, if noted on this client's chart, would alert the nurse to notify the HCP before the treatment with lindane? ✓ Client history of seizure disorders 46) Isotretinoin has been prescribed for an adolescent with a diagnosis of severe cystic acne. The nurse provides instructions to the adolescent regarding the use of the medication. Which statement, if made by the adolescent, indicates a need for further instruction? ✓ "I need to be sure to take my vitamin A supplement so that the treatment will work." 47) The clinic nurse is caring for a client with a diagnosis of scabies who has just been prescribed crotamiton. The nurse instructs the client to perform which action when applying this medication? ✓ Massage the medication into the skin from the chin downward. Apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application. 48) A client has been given diphenhydramine as a topical agent for allergic dermatitis. The nurse should instruct the client to observe for which intended medication effect? ✓ A decrease in urticaria 49) A home health nurse is visiting a client who has been started on therapy with clotrimazole. The nurse determines the effectiveness of the medication by noting a decrease in which problem? ✓ Rash 50) An outbreak of head lice infestation has occurred at a local school. The school nurse is providing instructions to the mothers of the children attending the school regarding the application of malathion. The nurse should tell the mothers to take which action? ✓ Leave the lotion on for 8 to 12 hours, and then wash the hair with nonmedicated shampoo. 51) A client is seen in the clinic for a complaint of scalp itching that has been persistent over the past several weeks. After an assessment, it is determined that the client has head lice. Permethrin shampoo is prescribed, and the nurse provides instructions to the client regarding the use of the medication. The nurse should tell the client to take which measure? ✓ Wash, rinse, and towel-dry the hair before applying. 52) Lindane is prescribed. The nurse reviews the client's record, knowing that this medication therapy would be contraindicated in which client? ✓ A child 53) The nurse is applying a topical glucocorticoid as prescribed for a client with psoriasis. The nurse would be concerned about the potential for systemic absorption of the medication if it were being applied in which situation? ✓ Applied to a reddened, itchy area underneath an occlusive dressing 54) A topical corticosteroid is prescribed for an infant with dermatitis in the gluteal area. The nurse provides instructions to the mother regarding the use of the medication. Which statement by the mother indicates an understanding of the use of the medication? ✓ "The medication will help relieve the inflammation." 55) A child with severe seborrheic dermatitis is receiving treatments of topical corticosteroid applied over an extensive area of the body, followed by the application of an occlusive dressing. The nurse should monitor the child closely, knowing that which systemic effect can occur as a result of this treatment? ✓ Growth retardation 56) A client with acute seborrheic dermatitis of the back, chest, and legs is receiving treatments with salicylic acid. The nurse should monitor the client for which symptom that indicates the presence of systemic toxicity from this medication? ✓ Increased respirations 57) Topical azelaic acid is prescribed for a client, and the clinic nurse provides instructions regarding the use of this medication. Which statement by the client indicates a need for further instruction? ✓ "The medication is used to treat my eczema." 58) Minoxidil is prescribed for a client to treat hair loss. The nurse provides instructions to the client regarding the application of the medication. Which statement by the client indicates that teaching is effective? ✓ "I will apply the prescribed amount of solution twice a day." 59) Minoxidil is prescribed for a client to treat hair loss. The client asks the nurse if the hair will continue to grow when the medication is stopped. What is the appropriate nursing response? ✓ "Newly gained hair is lost in 3 to 4 months." 60) The school nurse has provided instructions regarding the use of permethrin rinse to the parents of children diagnosed with pediculosis capitis (head lice). Which statement by one of the parents indicates a need for further instruction? ✓ "It is applied to the hair and then shampooed out." 61) A child is diagnosed with impetigo. The health care provider prescribes a topical medication for treatment. The nurse anticipates that which medication will be prescribed? ✓ Mupirocin 62) Coal tar has been prescribed for the client with psoriasis, and the nurse provides instructions to the client regarding this treatment. Which statement by the client indicates a need for further instruction? ✓ "The medication can cause diarrhea." 63) Mafenide acetate is prescribed for a client with a burn injury to the hand. Which should the nurse include in the instructions to the client regarding the use of this medication? ✓ It is normal to experience local discomfort and stinging and burning after the medication is applied. 64) A burn-injured client is receiving treatments of topical mafenide acetate to the site of injury. The nurse should monitor the client for which systemic effect that can occur from the use of this medication? ✓ Acidosis 65) The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"? ✓ Leave the dressing intact for 3 to 5 days. 66) Sodium hypochlorite solution is prescribed for a client with a wound on the left foot that is draining purulent material. Which action should the nurse plan to take? ✓ Irrigate the wound with the solution. 67) Tretinoin is prescribed for a client with acne, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates a need for further instruction? ✓ "If my skin begins to peel, I will notify the health care provider (HCP)." 68) The nurse provides instructions to a client regarding the use of topical tretinoin. Which statement by the client indicates a need for further instruction? ✓ "I cannot use any cosmetics while I am using this medication." 69) Isotretinoin is prescribed for a client to treat severe cystic acne, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates a need for further instruction? ✓ "I cannot crush or chew the tablets if I have difficulty swallowing them whole." 70) Tetracycline is prescribed for a client with severe acne. The nurse instructs the client regarding the importance of reporting which finding if it occurs? ✓ Persistent diarrhea 71) A health care provider (HCP) prescribes isotretinoin for a client with severe acne. The nurse reviews the client's record 72) and notifies the HCP if which prescribed medication is noted on the medication record? ✓ Doxycycline 73) The health care provider has prescribed a topical antiinflammatory cream for a client with a muscular sprain. The nurse provides instructions to the client regarding the medication. Which statement by the client indicates an understanding of this prescribed treatment? ✓ "The medication will act as a local anesthetic." 74) Collagenase is prescribed for a client with a severe burn to the hand. The home care nurse provides instructions to the client regarding the use of the medication. Which client statement 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." 75) Which clients can safely receive lindane? Select all that apply. ✓ An 89-year-old client with dementia ✓ A 32-year-old client with renal stones ✓ A 42-year-old woman with osteoporosis ✓ A 52-year-old man with hypertension and high cholesterol 76) A hydrocolloid dressing is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and should appropriately document which intervention? ✓ Change the hydrocolloid dressing every 3 to 5 days. 77) A client is prescribed mupirocin intranasally twice daily. The nurse correlates this prescription with the client's medical record and expects to note which result specifically related to the indication for this medication? ✓ Positive methicillin-resistant Staphylococcus aureas (MRSA) by polymerase chain reaction (PCR) 78) The health care provider has prescribed coal tar treatments for a client with psoriasis, and the nurse provides information to the client about the treatments. Which statement made by the client indicates a need for further education about the treatments? ✓ "The medication always causes systemic toxicity." 79) Sodium hypochlorite is prescribed for a client with a leg wound that is draining purulent material. The home health nurse 80) teaches a family member how to perform wound treatments. Which statement, if made by the family member, indicates a need for further teaching? ✓ "I will soak a sterile dressing with solution and pack it into the wound." 81) The nurse has provided instructions to a client regarding the use of tretinoin. Which statement made by the client indicates the need for further instruction? ✓ "I must apply it to wet to damp skin." 82) A client is seen in the clinic for complaints of skin itchiness that has persisted for several weeks. After an assessment, the client is determined to have scabies. Lindane is prescribed, and the nurse provides instructions to the client regarding the use of the medication. Which action should the nurse tell the client to take? ✓ Leave the cream on for 8 to 12 hours, and then remove it by washing. 83) A topical corticosteroid is prescribed for a client with dermatitis. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client would indicate a need for further instruction? ✓ "I should place a bandage over the site after applying the medication." 84) A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor? ✓ Semipermeable transparent film 85) The home health care nurse makes a home visit to a client who has an ulcer on the medial aspect of the left ankle. The wound is being treated with a hydrocolloid dressing. The nurse removes the hydrocolloid dressing, cleanses the wound as prescribed, and reapplies the hydrocolloid dressing. The nurse schedules the next visit for wound care and changing the hydrocolloid dressing in how many days, which is the maximum number of days? Fill in the blank. ✓ Correct Answer: 7 days 86) Isotretinoin is prescribed for a client with severe cystic acne. The nurse provides instructions to the client regarding administration of the medication. Which phrase stated by the client indicates a need for further teaching regarding this medication? ✓ "I need to continue to take my vitamin A supplements." 87) A burn client has been having 1% silver sulfadiazine applied to burns twice a day for the past 3 days. Which laboratory abnormality indicates that the client is experiencing a side or adverse effect of this medication? ✓ White blood cell count of 3000 mm3 (3 × 109/L) 88) The nurse is providing instructions to a mother of a child with atopic dermatitis (eczema) regarding the application of topical cortisone cream to the affected skin sites. Which statement made by the mother indicates an understanding of the use of this medication? ✓ "I need to wash the sites gently before I apply the medication." 89) A client with psoriasis is being treated with calcipotriene cream. Administration of high doses of this medication can cause which side or adverse effect? ✓ Hypercalcemia 90) Collagenase is prescribed for a client with a severe burn to the hand. The nurse is providing instructions to the client and spouse regarding wound treatment. Which should the nurse include in the instructions? ✓ Apply once a day and cover it with a sterile dressing. 91) The nurse is caring for a client at home with a diagnosis of actinic keratosis. The client tells the nurse that her skin is very dry and irritated. The treatment includes diclofenac sodium. The nurse teaches the client that this medication is from which class of medications? ✓ Nonsteroidal antiinflammatory drugs (NSAIDs) 92) A client with muscle aches and a diagnosis of rheumatism has been given a prescription for capsaicin topical cream. The nurse determines that the client understands the use of the medication if the client makes which statement? ✓ "The medication will act as a local analgesic." 93) A client with a burn injury is applying mafenide acetate cream to the wound. The client calls the health care provider's (HCP's) office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. The nurse should instruct the client to take which action? ✓ Continue with the treatment, as this is expected. 94) A client with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite to be used in the care of the wound. The nurse should implement which action while using this solution? ✓ Rinse off immediately following irrigation. 95) An adolescent with severe cystic acne has been prescribed isotretinoin. Which statement by the client would suggest the need for further teaching? ✓ "I need to take my vitamin A supplement so that the treatment will work." 96) An ambulatory care client with allergic dermatitis has been given a prescription for a tube of diphenhydramine 1% to use as a topical agent. The nurse determines that the medication was effective if which finding was noted? ✓ Decrease in urticaria 97) The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? ✓ "All caregivers should be told about the metal implant." 98) The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse should include which in the plan of care? ✓ Use a fracture pan for bowel elimination. 99) The nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment should include which information? ✓ The client's vital signs, muscle strength, and previous activity level 100) The nurse is providing instructions to a client regarding ambulation after the application of a fiberglass cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin at which time period? ✓ Within 20 to 30 minutes of application 101) The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self- positioning in bed? ✓ Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed. 102) The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? ✓ Call the health care provider. 103) The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? ✓ Petal the cast edges with appropriate material. 104) A client who has been taking high doses of acetylsalicylic acid to relieve pain from osteoarthritis now has more generalized joint pain and an elevated temperature. The nurse should assess for which complication to determine whether the client has other signs of aspirin toxicity? ✓ Ringing in the ears 105) The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? ✓ Weak pedal pulses 106) The nurse is caring for a client in skeletal traction. On assessing the pin sites, the nurse notes the presence of purulent drainage. Which nursing action is most appropriate? ✓ Notify the health care provider. 107) The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture should be included by the nurse in the client's education? ✓ Comminuted fracture 108) The home care nurse is providing instructions to a client regarding the use of crutches. The client asks the nurse to demonstrate the method for going down the stairs with the crutches. How should the nurse accurately demonstrate this technique? ✓ Crutches and the affected leg down, followed by the unaffected leg 109) The home care nurse has instructed a client how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers. Which observation, if made by the nurse, would indicate that the client understands how to perform this type of gait? ✓ The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward. 110) A male client arrives in the hospital emergency department and tells the nurse that he twisted his ankle while jogging. The client is seen by the health care provider and is diagnosed with a sprained ankle. The nurse provides instructions to the client regarding home care for the injury. Which statement, if made by the client, would indicate an understanding of appropriate care measures for the next 24 hours? ✓ "I should elevate my foot above the level of the heart." 111) The community health nurse is providing an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse should instruct the community members to increase dietary intake of which food known to be helpful in minimizing this risk? ✓ Yogurt 112) The nurse is teaching a client with a right arm cast how to prevent stiff or frozen shoulder. What should the nurse instruct the client to do? ✓ Lift the shoulder of the casted arm over the head periodically throughout the day. 113) The nurse is preparing to perform pin site care for a client in skeletal traction. On assessment of the pin site, the nurse notes the presence of serous drainage. Which nursing action would be appropriate? ✓ Document the findings. 114) The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse should make which interpretation about this finding? ✓ Impaired venous return 115) The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)? ✓ The neurological and respiratory systems 116) The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings should be listed in the care plan as a sign/symptom of fat embolism? ✓ Dyspnea and chest pain 117) The nurse is caring for a client at risk for fat embolism because of a fracture of the left femur and pelvis sustained in a fall. The client also sustained a head injury, is comatose, and is unable to communicate verbally. Which assessment findings should the nurse identify as early signs of possible fat embolism? ✓ Increased heart rate and adventitious breath sounds 118) The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast is applied, the client reports a significant increase in pain level even after administration of the prescribed dose of opioid analgesic. What is the initial nursing action? ✓ Check the neurovascular status of the toes on the casted leg. 119) The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. ✓ Client report of severe, deep, unrelenting pain ✓ Client report of pain as nurse assesses finger movement ✓ Client report of numbness and tingling sensation in the fingers 120) The nurse has delegated the ambulation of a client to the unlicensed assistive personnel (UAP). Which actions by the UAP support a clear understanding of the appropriate steps to carry out this task safely? Select all that apply. ✓ Remove clutter that may interfere with ambulation. ✓ Assist client in applying nonskid shoes before ambulation. ✓ Instruct client to sit up on the bedside and dangle before ambulation. ✓ Observe the client for dizziness during ambulation and report immediately. 121) A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what should the nurse plan to use as the most important item for this maneuver? ✓ Abductor splint 122) A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. ✓ Heat ✓ Analgesics ✓ Muscle relaxers ✓ Intermittent traction 123) The nurse has reviewed activity restrictions with a client who is being discharged after insertion of a femoral head prosthetic system. What statement by the client will help the nurse determine that the client understands the material presented? ✓ Use a raised toilet seat. 124) The nurse is talking to a client who had a below-the- knee amputation 2 days earlier. The client states, "I hate looking at this; I feel that I'm not even myself anymore." What client problem should the nurse incorporate in the plan of care based on the statement by this client? ✓ Altered body image 125) The home health nurse is planning to teach a client with osteoporosis about home modifications to reduce the risk of falls. Which recommendations would be necessary to include in the teaching plan? Select all that apply. ✓ Use night lights. ✓ Remove scatter rugs. ✓ Use staircase railings. ✓ Place hand rails in the bathroom. 126) A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse identifies which client problem as the priority? ✓ Inability to entertain self 127) A client with a fractured femur experiences sudden dyspnea, tachypnea, and tachycardia. A set of arterial blood gas tests reveals the following: pH, 7.35 (7.35); Paco2, 43 mm Hg (43 mm Hg); Pao2, 58 mm Hg (58 mm Hg); HCO3, 23 mEq/L (23 mmol/L). The nurse interprets that the client probably has experienced fat embolus because of the result of which parameter? o Pao2 128) The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? o "Bleeding and swelling caused increased pressure in an area that couldn't expand." 129) The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse should use which method to reposition the client? o A pillow to keep the right leg abducted during turning 130) The nurse has completed giving discharge instructions to a client after total knee arthroplasty and replacement with a prosthetic system. The nurse teaches the client about weight-bearing status. What information should the nurse include? o "You will use full weight bearing by discharge." 131) The nurse is planning to teach the client with below- the-knee amputation about care to prevent skin breakdown. Which point should the nurse include in developing the teaching plan? o The socket of the prosthesis must be dried carefully before it is used. 132) A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The nurse should include which interventions to maintain client safety after this procedure? Select all that apply. o Keep the head of the bed flat. o Place pillows under the length of the legs. o Use logrolling technique for repositioning. o Assist the client with eating meals and drinking fluids. 133) A client has several fractures of the lower leg, which has been placed in an external fixation device. The client is upset about the appearance of the leg, which is edematous. The nurse documents which client problem in the plan of care? o Body image alteration 134) A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action? o Slightly elevating the foot of the bed 135) The nurse is reviewing the postprocedure plan of care formulated by a nursing student for a client scheduled for a bone biopsy. The nurse determines that the student needs additional information about postprocedure care if which inaccurate intervention is documented? o Administering opioid analgesics intramuscularly 136) A client has had a bone scan done. The nurse determines that the client demonstrates understanding of postprocedure care when the client makes which statement? ✓ "I need to drink plenty of water for 1 to 2 days after the procedure." 137) A client seeks treatment in the hospital emergency department for a lower leg injury. Deformity of the lower portion of the leg is evident, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced which injury? ✓ Fracture 138) The nurse is caring for a client who is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What should the nurse include in the teaching? Select all that apply. ✓ Physical therapy ✓ Knee immobilizer ✓ Aspiration of joint fluid ✓ Antiinflammatory medications 139) The nurse is evaluating a client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performs which action? ✓ Moves the cane when the right leg is moved 140) The nurse is planning to teach a client how to stand on crutches. The nurse will incorporate into written instructions that the client should be told to place the crutches in what manner? ✓ 6 inches (15 cm) to the front and side of the toes 141) A client is admitted to the nursing unit after a left below-the-knee amputation after a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How should the nurse interpret this client statement? ✓ A normal response that indicates the presence of phantom limb sensation 142) The nurse has provided instructions to a client with a diagnosis of rheumatoid arthritis about measures to protect the joints. Which statement by the client indicates a need for further instruction? ✓ "Pain or fatigue is expected, and I should try to continue with the activity if this occurs." 143) The nurse has provided discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further instruction? ✓ "I should sit in my recliner when I get home." 144) The community health nurse is providing a teaching session on osteoporosis to women living in the community. The nurse informs these community residents that which is a risk factor for this disorder? ✓ A diet low in vitamin D 145) The nurse is performing an assessment on a client with suspected Paget's disease. On assessment the nurse would expect the client to report which as the most common symptom of this disease? ✓ Bone pain 146) Diagnostic studies are prescribed for a client with suspected Paget's disease. In reviewing the client's record, the nurse would expect to note that the health care provider has prescribed which laboratory study? ✓ Alkaline phosphatase 147) A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client's recent history? ✓ Open trauma to the left leg 148) A nursing student is providing health maintenance education to a client with osteitis deformans (Paget's disease). Which statement by the client indicates a need for further education? ✓ "Because I have no symptoms, my disease is not progressing." 149) An older client is diagnosed with osteoporosis. The nurse teaches the client about self-care measures, knowing that the client is most at risk for which problem as a result of this disorder of the bones? ✓ Fractures 150) The nurse provides instructions to a client with bilateral deformities of the joints of the fingers due to rheumatoid arthritis. When providing teaching about the disease process, the nurse should inform the client that the changes are most likely due to what type of response? ✓ Autoimmune 151) A client has been diagnosed with osteomalacia, or adult rickets. The nurse should anticipate that the health care provider will include a new prescription for which vitamin supplement? ✓ D 152) A client is having a plaster cast placed on the lower extremity that will extend from mid-thigh to the center of the foot. Which instruction should be given to the client before hospital discharge? ✓ The need to notify the health care provider immediately if the client notices numbness or swelling or if the foot becomes cold and pale 153) A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client's signs and symptoms are compatible with which conditions? Select all that apply. ✓ Infection ✓ Recent injury ✓ Inflammation 154) The nurse witnesses a client sustain a fall and suspects that the right leg may be broken. The nurse should take which priority action? ✓ Immobilize the right leg before moving the client. 155) The nurse in the hospital emergency department is caring for a client with a fractured arm and is preparing the client for a reduction of the fracture that will be done in the casting room in the emergency department. The nurse should take which actions? Select all that apply. ✓ Administer a prescribed analgesic. ✓ Explain the procedure to the client. ✓ Obtain informed consent for the procedure. 156) The nurse teaches a client who is going to have a plaster cast applied about the procedure. Which statement by the client indicates a need for further teaching? ✓ "I can bear weight on the cast in one-half hour." 157) The nurse has suggested specific leg exercises for a client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further instruction if the nurse observes the client performing which action? ✓ Performing active range of motion to the right ankle and knee 158) The nurse is giving a client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed touch-down of the affected leg. The nurse should tell the client to perform which action? ✓ Advance the crutches along with the left leg, and then advance the right leg. 159) A client has slight weakness in the right leg. On the basis of this assessment finding, the nurse determines that the client would benefit most from the use of which item? ✓ A straight leg cane 160) A client who has experienced a stroke has partial hemiplegia of the left leg. The nurse interprets that the client could benefit from the support and stability provided by which item? ✓ Quad cane 161) A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. The nurse provides the client with the most reassurance by making which statement? ✓ "The cane has a flared tip with concentric rings to give stability." 162) The nurse is caring for a client who has just had a plaster leg cast applied. The nurse should plan to prevent the development of compartment syndrome by performing which action? ✓ Elevate the limb slightly. 163) A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse should anticipate that which type of wound care to the fasciotomy site will be prescribed? ✓ Moist sterile saline dressings 164) The nurse is assessing a client with a shortened, adducted, and externally rotated left leg. On the basis of this finding, which condition should the nurse anticipate? ✓ Fracture of the femoral neck 165) A client who has had a total knee arthroplasty tells the nurse that there is pain with extension of the knee. The nurse should perform which action? ✓ Administer an analgesic. 166) The nurse has taught a client with a below-the-knee amputation about prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client makes which statement? ✓ Use a mirror to inspect all areas of the residual limb each day. 167) The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is complaining about stabbing pain radiating to the lower back and the right buttock. The nurse determines that the client's signs/symptoms are most likely due to which condition? ✓ Muscle spasm in the area of the herniated disk 168) The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest in Williams' position to minimize the pain. The nurse should put the bed in what position? ✓ In semi Fowler's position, with the knees slightly flexed 169) A client who has had spinal fusion and insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to which member of the health care team? ✓ A social worker 170) The nurse is planning to teach proper use of a thoracolumbosacral orthosis to a client who has had spinal fusion with instrumentation. The nurse should include which teaching point in the discussion with the client? ✓ The device is applied before getting out of bed in the morning. 171) A client is being transferred to the nursing unit from the postanesthesia care unit after spinal fusion with rod insertion. The nurse should prepare to transfer the client from the stretcher to the bed by using which best method? ✓ A transfer (slider) board and the assistance of three people 172) A client is being discharged to home after spinal fusion with insertion of instrumentation (rod). The unit nurse should consult with the continuing care nurse regarding the need for modification of the home environment if the client makes which statement? ✓ "My bedroom and bathroom are on the second floor of my home." 173) The nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse should inquire about the last time the client had which done? ✓ Tetanus vaccine 174) A client who has experienced nonunion of a fracture is scheduled for bone grafting using cadaver bone. The client appears restless and anxious about the procedure. After determining that the client understands the surgical procedure, the nurse should explore which item next? ✓ Potential worry about contracting hepatitis or possibly human immunodeficiency virus infection 175) A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms? ✓ Tachycardia and hypotension 176) A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need which intervention? ✓ To have a window cut in the cast 177) A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful? ✓ Showing the client the cast cutter and explaining how it works 178) A client has just had a cast removed, and the underlying skin is yellow-brown and crusted. The nurse gives the client instructions for skin care. The nurse determines that the client needs further teaching of the directions if he or she makes which statement? ✓ "I need to scrub the skin vigorously with soap and water." 179) A client has skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should assess which area as high risk for pressure and breakdown? ✓ Left heel 180) The nurse is planning measures to increase bed mobility for a client in skeletal leg traction. Which item should the nurse consider to be most helpful for this client? ✓ Overhead trapeze 181) The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the plan of care needs to be revised if which outcome is noted? ✓ Bowel movement every 4 days 182) The nurse is obtaining a health history from a client and is assessing for risk factors associated with osteoporosis. The nurse would be most concerned if which data were obtained? Select all that apply. ✓ The client reports that she doesn't exercise much at all. ✓ The client reports that she smokes a few cigarettes a day. ✓ The client reports that she is taking phenytoin to treat a seizure disorder. ✓ The client reports that she takes a daily low dose of prednisone to treat a chronic respiratory condition. 183) The home health nurse visits a client who is having an acute attack of gout. The nurse determines that the client needs further instruction regarding the treatment of gout if the client states to take which action? ✓ Restricting fluids 184) The clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse checks for which assessment finding that is associated with RA? ✓ Systemic symptoms such as fatigue, anorexia, and weight loss 185) A client who had a body cast applied 2 days earlier begins to complain of anorexia, nausea, and abdominal discomfort. The nurse should take which immediate action? ✓ Notify the health care provider. 186) The nurse is performing an assessment on a client after a closed reduction of a fractured right humerus and application of a plaster cast. To assess for signs of compartment syndrome, the nurse should perform which action? ✓ Assess capillary refill, temperature, color, and amount of pain in the right hand. 187) The nurse is caring for a client admitted for a fractured hip status post fall at home. On assessment of the client's affected lower extremity, which signs/symptoms would most likely be noted? ✓ Shortening and external rotation 188) The nurse is preparing a plan of care for a client who is scheduled to return from the recovery room after a left total knee arthroplasty. The nurse includes in the plan of care to assess the client's neurovascular status the monitoring of which parameter? ✓ Capillary refill, sensation, color, and pulse of the left foot 189) The nurse is preparing instructions for a client who is diagnosed with osteomalacia. Which information should the nurse include in the teaching? ✓ "Ensure adequate intake of vitamin D fortified foods." 190) The nurse provides instructions to a client diagnosed with osteoporosis. Education about prevention of which complication is the most important? ✓ Fractures 191) The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease). Which does the nurse identify as the cause of the client's stooped posture and bowing of lower extremities? ✓ Bone resorption and regeneration 192) The nurse is caring for a client diagnosed with osteomyelitis. Which mechanism of the disease process can result in necrosis of the bone? ✓ Devascularization 193) The nurse is providing dietary instructions to a client with osteoporosis and is discussing appropriate food items to include in the diet. Which food items should the nurse recommend as being high in calcium? Select all that apply. ✓ Tofu ✓ Spinach ✓ Sardines ✓ Salmon 194) A client is seen in the health care provider's office for complaints of wrist pain. A diagnosis of carpal tunnel syndrome is made. In explaining this disorder to the client, the nurse states that it is caused by compression of which nerve? ✓ Median 195) The nurse is caring for a client diagnosed with the rotator cuff lesion. The nurse assesses the client knowing that the client most likely has which structure affected? ✓ Tendon 196) The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? Select all that apply. ✓ Fatigue ✓ Morning stiffness 197) The nurse is performing a musculoskeletal assessment of an immobile client for disuse osteoporosis. Which should the nurse assess to obtain the best information about the bone remodeling process? ✓ Calcitonin 198) The nurse is planning discharge teaching for a client admitted with a fracture of the leg that does not extend all the way through the bone. The nurse should include information about which types of fractures? ✓ Incomplete 199) A client has been diagnosed with subluxation of the shoulder. The nurse explains to the client that which injury has occurred to the joint? ✓ It has incompletely dislocated. 200) A client who suffered a contusion after being hit on the thigh with a racquetball has been told that it is acceptable to apply heat to the area 72 hours after the injury. The nurse explains the rationale for this treatment to the client, stating that which is the physiological benefit of heat in this case? ✓ It promotes reabsorption of blood from the injured tissue. 201) The nurse is caring for a client admitted for a torn meniscus. What is the focus of the nurse's immediate assessment? ✓ The knee 202) The nurse is caring for a client with a swollen left ankle who has difficulty bearing weight on this leg and states that he twisted his ankle. Based on these findings, which condition does the nurse determine the client has most likely experienced? ✓ Sprain 203) A client with a short-leg plaster cast complains of an intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which client statement indicates an understanding of appropriate measures to relieve the itching? ✓ "I can use a hair dryer on the low setting and allow the cool air to blow into the cast." 204) A client has been experiencing muscle weakness over a period of several months. The health care provider suspects polymyositis. Which client statement correctly identifies a confirmation of test results and this diagnosis? ✓ "I will know I have polymyositis if the muscle fibers are inflamed." 205) Which tests can be used to diagnose gout? Select all that apply. ✓ Serum uric acid level ✓ Synovial fluid aspiration ✓ 24-hour urine uric acid level 206) The nurse is preparing a client for an arthroscopy of the knee. When providing teaching, which information is essential for the nurse to include? ✓ It will identify if there is joint injury and provide a route for surgical repair if indicated. 207) The nurse is creating a plan of care for a client scheduled for a left total hip arthroplasty. Which interventions should the nurse include in the plan to prevent complications of the surgery? Select all that apply. ✓ Keep the leg slightly abducted. ✓ Teach leg exercises to the client. ✓ Use aseptic technique for wound care. ✓ Prevent hip flexion beyond 90 degrees. 208) The nurse has given activity guidelines to a client with chronic low back pain. The nurse determines that the client understands the instructions if the client states to do which activities? Select all that apply. ✓ Sitting using a lumbar roll or pillow ✓ Standing with one foot on a step or stool 209) The nurse is assigned to care for a client who is in Buck's traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan? ✓ Inspect the skin under the boot at least every 8 hours. 210) The nurse is creating a plan of care for a client in skin traction. Which frequent assessment should the nurse include in the plan as a priority intervention? ✓ Signs of skin breakdown 211) The nurse has developed a plan of care for a client in traction and documents a problem of inability to perform self-care independently. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome? ✓ The client assists in self-care as much as possible. 212) The nurse is caring for a client with osteoarthritis. The nurse performs an assessment knowing that which clinical manifestations are associated with the disorder? Select all that apply. ✓ Joint pain that diminishes after rest ✓ Joint pain that intensifies with activity 213) A client is treated in a health care provider's office for a sprained ankle after a fall. Radiographic examination has ruled out a fracture. Before sending the client home, the nurse plans to teach the client to avoid which activity in the next 24 hours? ✓ Applying a heating pad 214) A client has Buck's extension traction applied to the right leg. Which intervention should the nurse plan to prevent complications of the device? ✓ Inspect the skin on the right leg. 215) The client is complaining of skin irritation from the edges of a cast applied the previous day. Which action should the nurse take? ✓ Petal the cast edges with adhesive tape. 216) The nurse determines that a client's skeletal traction needs correction if which observation is made? ✓ Traction ropes rest against the footboard. 217) The nurse is lecturing to a group of women who are at high risk for osteoporosis. The nurse should inform the women about which most important measure? ✓ Limit caffeine intake. 218) A client is admitted to the emergency department with an open fracture of the right tibia. What intervention is most appropriate for this client? ✓ Check the neurovascular status of the area distal to the extremity. 219) The nurse is caring for a client with a hip fracture who has just been placed in Buck's traction. What intervention is most important for the nurse to perform? ✓ Inspect the skin at least every 8 hours for signs of irritation or inflammation. 220) The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis? Select all that apply. ✓ Pyrexia ✓ Elevated white blood cell count ✓ Elevated erythrocyte sedimentation rate ✓ Bone scan impression indicative of infection 221) The nurse provides information to a client scheduled for a dual x-ray absorptiometry (DEXA) test. Which information should the nurse provide to the client? Select all that apply. ✓ It is a painless test. ✓ Metallic objects such as jewelry or belt buckles may interfere with the test and need to be removed. 222) The nurse is providing care for a client admitted 3 days ago with a severe left ankle contusion. The nurse determines that heat application to the area has been effective if which has occurred? ✓ There is reabsorption of blood noted at the injured site. 223) The nurse is assisting in performing a physical assessment of a right-handed client's musculoskeletal system. Which would be an abnormal finding? ✓ Presence of fasciculations 224) A client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which changes in vital signs? ✓ Tachycardia, hypotension 225) Which teaching point is the priority when the nurse is teaching the client about caring for a plaster cast? ✓ Immediately report any increase in drainage or interruption in cast integrity. 226) The nurse is receiving a client from the postanesthesia care unit following left above-knee amputation. Which is the priority nursing action at this time? ✓ Elevate the foot of the bed. 227) A client has been diagnosed with gout, and the nurse provides dietary instructions. The nurse determines that the client needs additional teaching if the client states that it is acceptable to eat which food? ✓ Chicken liver 228) The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply. ✓ Twisting of the spine ✓ Hyperflexion of the spine ✓ Herniation of an intervertebral disk 229) A client who sustained a severe sprain of the ankle is told by the health care provider that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which interventions should the nurse anticipate will be included in the client's initial plan of care? Select all that apply. ✓ Ice bags ✓ Elevation ✓ Compression bandage 230) The nurse is collecting data related to a client's risk factors associated with osteoporosis. Which data should the nurse include? Select all that apply. ✓ Thin body build ✓ Smoking history ✓ Postmenopausal age ✓ Chronic corticosteroid use ✓ Family history of osteoporosis 231) The nurse is caring for a client who had surgery to repair a fractured left-sided hip using a posterior approach. In implementing hip precautions, which action should the nurse teach the client to avoid? ✓ Crossing legs at the ankle 232) A client is taking large doses of acetylsalicylic acid for rheumatoid arthritis. Which assessment findings indicate that the client is experiencing ototoxicity as a result of the medication? ✓ Tinnitus, hearing loss, dizziness, and ataxia 233) A client is seen in the hospital emergency department after injury to the right ankle. The client tells the nurse that she twisted her ankle while playing volleyball. The health care provider (HCP) has prescribed a topical analgesic cream for the injury. The nurse providing instruction about the medication should provide the client with which information? ✓ That the medication contains a combination of medications, one of which is an analgesic 234) The client is given medication instructions for maintenance therapy for oral dantrolene sodium for the treatment of spasticity. Which client statement indicates understanding of the instructions? ✓ "I will take 100 mg twice a day." 235) A client with gout has begun to take allopurinol. The nurse informs the client that which medication may also be necessary during the beginning phase of medication therapy with allopurinol? Select all that apply. ✓ Naproxen ✓ Colchicine ✓ Indomethacin 236) The home health nurse is providing dietary instructions to a client who is taking probenecid for the treatment of gout. Which food should the nurse instruct the client to continue to eat? ✓ Spinach 237) Auranofin has been prescribed for a client with rheumatoid arthritis. The nurse provides instructions to the client about the medication and tells the client to notify the health care provider if which occurs? ✓ Metallic taste in the mouth 238) An older client with rheumatoid arthritis has been instructed by the health care provider to take ibuprofen 400 mg orally (PO) three times daily. The home care nurse reading the medication prescription knows that the instruction has been effective when the client states the instructed dose is which? ✓ The normal adult dose 239) A client with multiple sclerosis is receiving baclofen. The nurse assessing the client monitors for which finding as an indication of a primary therapeutic response to the medication? ✓ Decreased muscle spasms 240) The nurse is providing medication instructions to a client with multiple sclerosis receiving baclofen. Which information should the nurse include in the instructions? ✓ Watch for urinary retention as a side effect. 241) The nurse overhears the health care provider (HCP) tell a client with rheumatoid arthritis that the condition needs to be treated with gold therapy. The nurse interprets that the HCP is referring to which medication? ✓ Auranofin 242) The home care nurse is visiting a client who sustained a severe muscle sprain to the back. Carisoprodol is prescribed for the client. The nurse provides instructions to the client regarding the medication and should teach the client to take which measure? ✓ To avoid driving until the reaction to the medication is known 243) A client with muscle spasms in the lumbar area of the spine has been started on cyclobenzaprine. The nurse should monitor for which most frequent side effect of the medication? ✓ Drowsiness 244) Etanercept is prescribed for a client with rheumatoid arthritis. The nurse should monitor the client for which side/adverse effect of the medication following administration? ✓ Dyspnea 245) The nurse gives a dose of diazepam to an assigned client. What is the most important action to be taken by the nurse before leaving the room? ✓ Instituting safety measures 246) The nurse notes that a client has been taking colchicine. The nurse assesses the client for which finding that is an indication for the use of this medication? ✓ Joint inflammation and pain 247) A clinic nurse is performing an assessment on a client with rheumatoid arthritis who has been taking acetylsalicylic acid for the disorder. The nurse assesses the client for signs of aspirin toxicity. Which finding should alert the nurse to the possibility of toxicity? ✓ Fever and signs of hyperventilation 248) Dantrolene is prescribed for a client experiencing discomfort caused by spasticity. In providing instructions to the client regarding the medication, what should the nurse emphasize? ✓ Expect that periodic liver function studies will be required. 249) A client has been administered cyclobenzaprine for the management of muscle spasms in the cervical spine. The client is experiencing drowsiness, dizziness, and dry mouth. How should the nurse interpret these findings? ✓ Are the most common side effects of this medication 250) The health care provider has prescribed a lidocaine 5% patch for a client with a diagnosis of neck pain due to osteoarthritis. Which should the nurse tell the client regarding this medication? ✓ The medication patch will act as a local anesthetic. 251) Dantrolene is prescribed for a client with spinal cord injury for discomfort caused by spasticity. Which finding would alert the nurse to a potential adverse effect associated with this medication? ✓ Elevated temperature 252) A client with multiple sclerosis is receiving diazepam, a centrally acting skeletal muscle relaxant. Which finding, if noted during the nursing assessment, would indicate that the client is experiencing a side/adverse effect of this medication? ✓ Drowsiness 253) A client with a diagnosis of rheumatoid arthritis is taking sulindac. The health care provider prescribes misoprostol for the client. The nurse explains that this medication has been prescribed for which purpose? ✓ To prevent gastric complications such as ulcer disease 254) Probenecid has been prescribed for a client with a diagnosis of gout, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates a need for further instruction? ✓ "I should take acetylsalicylic acid for relief of headache." 255) Allopurinol has been prescribed for a client with a diagnosis of gout. The nurse develops a list of instructions for the client regarding the use of this medication. Which measures should be included on the list? Select all that apply. ✓ Increase fluid intake. ✓ Take the medication with food. ✓ Consume items to maintain an alkaline urine. ✓ Return to the health care clinic for liver and renal function tests. 256) Diclofenac is prescribed for a client with osteoarthritis. Which medication, if noted on the client's record, would alert the nurse to consult with the health care provider? ✓ Warfarin sodium 257) The home health nurse is reviewing medications with a client receiving colchicine for the treatment of gout. The nurse evaluates that the medication is effective if the client reports a decrease in which measure? ✓ Joint inflammation 258) The nurse is collecting data from a client and notes that the client is taking acetylsalicylic acid 5 g daily in divided doses. The nurse determines that this medication has been prescribed to treat which condition? ✓ Rheumatoid arthritis 259) The nurse is evaluating the serum acetylsalicylic acid results for a client receiving acetylsalicylic acid for rheumatoid arthritis. Which noted result is indicative that the client is within the range for the medication's antiarthritic effect? ✓ 26 mg/dL (1.88 mmol/L) 260) The nurse is giving medication instructions to a client who has been prescribed acetylsalicylic acid. Which client statement indicates that education was effective? ✓ "I may develop heartburn." 261) A client is admitted to the hospital, and the nurse notes that the client is taking acetylsalicylic acid to treat a chronic rheumatoid disorder. The nurse should monitor the client for which sign or symptom that indicates a toxic effect of the medication? ✓ Ringing in the ears 262) Acetylsalicylic acid has been prescribed for a client with rheumatoid arthritis, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further teaching? ✓ "I need to take this medication on an empty stomach for it to work." 263) What should the nurse anticipate when evaluating for the effects of raloxifene in an older client? ✓ Increased bone density 264) The nurse is giving medication instructions to a client who is receiving dantrolene sodium. Which statement by the client indicates that the educational session was effective? ✓ "This medication acts directly on the skeletal muscle to relieve spasticity." 265) The health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication will be administered intrathecally. Which medication should the nurse expect to be prescribed and administered by this route? ✓ Baclofen 266) The nurse is reviewing the health care provider's prescriptions for an adult client who has been admitted to the hospital after a back injury. Carisoprodol is prescribed for the client to relieve the muscle spasms. The health care provider has prescribed 350 mg to be administered four times a day. What should the nurse conclude? ✓ The prescription is the normal adult dosage. 267) A client who has rheumatoid arthritis has begun treatment with anakinra and has received the first injection. What finding would indicate that the health care provider should be notified and that the medication should be discontinued? ✓ White blood cell count of 12,000 mm3 (12 × 109/L) and a temperature of 99.9°F (37.7°C) 268) A film-coated form of diflunisal, a nonsteroidal antiinflammatory medication, has been prescribed for a client to treat chronic rheumatoid arthritis. The client calls the clinic nurse because of difficulty swallowing the tablets. Which instruction should the nurse provide to the client? ✓ Swallow the tablets with large amounts of water or milk. 269) The nurse is giving medication instructions to a client who is receiving baclofen as maintenance therapy. Which client statement about the maintenance dose of baclofen indicates that education was effective? ✓ "I will take 15 mg four times daily." 270) A client is to receive a prescription for methocarbamol. The nurse provides instructions to the client about the medication. Which client statement would indicate a need for further education? ✓ "If my vision becomes blurred, I don't need to be concerned about it." 271) A client is receiving baclofen for muscle spasms because of a spinal cord injury. Which side/adverse effect related to this medication should the nurse monitor the client for? ✓ Slurred speech 272) Calcium carbonate is prescribed for a client with hypocalcemia. How should the nurse instruct the client to take the medication? ✓ 1 hour after meals 273) The nurse is teaching a client who will be discharged on alendronate about the medication. Which should be included in the teaching plan? Select all that apply. ✓ Take the medication at the same time daily. ✓ Take the medication on an empty stomach. ✓ Remain upright for 30 minutes following ingestion. 274) The nurse asks a nursing student about the uses of the medication dantrolene. The nursing student correctly states that dantrolene is used to manage hypermetabolism of skeletal muscle that occurs in which condition? ✓ Malignant hyperthermia 275) The nurse teaches the client with hypocalcemia how to take calcium carbonate. Which statement by the client indicates an understanding of the instructions? ✓ "I should take the tablet an hour after lunch." 276) A client with a history of spinal cord injury is beginning medication therapy with baclofen. The nurse determines that the client understands the side/adverse effects of the medication if the client makes which statement? ✓ "The medication may make me drowsy." 277) A client with a new medication prescription for allopurinol asks the nurse, "I know this is for gout, but how does it work?" The nurse plans to reply based on which medication action? ✓ Allopurinol decreases uric acid production. 278) A client newly diagnosed with gout has been prescribed allopurinol. The nurse would be concerned if the client was also currently taking which medication? ✓ Warfarin 279) A client is receiving a new prescription for colchicine. Which information about this medication should the nurse include in an educational session? ✓ "This is an antiinflammatory agent specific for gout." 280) A client with osteoarthritis is receiving diclofenac sodium. The nurse would be concerned about the administration of this medication if the client's history and physical included a diagnosis of which condition? ✓ Peptic ulcer disease 281) Baclofen is prescribed for the client with multiple sclerosis. The nurse determines that the medication is having the intended effect if which finding is noted in the client? ✓ Decreased muscle spasms 282) Dantrolene sodium is prescribed for the client experiencing flexor spasms. The client asks the nurse how the medication is going to help. The nurse replies that this medication acts in which way? ✓ Acts directly on the skeletal muscle to relieve the spasms 283) The nurse is reviewing laboratory results for a client taking dantrolene sodium. The nurse should notify the health care provider if which finding is noted on the laboratory report sheet? ✓ Alanine aminotransferase (ALT) 96 U/L (96 U/L) 284) The nurse is reviewing the medical record of a newly assigned client and notes that the client is receiving cyclobenzaprine hydrochloride for the treatment of muscle spasms. The nurse questions the prescription if which disorder is noted in the admission history? ✓ Angle-closure glaucoma 285) The nurse is assigned to care for a client with multiple sclerosis who is receiving an intravenous dose of methocarbamol. The nurse monitors the client knowing that which is an expected side effect? ✓ Dark green–colored urine 286) The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate? ✓ Notify the health care provider (HCP). 287) The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks? ✓ "I need to be sure to consume foods that are low in sodium." 288) The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? ✓ Contact the health care provider (HCP). 289) A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? ✓ A hearing aid 290) The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approaches by the nurse would be helpful in assisting this client? Select all that apply. ✓ Providing sensory cues ✓ Giving simple, clear directions ✓ Providing a stable environment ✓ Keeping family pictures at the bedside 291) The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. ✓ Keep suction equipment at the bedside. ✓ Elevate the head of the bed 30 degrees. ✓ Keep the head and neck in good alignment. ✓ Administer prescribed respiratory treatments as needed. 292) The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family? ✓ Explaining equipment and procedures on an ongoing basis 293) Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? ✓ It is possible the client can hear the family. 294) The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional? ✓ A neuropsychologist 295) The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? ✓ Head of bed elevated 30 to 45 degrees, head and neck midline 296) The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of over hydration, which would aggravate cerebral edema? ✓ Serum osmolality 280 mOsm/kg H2O (280 mmol/kg) 297) The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? ✓ Sounds will not be heard clearly unless they are loud. 298) The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action? ✓ Indicates that facial puffiness will be a permanent problem 299) A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? ✓ Altered breathing pattern 300) A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? ✓ Acknowledge the client's anger and continue to encourage participation in care. 301) The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply. ✓ Provide physical aspects of care. ✓ Prevent pushing or straining activities. ✓ Maintain the head of the bed at 15 degrees. 302) The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which is the appropriate response by the nurse? ✓ "Pain is due to stimulation of the affected nerve by pressure and temperature." 303) The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action? ✓ Initiating a bowel movement every other day, 45 minutes after the largest meal of the day 304) A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? ✓ Raised toilet seat 305) The nurse is assessing the client's gait and notes it is unsteady and staggering. Which description should the nurse use when documenting the assessment finding? ✓ Ataxic 306) A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration? ✓ Establishing a toileting schedule 307) A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. ✓ Giving tepid sponge baths ✓ Applying a hypothermia blanket ✓ Administering acetaminophen per protocol 308) A client is somewhat nervous about undergoing magnetic resonance imaging (MRI). Which statement by the nurse would provide the most reassurance to the client about the procedure? ✓ "Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure." 309) The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. ✓ Position the client on his or her side. ✓ Brush the teeth with a small, soft toothbrush. ✓ Cleanse the mucous membranes with soft sponges. 310) The nurse assigned to the care of an unconscious client is making initial daily rounds. On entering the client's room, the nurse observes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious breath sounds. Which judgment should the nurse formulate for the client? ✓ Increased risk for aspiration 311) Which intervention should the nurse include in a postoperative teaching plan for a client who underwent a spinal fusion and will be wearing a brace? ✓ Tell the client to inspect the environment for safety hazards. 312) The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position following the procedure? ✓ Prone with a small pillow under the abdomen 313) The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan? ✓ Restrict fluid intake for a period of 2 hours. 314) The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the health care provider (HCP)? ✓ Neck stiffness 315) The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? ✓ The intracranial pressure reading is normal. 316) The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? ✓ Blood pressure 317) The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client? ✓ A cervical cord injury 318) The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How should the nurse document these findings? ✓ Abnormal 319) The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves? ✓ Eye movements 320) The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? ✓ The client experienced paresthesias a few days before admission to the hospital. 321) The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? ✓ Liver function studies 322) The home care nurse is preparing to visit a client with a diagnosis of trigeminal neuralgia (tic douloureux). When performing the assessment, the nurse should plan to ask the client which question to elicit the most specific information regarding this disorder? ✓ "Is the pain experienced a stabbing type of pain?" 323) The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit specific information regarding this client's disorder? ✓ "Are you having any difficulty chewing food?" 324) The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition should the nurse document? ✓ Damage to the auditory association areas 325) The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions should be included in the plan? Select all that apply. ✓ Place a blood pressure cuff at the client's bedside. ✓ Close the shades in the client's room during the day. 326) The nurse is providing instructions to a client who will be taking phenytoin. Which statement, if made by the client, would indicate an understanding of the information about this medication? ✓ "I need to perform good oral hygiene, including flossing and brushing my teeth." 327) The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke? ✓ "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?" 328) The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. ✓ Thicken liquids. ✓ Assist the client with eating. ✓ Assess for the presence of a swallow reflex. ✓ Provide ample time for the client to chew and swallow. 329) The nurse is creating a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which should the nurse include in the plan of care for the client? ✓ Instruct the client to turn the head to scan the right visual field. 330) The nurse is providing discharge education to a client diagnosed with trigeminal neuralgia. Which medication will likely be prescribed upon discharge for this condition? ✓ Gabapentin 331) The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which should the nurse instruct the client to do? ✓ Avoid activities that may cause pressure near the face. 332) The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse should expect to observe which finding in the client? ✓ Facial drooping 333) The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse should document which desired outcome in the plan of care? ✓ The client's fingers and toes are cool to touch. 334) The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention should be included in the care plan for this client? Select all that apply. ✓ Provide oral hygiene after each meal. ✓ Assess swallowing ability frequently. ✓ Allow the client sufficient time to eat. ✓ Maintain a suction machine at the bedside. 335) The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record? ✓ Mild clumsiness 336) The nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction? ✓ Level of consciousness 337) The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? ✓ Confusion 338) The nurse is planning discharge teaching for a client started on acetazolamide for a supratentorial lesion. Which information about the primary action of the medication should be included in the client's education? ✓ It decreases cerebrospinal fluid production. 339) The nurse is preparing for the admission to the unit of a client with a diagnosis of seizures and asks the nursing student to institute full seizure precautions. Which item if noted in the client's room would need to be removed and warrants the need to review seizure precautions with the student? ✓ Padded tongue blade 340) The clinic nurse is reviewing the record of a client scheduled to be seen in the clinic. The nurse notes that the client is taking selegiline hydrochloride. The nurse suspects that the client has which disorder? ✓ Parkinson's disease 341) The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. The nurse should expect to note documentation of which early symptom of this disease? ✓ Balance and coordination problems 342) The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which assessment question? ✓ "Are you getting up at night to urinate?" 343) The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. When the client arrives at the nursing unit, the nurse reviews the health care provider's documentation. The nurse expects to note documentation of which hallmark clinical manifestation of this syndrome? ✓ Development of progressive muscle weakness 344) A thymectomy accomplished via a median sternotomy approach is performed in a client with a diagnosis of myasthenia gravis. The nurse creates a postoperative plan of care for the client that should include which intervention? ✓ Monitor the chest tube drainage. 345) The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? ✓ Is likely to have perceptual and spatial disabilities 346) The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? ✓ The client will exhibit neglect of the affected side. 347) The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech? ✓ Associated with poor comprehension 348) The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome? 349) Increase the client's awareness of the affected side. 350) The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? ✓ Elevate the head of the bed. 351) The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate orally daily. The nurse provides information to the spouse regarding the side effects of this medication and should tell the spouse to report which side effect if it occurs? ✓ Inability to urinate 352) The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? ✓ Spasms of the entire body 353) The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? ✓ Leaving the client in an unchilled area of the room 354) A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family had hoped. The nurse plans to implement which approach as most helpful to the client and family at this time? ✓ Emphasize progress in a realistic manner. 355) At 8:00 a.m., A client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98°F (37.2°C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99°F (36.7°C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? ✓ Call the health care provider (HCP). 356) The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety precautions after discharge. The nurse determines that the client needs further teaching if the client states an intention to take which action? ✓ Drink alcohol in small amounts and only on weekends. 357) A client had a transsphenoidal resection of the pituitary gland. The nurse notes drainage on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the nurse should look for drainage that is of which characteristic? ✓ Serosanguineous, surrounded by clear to straw-colored fluid 358) A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? ✓ The left side of the body 359) The nurse has a prescription to begin aneurysm precautions for a client with a subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to incorporate which intervention in controlling the environment for this client? ✓ Prohibit or limit the use of a radio or television and reading. 360) The nurse is caring for a client who is on bed rest as part of aneurysm precautions. The nurse should avoid doing which action when giving respiratory care to this client? ✓ Encouraging hourly coughing 361) At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with a stroke (brain attack) earlier in the day. The nurse determines that the client's airway is patent if which data are identified? ✓ Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear 362) At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention? ✓ Red skin areas under the jacket 363) A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? ✓ Autonomic dysreflexia (hyperreflexia) 364) A client who had a stroke (brain attack) has right- sided hemianopsia. What should the nurse plan to do to help the client adapt to this problem? ✓ Teach the client to scan the environment. 365) The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation? ✓ An intact brainstem 366) The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? ✓ Placing the client on a bed that provides spinal immobilization 367) The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. ✓ Postictal status ✓ Duration of the seizure ✓ Changes in pupil size or eye deviation ✓ Seizure progression and type of movements 368) A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse should keep which most important items available at the client's bedside? ✓ Ambu bag and suction equipment 369) The home health nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals related to decreased muscle strength. Which suggestions should the nurse give to the client? Select all that apply. ✓ Chew food thoroughly. ✓ Cut food into very small pieces. ✓ Sit straight up in the chair while eating. ✓ Swallow when the chin is tipped slightly downward to the chest. 370) The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement? ✓ "Going to the beach will be a nice, relaxing form of activity." 371) A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client? ✓ "This is not a stroke, and many clients recover in 3 to 5 weeks." 372) A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, should the nurse identify as being unrelated to the exacerbation? ✓ Ingestion of increased fruits and vegetables 373) A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse should include which client problem in the plan of care? ✓ Interruption in physical mobility 374) The nurse is planning care for the client with a neurogenic bladder caused by multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day. Which plan would be most helpful to this client? ✓ 400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon 375) The nurse has taught a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that further teaching is needed if the client states the need to take which action? ✓ Get out of bed by sitting straight up and swinging the legs over the side of the bed. 376) Which assessment finding should the nurse expect to note in the client hospitalized with a diagnosis of stroke who has difficulty chewing food? ✓ Dysfunction of trigeminal nerve (cranial nerve V) 377) The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which condition that is a complication of hypothermia blanket use? ✓ Skin breakdown 378) The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. On the basis of these findings the nurse suspects dysfunction in which area of the brain? ✓ Hypothalamus 379) The nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication should the nurse anticipate to be prescribed? ✓ Chlorpromazine 380) The nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding? ✓ 22 mm Hg 381) The nurse is caring for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care? ✓ Use strict aseptic technique when touching the monitoring system. 382) A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? ✓ PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg) ✓ 383) The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint? ✓ Reduce environmental noise. 384) The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even tempered, is prone to outbursts of temper now. The nurse determines that these behaviors are indicative of which problem? ✓ A long-term sequela of the injury. 385) A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that the family needs further teaching if they verbalize to call the health care provider (HCP) for which client sign or symptom? ✓ Minor headache 386) A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information? ✓ Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable. 387) The nurse is teaching a client with paraplegia measures to maintain skin integrity. Which instruction will be most helpful to the client? ✓ Shift weight every 2 hours while in a wheelchair. 388) The nurse is caring for a client with an intracranial aneurysm who has been alert. Which signs and symptoms are an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply. ✓ Mild drowsiness ✓ Slight slurring of speech ✓ Less frequent spontaneous speech 389) The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching? ✓ "I can change the time of my medication on the mornings when I feel strong." 390) A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom? ✓ Difficulty closing the eyelid on the affected side 391) The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern? ✓ Lung vital capacity of 10 mL/kg 392) A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action? ✓ Observe the client demonstrating the transfer technique. 393) The nurse is performing an assessment on a client with a head injury and notes that the client is assuming this posture. The nurse contacts the health care provider and reports that the client is exhibiting which posture? Refer to Figure. View Figure ✓ Decorticate rigidity 394) An older client is brought to the hospital emergency department by a neighbor who heard the client talking and found him wandering in the street at 3 a.m. The nurse should first determine which data about the client? ✓ Whether this is a change in usual level of orientation 395) An older client in an acute state of disorientation is brought to the hospital emergency department by the client's daughter. The daughter states that the client was "clear as a bell this morning." The nurse determines from this piece of information that which is an unlikely cause of the disorientation? ✓ Alzheimer's disease 396) The nurse is evaluating a function of the limbic system as a part of the neurological status of a client. What should the nurse assess? ✓ Affect or emotions 397) The nurse is assessing the client's level of consciousness and documents that the client has delirium. On the basis of this documentation, the nurse should determine that there is damage to which area of the nervous system? ✓ Reticular activating system and cerebral hemispheres 398) The nurse is caring for a client with a neurological deficit involving the hippocampus. On assessment of the client, which signs and symptoms would most likely be noted? ✓ Cannot recall what was eaten for breakfast today 399) A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? ✓ Problem with understanding language 400) A client with a traumatic brain injury is able, with eyes closed, to identify a set of keys placed in his or her hands. On the basis of this assessment finding, the nurse determines that there is appropriate function of which lobe of the brain? ✓ Parietal 401) A client has suffered a head injury affecting the occipital lobe of the brain. What is the focus of the nurse's immediate assessment? ✓ Vision 402) A client has suffered damage to Broca's area of the brain. Which priority assessment should the nurse perform? ✓ Speech 403) The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly? ✓ Hypothalamus 404) A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2? ✓ It will cause vasodilation of blood vessels in the brain. 405) A client is anxious about an upcoming diagnostic procedure. The client's pupils are dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline. The nurse determines that the client's clinical manifestations are due to what type of physiologic response? ✓ Sympathetic nervous system 406) A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the range of 50 to 56 beats/minute. The client also is complaining of nausea. On the basis of these findings, the nurse determines that the client is experiencing parasympathetic stimulation of which cranial nerve? ✓ Vagus (CN X) 407) The nurse overhears a neurologist saying that a client has an aneurysm located in the circle of Willis. The nurse understands that which blood vessels are part of the circle of Willis? Select all that apply. ✓ Anterior cerebral artery ✓ Internal carotid arteries ✓ Posterior cerebral artery 408) The nurse is caring for a client diagnosed with Alzheimer's disease. The nurse should anticipate that the client has changes in which component of the nervous system? ✓ Neuronal dendrites 409) To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse should place the client with an incision in the anterior or middle fossa, in which position? ✓ With the head of the bed elevated at least 30 degrees 410) The nurse is caring for a client diagnosed with a hydrocephalus. Which should the nurse anticipate as being the cause of this disorder? ✓ Closure of cranial sutures 411) The nurse is testing the spinal reflexes of a client during neurological assessment. Which assessment by the nurse would help to determine the adequacy of the spinal reflex? ✓ Withdrawal reflex 412) A client with neck and upper extremity pain has been diagnosed with cervical radiculitis. What does the nurse anticipate as being the cause of these clinical manifestations? ✓ Pressure on a spinal nerve root 413) A client brought to the emergency department had a seizure 1 hour ago. Family members were present during the episode and reported that the client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what should the nurse include in the client's assessment? ✓ History of prior trauma 414) The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The client asks for a snack and something to drink. The nurse should offer which best snack to the client? ✓ Vanilla wafers and room-temperature water 415) The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention should the nurse plan to implement? ✓ Draw blood for arterial blood gas analysis. 416) A client who suffered a stroke is prepared for discharge from the hospital. The health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What action should the nurse include in the client's plan of care? ✓ Consider the use of active, passive, or active-assisted exercises in the home. 417) The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? ✓ Ipsilateral paralysis and loss of touch and vibration 418) The nurse reviews the health care provider's (HCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the HCP should the nurse question? ✓ Clear liquid diet 419) A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis? ✓ Atropine sulfate 420) A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? ✓ Listen to breath sounds. 421) The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? ✓ Extend the tongue. 422) The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should place the client in which position? ✓ Head of the bed elevated 30 degrees with the head in midline position 423) The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse should plan to place the client in which position? ✓ Semi Fowler's ✓ The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? ✓ "Was the client awake and talking right after the injury?" 424) The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should plan to place the client in which positions? Select all that apply. ✓ Head midline ✓ Neck in neutral position ✓ Head of bed elevated 30 to 45 degrees 425) The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. ✓ Hyperoxygenating before suctioning ✓ Maintaining the head and neck in midline position ✓ Maintaining the head of the bed (HOB) at 30 degrees elevation 426) The nurse is trying to communicate with a client who had a stroke and has aphasia. Which actions by the nurse would be most helpful to the client? Select all that apply. ✓ Speaking to the client at a slower rate ✓ Allowing plenty of time for the client to respond ✓ Looking directly at the client during attempts at speech 427) The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs further teaching if the client makes which statements? ✓ "I will expose my face to cold to decrease the pain." 428) The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse include when planning care for this client? Select all that apply. ✓ Using a RotoRest bed ✓ Ensuring that weights hang freely ✓ Assessing the integrity of the weights and pulleys ✓ Comparing the amount of prescribed traction with the amount in use 429) The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse assess for when monitoring for gastrointestinal complications? ✓ Hematest-positive nasogastric tube drainage 430) The client has an impairment of cranial nerve II. Specific to this impairment, what should the nurse plan to do to ensure client safety? ✓ Provide a clear path for ambulation without obstacles. 431) Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain, and the nurse instructs the client about the purpose of the TENS unit. Which statement by the client indicates the need for further teaching? ✓ "Hospitalization is required because the unit is not portable." 432) The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? ✓ GCS = 9 433) The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? ✓ Place the client in a sitting position. 434) The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the appropriate nursing intervention? ✓ Assist the client to eat with the left hand to build strength. 435) A client is newly admitted to the hospital with a diagnosis of stroke (brain attack) manifested by complete hemiplegia. Which item in the medical history of the client should the nurse be most concerned about? ✓ Emphysema 436) The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? ✓ Shuffling and propulsive 437) The nurse is evaluating the respiratory outcomes for a client with Guillain-Barré syndrome. The nurse determines that which are acceptable outcomes for the client? Select all that apply. ✓ Spontaneous breathing ✓ Oxygen saturation of 98% ✓ Normal arterial blood gas levels ✓ Vital capacity within normal range 438) A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor? ✓ Omitting doses of medication 439) The nurse is positioning a client who has increased intracranial pressure. Which position should the nurse avoid? ✓ Head turned to the side 440) A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should take which actions? Select all that apply. ✓ Thickening liquids to the consistency of oatmeal ✓ Placing food on the unaffected side of the mouth ✓ Allowing plenty of time for chewing and swallowing 441) A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client? ✓ Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head. 442) A client has a cerebellar lesion. The nurse would plan to obtain which item for use by this client? ✓ Walker 443) The nurse is caring for a client who was admitted for a stroke (brain attack) of the temporal lobe. Which clinical manifestations should the nurse expect to note in the client? ✓ The client will have difficulty understanding language. 444) The nurse is caring for a client with bacterial meningitis. The nurse should anticipate that an antibiotic with which characteristics will be prescribed for the client? ✓ One that is able to cross the blood- brain barrier 445) A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/minute range. The client is also complaining of nausea. Which cranial nerve damage should the nurse expect that the client is experiencing? ✓ Vagus (CN X) 446) The nurse is assessing a client's muscle strength and notes that when asked, the client cannot maintain the hands in a supinated position with the arms extended and eyes closed. How should the nurse correctly document this finding on the medical record? ✓ Client is exhibiting pronator drift. 447) The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which position? ✓ Semi Fowler's position 448) The nurse is planning to perform an assessment of the client's level of consciousness using the Glasgow Coma Scale. Which assessments should the nurse include in order to calculate the score? Select all that apply. ✓ Eye opening ✓ Best verbal response ✓ Best motor response 449) The nurse is caring for a client receiving mannitol via intravenous (IV) infusion. A vial is sent from the pharmacy, and in preparing the medication the nurse notes that the vial contains crystals. What is the most appropriate nursing action? ✓ Place the vial in warm water. 450) The nurse in a long-term care facility is reviewing the health care provider's (HCP's) prescriptions on an assigned client. The nurse notes that the HCP prescribed ropinirole hydrochloride. The nurse determines that this medication has been prescribed to treat which condition in the client? ✓ Parkinsonian syndrome 451) A client is receiving phenobarbital sodium. Which finding on the nursing assessment would indicate that the client is experiencing a common side or adverse effect of this medication? ✓ Drowsiness 452) A client with suspected opioid overdose has received a dose of naloxone hydrochloride. The client subsequently becomes restless, starts to vomit, and complains of abdominal cramping. The blood pressure increases from 110/72 mm Hg to 160/86 mm Hg. The nurse provides emotional support and reassurance while administering care to the client, knowing which piece of information? ✓ These are signs of opioid withdrawal. 453) The nurse is preparing to give a postcraniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate and not "something stronger." In formulating a response, the nurse incorporates which information about codeine sulfate? ✓ It does not alter respirations or mask neurological signs as do other opioids. 454) The nurse is administering medications to a client with trigeminal neuralgia. The nurse expects that which medication will be prescribed for pain relief? ✓ Carbamazepine and gabapentin 455) The nurse is caring for a client with an exacerbation of multiple sclerosis. Which medication(s) will the nurse expect to be prescribed to hasten recovery from the exacerbation? ✓ Methylprednisolone and cyclophosphamide intravenously 456) The nurse is observing a new nursing graduate who is preparing an intermittent intravenous (IV) infusion of phenytoin for a client with a diagnosis of seizures. Which solution used by the nursing graduate should indicate to the nurse an understanding of proper preparation of this medication? ✓ 0.9% sodium chloride 457) The nurse has given instructions for taking codeine sulfate to a client with a severe headache. Which statement by the client indicates the teaching has been effective? ✓ "I should increase fluid intake." 458) A client experiencing spasticity as a result of spinal cord injury has a new prescription for dantrolene. Before administering the first dose, the nurse checks to see if which baseline study has been done? ✓ Liver function studies 459) The client with a head injury is experiencing signs of increased intracranial pressure (ICP), and mannitol is prescribed. The nurse administering this medication expects which as intended effects of this medication? Select all that apply. ✓ Reduced ICP ✓ Increased diuresis ✓ Increased osmotic pressure of glomerular filtrate ✓ Reduced tubular reabsorption of water and solutes 460) The nurse has a prescription to give dexamethasone by the intravenous (IV) route to a client with cerebral edema. How should the nurse prepare this medication? ✓ Preparing an undiluted direct injection of the medication 461) The nurse who is caring for a client with myasthenia gravis has a prescription to perform an edrophonium test. After obtaining edrophonium the nurse should be certain that which also is available at the bedside? ✓ Atropine sulfate 462) After review of the client's laboratory values, the nurse notes that a phenytoin level for a client receiving phenytoin is 7 mcg/mL (27.78 mmol/L). The nurse makes which interpretation regarding this laboratory result? ✓ The level is lower than the expected therapeutic range. 463) A client with status epilepticus has been prescribed phenytoin to be given by the intravenous (IV) route. The nurse administering the medication is careful not to exceed which recommended infusion rate? ✓ 50 mg/min 464) A client is scheduled to begin medication therapy with valproic acid. The nurse looks for the results of which laboratory test(s) before administering the first dose? ✓ Liver function tests 465) A client is scheduled to begin therapy with carbamazepine. The nurse should assess the results of which test(s) before administering the first dose of this medication to the client? ✓ Complete blood cell count 466) Dantrolene sodium has been administered to a client with a spinal cord injury. The nurse determines that the client is experiencing a side or adverse effect of the medication if which is noted? ✓ Abdominal pain 467) The nurse notes that a client taking ergotamine tartrate is having the intended effects of therapy if the client states relief from which symptom? ✓ Headaches 468) A client who has been taking phenytoin for seizure control has a serum phenytoin level of 8 mcg/mL (35.71 mmol/L). On the basis of this finding, which note should the nurse enter in the client's health record? ✓ Client has an inadequate medication level. 469) A client has a medication prescription for phenytoin to be administered by the intravenous route. After drawing up the medication, the nurse notes the presence of precipitate in the syringe. Which action should the nurse take? ✓ Discard the syringe and begin again. 470) A client began taking amantadine approximately 2 weeks ago. The client reports to the clinic for a follow-up evaluation. The nurse determines that the client is experiencing a side or adverse effect related to the use of this medication if which is noted? ✓ Client complaints of urinary retention 471) A client has been started on zolpidem. After instructing the client in how to obtain the maximal effect of zolpidem, the nurse determines that the client demonstrates understanding of correct administration of the medication by which statement? ✓ "I need to swallow the medication whole with a full glass of water." 472) A client is taking benztropine mesylate orally daily. In monitoring this client for medication side effects, the nurse should plan to focus the assessment on which item? ✓ Voiding pattern 473) Benztropine mesylate is prescribed for a client. What statement by the client indicates that the client needs further teaching about the medication? ✓ "I will sit in the sun for an hour a day to enhance medication effectiveness." 474) A client has received a dose of dimenhydrinate. The nurse evaluates the effect of the medication by noting whether the client obtained relief from what symptom? ✓ Nausea and vomiting 475) A home health nurse visits a client who suffered a back injury. On reviewing the health care provider's prescriptions, the nurse notes that codeine sulfate has been prescribed for the client, and the nurse provides instructions to the client regarding the medication. Which statement, if made by the client, indicates an understanding of health measures related to the medication? ✓ "I should increase my fluid intake while taking this medication." 476) Phenytoin 100 mg to be given orally 3 times daily has been prescribed to a client. The home health nurse visits the client and provides instructions regarding the medication. Which statement, if made by the client, would indicate an understanding of the instructions? ✓ "I will use a soft toothbrush to brush my teeth." 477) Dexamethasone intravenously is prescribed for the client with cerebral edema. The nurse prepares the medication for administration and plans to perform which action? ✓ Administer by direct injection 478) The nurse has the following prescription for a postcraniotomy client: "dexamethasone 4 mg by the intravenous (IV) route now." How does the nurse administer the medication? ✓ IV push over 1 minute 479) A client is experiencing impotence after taking guanfacine. The client states, "I would sooner have a stroke than keep living with the effects of this medication." What is the most appropriate response by the nurse? ✓ "You are concerned about the effects of your medication." 480) A client has been prescribed benztropine. The nurse should assess for which gastrointestinal (GI) problems as a side or adverse effect of this medication? ✓ Dry mouth 481) A client has been prescribed cyclobenzaprine for the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse should withhold the medication and question the prescription if the client has a concurrent prescription for which medication? ✓ Tranylcypromine 482) The nurse has a prescription to administer diazepam 5 mg by the intravenous (IV) route to a client. The nurse should administer the medication over a period of at least how long? ✓ 1 minute 483) A client is receiving phenytoin. To monitor for side and adverse effects of this medication, the nurse assesses the results of which laboratory test? ✓ Complete blood count (CBC) 484) A client who was started on clonazepam tells the nurse of increasing clumsiness and unsteadiness since starting the medication. The client is visibly upset by these manifestations and asks the nurse what to do. The nurse's response is based on which understanding? ✓ These symptoms are most severe during initial therapy and decrease or disappear with long-term use. 485) A client is having the dosage of clonazepam adjusted. The nurse should plan to perform which action? ✓ Institute seizure precautions. 486) The nurse has a prescription to administer phenytoin 100 mg mixed in 5% dextrose in water by the intravenous (IV) route to a client. After reading this prescription, which action should the nurse take? ✓ Contact the health care provider (HCP) to question the prescription. 487) The nurse in the health care provider's office is reviewing the results of a client's phenytoin level determination performed that morning. The nurse identifies that a therapeutic medication level has been achieved if which result is noted? ✓ 15 mcg/mL (59.52 mmol/L) 488) A client is taking clorazepate. The client asks the nurse if there is a risk of addiction with this medication. Which information should the nurse provide? ✓ It leads to physical and psychological dependence with prolonged high-dose therapy. 489) A client has a prescription for valproic acid. To maximize the client's safety, the nurse should plan to monitor for which potential complications of this medication? Select all that apply. ✓ Pancreatitis ✓ Hepatotoxicity 490) A client taking carbamazepine asks the nurse what to do if a dose is inadvertently missed. The nurse responds that which action should be taken? ✓ Take the dose as long as it is not close to the time for the next dose. 491) The nurse has given medication instructions to a client beginning carbamazepine. The nurse determines that the client understands the use of the medication if he makes which statement? ✓ "I will use sunscreen when outdoors." 492) A client with vascular headaches is taking ergotamine. The home health nurse should periodically assess him or her for which finding? ✓ Cool, numb fingers and toes 493) The nurse is caring for a client with myasthenia gravis who has received edrophonium by the intravenous route to test for myasthenic crisis. The client asks the nurse how long the improvement in muscle strength will last. Which response should the nurse make to the client? ✓ "It will last for 4 to 5 minutes." 494) A client has been prescribed dextroamphetamine. The client complains to the nurse that the client cannot sleep well at night and does not want to take the medication any longer. Before making any specific comment, the nurse plans to investigate whether the client takes the medication at which proper time schedule? ✓ At least 6 hours before bedtime 495) A hospitalized client has a prescription for dextroamphetamine daily. The unit nurse collaborates with the dietitian to limit the amount of which item on the client's dietary trays? ✓ Caffeine 496) A client with Parkinson's disease has begun therapy with levodopa/carbidopa. The nurse determines that the client understands the action of the medication if he or she verbalizes that results may not be apparent for how long? ✓ 2 to 3 weeks 497) A client is taking trihexyphenidyl hydrochloride. The nurse should assess for which side or adverse effect of this medication? ✓ Urinary retention 498) A client receiving therapy with carbidopa/levodopa is upset and tells the home health nurse that his urine has turned a darker color since he started taking this medication. The client wants to discontinue its use. In formulating a response to the client's concerns, the nurse interprets that this change is indicative of which condition? ✓ A harmless side effect of the medication 499) A client with myasthenia gravis has difficulty chewing and has received a prescription for pyridostigmine. The nurse should check to see that the client takes the medication at what time? ✓ 30 minutes before meals 500) A client with myasthenia gravis who is taking neostigmine is experiencing frequent exacerbations of myasthenic crisis and cholinergic crisis. The nurse teaches the client that it is most important that this medication be taken in which manner? ✓ On time 501) A client began taking amantadine approximately 2 weeks ago. The nurse determines that the medication is having a therapeutic effect if the client exhibits which finding? ✓ Decreased rigidity and akinesia 502) A client has been prescribed codeine sulfate. The nurse has given the client instructions for its use. The nurse concludes that the client understands the instructions if the client verbalizes to self-assess for which side effect? ✓ Constipation 503) Propofol is being administered to induce sedation in a client who is intubated and is being mechanically ventilated. The nurse should monitor for which adverse effect during infusion of the medication? ✓ Signs of respiratory depression 504) The nurse is collecting data from a client and notes that the client is taking carbamazepine. The nurse determines that this medication has been prescribed to treat which condition? ✓ Trigeminal neuralgia 505) The nurse has completed discharge teaching for a client prescribed carbamazepine. Which statement by the client indicates that education about the main effect of the medication was effective? ✓ "This medication has an anticonvulsant effect." 506) The health care provider (HCP) writes a prescription for carbamazepine for a client who was admitted to the hospital. The nurse contacts the HCP to verify the prescription if which condition is noted in the assessment data? ✓ Bone marrow depression 507) Carbamazepine has been prescribed for a client. The nurse should tell the client that which blood test will be done periodically while the client is taking this medication? ✓ Complete blood cell (CBC) count 508) The nurse is caring for a client diagnosed with bacterial meningitis. Which clinical manifestation should the nurse monitor for, indicating increased intracranial pressure? ✓ Altered mental status 509) The health care provider is preparing to administer edrophonium to the client with myasthenia gravis. In planning care, the nurse understands which about the administration of edrophonium? Select all that apply. ✓ Atropine is used to reverse the effects of edrophonium ✓ If symptoms worsen following administration of edrophonium, the crisis is cholinergic. ✓ Edrophonium is used to distinguish between a myasthenic crisis and a cholinergic crisis. ✓ An improvement in symptoms following administration of edrophonium indicates myasthenic crisis. 510) A client has a prescription to receive valproic acid daily. To ensure the client's safety, when is the best time for the nurse to schedule the administration of this medication? ✓ At bedtime 511) The nurse is preparing to ambulate a client with Parkinson's disease who has recently been started on levodopa/carbidopa. Before performing this activity with the client, the nurse should include which most important assessment in the client's plan of care? ✓ Postural (orthostatic) vital signs 512) The nurse is caring for a client who is taking oral benztropine mesylate daily. What is the priority nursing assessment for the client? ✓ Intake and output 513) A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine. The nurse provides instructions to the client about the side and adverse effects of the medication. Which client statement indicates an understanding of the side and adverse effects of the medication? ✓ "I will report a fever or sore throat to my health care provider." 514) A home care nurse visits a client at home. Clonazepam has been prescribed for the client, and the nurse teaches the client about the medication. Which client statement indicates that further teaching is necessary? ✓ "If I experience slurred speech, this problem will disappear in about 8 weeks." 515) A client who is taking phenytoin for a seizure disorder is being admitted to the hospital because of an increase in seizure activity. The client reports severe vomiting for the last 24 hours and an inability to take phenytoin during that time. The nurse anticipates that the health care provider will most likely prescribe which medication? ✓ Fosphenytoin sodium 516) The nurse teaches the wife of a client who is receiving levodopa/carbidopa to avoid pyridoxine medications. Which statement by the wife indicates an understanding of the instructions? ✓ "Vitamin B6 reverses the effectiveness of the medication, meaning a higher dose is needed." 517) The nurse is giving medication instructions to a client who is receiving phenytoin for epilepsy. Which instruction should the nurse include to promote adherence to the medication? ✓ Monitor plasma medication levels to provide information about compliance. 518) The nurse is preparing an intravenous (IV) infusion of phenytoin as prescribed by the health care provider for the client with seizures. Which solution should the nurse plan to use to dilute this medication? ✓ Normal saline solution 519) A client is suspected of having myasthenia gravis. Edrophonium is administered intravenously to determine the diagnosis. Which indicates that the client may have myasthenia gravis? ✓ An increase in muscle strength within 30 to 60 seconds following administration of the medication 520) Meperidine hydrochloride is prescribed for a client with pain. What should the nurse monitor for as a side or adverse effect of this medication? ✓ Urinary retention 521) The nurse is caring for a client receiving morphine sulfate for pain. Because this medication has been prescribed for this client, which nursing action should be included in the plan of care? ✓ Encourage the client to cough and deep breathe. 522) The nurse is caring for a client who has been taking hydrocodone for the last 3 months. For which side and adverse effects of this medication should the nurse assess the client? ✓ Psychological and physical dependence 523) The nurse is reviewing the results of a test on a sample drawn from a child who is receiving carbamazepine for the control of seizures. The results indicate a serum carbamazepine level of 10 mcg/mL (42.33 mmol/L). The nurse analyzes the results and anticipates that the health care provider (HCP) will note which prescription? ✓ Continuation of the presently prescribed dosage 524) The nurse is caring for a client who underwent an open reduction internal fixation to the right hip. When administering opioid analgesics for pain, the nurse should instruct the client that which are side and adverse effects of opioid analgesics? Select all that apply. ✓ Sedation ✓ Constipation ✓ Respiratory depression 525) The nurse should question a prescription for which medication in the client concurrently receiving tramadol? ✓ Monoamine oxidase inhibitors (MAOIs) 526) On admission the client tells the nurse that sumatriptan is prescribed. Based on this information, which question should the nurse ask the client? ✓ "Have you had migraine headaches?" 527) The nurse preparing to administer carbamazepine notices a number of items on the client's breakfast tray. Which item should be a cause for concern and should be removed from the tray? ✓ Grapefruit juice 528) The nurse is told that the result of a serum carbamazepine level for a client who is receiving the medication for the control of seizures is 13 mcg/mL (55.03 mmol/L). Based on this laboratory result, the nurse anticipates that the health care provider (HCP) will document which prescription? ✓ A decrease of the dosage of the medication 529) A client reports frequent use of acetaminophen for relief of headaches and other discomforts. The nurse should evaluate which diagnostic data to determine if the client is at risk for toxicity? ✓ Liver function studies 530) The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The health care provider gives a test dose of edrophonium. Evaluation of the results indicates that the test is positive. Which would be the expected response noted by the nurse? ✓ An increase in muscle strength within 1 to 3 minutes 531) The nurse is assisting in the care of a client with myasthenia gravis who is receiving pyridostigmine. Which medication should the nurse plan to have readily available should the client develop cholinergic crisis because of excessive medication dosage? ✓ Atropine sulfate 532) A client with myasthenia gravis becomes increasingly weaker. The health care provider injects a dose of edrophonium to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if in cholinergic crisis? ✓ A temporary worsening of the condition 533) The nurse is providing instructions to a client beginning medication therapy with divalproex sodium for treatment of absence seizures. The nurse instructs the client that which represents the most frequent side or adverse effect of this medication? ✓ Nausea and vomiting 534) The nurse is speaking with a client taking phenytoin for seizure control. The client states that she has started using birth control pills to prevent pregnancy. Which would be an important point for the nurse to emphasize to the client? ✓ Phenytoin may decrease the effectiveness of birth control pills, and additional measures should be taken to avoid pregnancy. 535) The nurse is reading the laboratory results for a client being treated with carbamazepine for prophylaxis of complex partial seizures. When evaluating the client's laboratory data, the nurse determines that which value is consistent with a side or adverse effect of this medication? ✓ White blood cell count, 3200 mm3 (3.2 × 109/L) 536) The nurse is caring for a client receiving codeine sulfate for pain. The nurse determines that the client is experiencing a side or adverse effect of the medication based on which finding? ✓ No bowel movement in 3 days 537) The nurse is assisting in the care of a client being discharged on phenytoin 100 mg three times daily. When providing client teaching about this medication, the nurse should be sure to include which points? Select all that apply. ✓ Use a soft toothbrush while taking this medication. ✓ The medication may turn the urine pink, red, or brown. ✓ Alcohol should be avoided while taking this medication. 538) The nurse is providing instructions to an adolescent prescribed phenytoin for the control of seizures. Which statement by the adolescent indicates a need for further teaching regarding the medication? ✓ "If my gums become sore and swollen, I need to stop the medication." 539) A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply. ✓ Hypoxia ✓ Ischemia ✓ Hypotension ✓ Increased intracranial pressure (ICP) 540) The nurse is teaching a client who has had a laryngectomy for laryngeal cancer how to use an artificial larynx. Which statement should the nurse include in the teaching? ✓ "Hold the device alongside the neck." 541) A client has been hospitalized for removal of a cervical radiation implant used to treat cancer. The implant is removed, and the nurse provides home care instructions to the client. Which statement made by the client indicates a need for further instruction? ✓ "Foul-smelling vaginal discharge is a sign of an infection." 542) The nurse is providing instructions to the client who is receiving external radiation therapy. Which statement, if made by the client, indicates the need for further instruction? ✓ "I will use a washcloth to wash the affected area." 543) The home health care nurse is visiting a client who has undergone a mastectomy. The nurse determines that the client demonstrates greatest adjustment to the loss of the breast if which behavior is noted? ✓ The client looks at the surgical site. 544) The home health care nurse is providing instructions to a client after a vulvectomy. Which instruction should the nurse provide to the client? ✓ "Resume activities slowly, keeping in mind that walking is a beneficial activity." 545) The ambulatory care nurse is providing discharge instructions to a female client who underwent cryosurgery with laser therapy because of a positive Papanicolaou test. Which statement by the client indicates an understanding of the instructions? ✓ "I should expect the vaginal discharge to be clear and watery." 546) The nurse has provided discharge instructions to a client who underwent a right mastectomy with axillary lymph node dissection. Which statement made by the client indicates a need for further instruction regarding home care measures? ✓ "It is all right to use a straight razor to shave under my arms." 547) A client is admitted to the nursing unit after undergoing radical prostatectomy for cancer. The nurse anticipates that which problem would be of most concern to the client in the immediate postoperative period? ✓ Concern about the outcome of surgery 548) The home care nurse visits a client who has just returned home from the hospital after a mastectomy with a suction drain in place. Which observed client behavior requires a need for further teaching? ✓ Performs full range-of- motion exercises to the upper arm 549) The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia who is receiving chemotherapy. The nurse notes that the client's platelet count is 20,000 mm3 (200 × 109/L). The nurse should prepare to implement which action based on this finding? ✓ Remove the rectal thermometer from the client's room. 550) The clinic nurse has conducted a health screening clinic to identify clients who are at risk for cervical cancer. The nurse is reviewing the assessment findings in the records of the clients who attended the clinic. Which client is at lowest risk for developing this type of cancer? ✓ A single white client 551) The nurse is reviewing the medical record for a client who has been diagnosed with Hodgkin's disease. The nurse should check which diagnostic test noted in the client's record to determine the stage of the disease? ✓ Positron emission topography (PET) scan 552) The nurse is reviewing the record of a client who was admitted to the hospital with a diagnosis of ovarian cancer. A client has received an unsealed radioactive isotope for treatment of thyroid cancer. Which instruction is essential for the nurse to provide the client? ✓ "Flush the toilet at least 3 times after use." 553) The nurse is reviewing the laboratory test results for a client with bladder cancer with bone metastasis. The nurse should contact the health care provider (HCP) if which finding is noted? ✓ Calcium level of 15 mg/dL (3.75 mmol/L) 554) The community health nurse has conducted a teaching session for community members about the risk factors for laryngeal cancer. Which statement by a person attending the session indicates that teaching was effective? ✓ "Exposure to airborne carcinogens can cause this type of cancer." 555) A client is admitted to the hospital with suspected bladder cancer. The nurse assesses the client for which early signs and symptoms of the disease? ✓ Hematuria and absence of pain 556) The nurse is caring for a client with leukemia. In assessing the client for signs of leukemia, the nurse determines that what should be monitored? ✓ Bone marrow biopsy 557) The nurse conducted discharge teaching for the client diagnosed with melanoma. Which statement by a client indicates that education was effective? ✓ "It is highly metastatic." 558) The nurse is performing a skin assessment on a client diagnosed with malignant melanoma. The nurse should expect to note which characteristic of this type of skin lesion? ✓ An irregularly shaped lesion 559) The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of Hodgkin's disease. Which assessment findings noted in the client's record are associated with this diagnosis? Select all that apply. ✓ Fever ✓ Weight loss ✓ Night sweats ✓ Enlarged, painless lymph nodes 560) The nurse is reviewing the laboratory test results for a client receiving chemotherapy. The nurse notes that the white blood cell count is extremely low and places the client on neutropenic precautions. Which interventions are components of these types of precautions? Select all that apply. ✓ Removing fresh-cut flowers from the client's room ✓ Instructing family members on the proper technique for hand washing ✓ Instructing family members to wear a mask when entering the client's room 561) The nurse is preparing to care for a client with a diagnosis of metastatic cancer. The nurse notes documentation in the client's chart that the client is experiencing cachexia. Which should the nurse expect to note on assessment of the client? ✓ Sunken eyes and a hollow cheek appearance 562) The nurse is caring for a client with leukemia who is receiving intravenous chemotherapy. The nurse reviews the laboratory results and notes that the white blood cell count is 2000 mm3 (2 × 109/L), the platelet count is 150,000 mm3 (150 × 109/L), the clotting time is 10 minutes, and the ammonia level is 20 mcg/dL (12 mcmol/L). Which nursing action would be appropriate? ✓ Place the client on neutropenic precautions. 563) The client has undergone mastectomy. The nurse determines that the client is making the best adjustment to the loss of the breast if which behavior is observed? ✓ Participating in the care of the surgical drain 564) The client is preparing for discharge from the hospital after radical vulvectomy. The nurse should include which activity as appropriate for the client immediately after discharge? ✓ Walking 565) A community health nurse is providing an educational session on cancer of the cervix for women living in the community. The nurse informs the community residents that which is an early sign of this type of cancer? ✓ Irregular vaginal bleeding or spotting 566) The nurse is doing preoperative teaching with a client newly diagnosed with a stage I cervical cancer. Which statement by the client indicates that education was effective? ✓ "I have carcinoma that is just in the cervix." 567) The nurse is reviewing a plan of care for a client with cancer of the cervix who is undergoing treatment with a cesium (radiation) implant. Which nursing interventions are most appropriate for this client? Select all that apply. ✓ Maintain the client on bed rest. ✓ Place the client on a low-fiber diet. ✓ Stand at the entrance of the room to communicate with the client when possible. 568) The nurse is providing discharge instructions to a client who has undergone treatment of cervical cancer with a radiation (cesium) implant. Which instruction should the nurse provide to the client? ✓ Use a vaginal dilator 3 times a week. 569) The nurse is caring for a client with metastatic breast cancer. The client describes a new and sudden sharp pain in the back. Based on this assessment finding, which is the priority nursing intervention? ✓ Notify the health care provider (HCP). 570) The nurse is counseling a woman about decreasing her risk for cervical cancer. Which statement by the client indicates a need for further counseling? ✓ "Condoms are needed only if I do not trust a new partner." 571) A woman has just been told by the health care provider that she has breast cancer. The woman responds, "Oh, no! Does this mean I'm going to die?" The nurse interprets the woman's initial reaction as which response? ✓ Fear 572) The nurse has provided instructions to a client receiving external radiation therapy. Which client statement would indicate a need for further instruction regarding self-care related to the radiation therapy? ✓ "I need to apply pressure on the irritated area by wearing snug clothing to prevent bleeding." 573) The nurse has provided instructions to a client regarding testicular self-examination (TSE). Which client statement indicates the need for further teaching regarding TSE? ✓ "I examine myself every 2 months." 574) A client seeks treatment in an ambulatory clinic for a complaint of hoarseness that has lasted for 6 weeks. On the basis of this symptom, the nurse should consider developing a plan of care for which possible medical diagnosis? ✓ Laryngeal cancer 575) A client calls the ambulatory care clinic and tells the nurse that she found an area that looks like the peel of an orange when performing breast self-examination (BSE) but found no other changes. What is the nurse's best response to this client? ✓ "I am glad you called to report this finding. Can you come to the clinic to see your health care provider tomorrow?" 576) The nurse is taking a history from a client suspected of having testicular cancer. Which data will be most helpful in determining the risk factors for this type of cancer? ✓ Age and race 577) For the client with stomatitis resulting from chemotherapy, the care plan should include which intervention? ✓ Encourage foods with neutral or cool temperatures. 578) Which interventions are the most appropriate for a client who is experiencing thrombocytopenia? Select all that apply. ✓ Check secretions for frank or occult blood. ✓ Encourage fluid intake to avoid constipation. ✓ Provide oral sponges or a soft toothbrush for oral care. 579) The nurse is providing care to a client who has undergone modified right mastectomy for the treatment of breast cancer. Which activity should the nurse incorporate into the plan of care? ✓ Maintain head of the bed elevation at 30 degrees with the right arm elevated on a pillow. 580) The community health nurse is preparing an educational session for a group of women and will be discussing the primary prevention strategies and treatment measures for breast cancer. What information should the nurse include in the educational session? ✓ Treatment decisions are based on a woman's overall health. 581) The community nurse is conducting a health promotion program at a local school and is discussing the risk factors associated with cervical cancer. Which are risk factors for cervical cancer? Select all that apply. ✓ Smoking ✓ Multiple sex partners ✓ Human papillomavirus infection ✓ First intercourse before 17 years of age 582) The nurse should include which intervention in the care of a client who has undergone a vaginal hysterectomy for the treatment of cancer? Select all that apply. ✓ Encourage ambulation as prescribed. ✓ Remove antiembolism stockings twice daily. ✓ Assist with range-of-motion (ROM) leg exercises. ✓ Check placement of pneumatic compression boots. 583) The oncology nurse specialist provides an educational session for nursing staff regarding the characteristics of Hodgkin's disease. The nurse determines that further teaching is needed if a nursing staff member states that which is a characteristic of the disease? ✓ The disease occurs most often in those older than 75 years of age. 584) The community health nurse conducts a health promotion program for community members regarding testicular cancer. The nurse determines that further information needs to be provided if a community member states that which is a sign of testicular cancer? ✓ Alopecia 585) A client is receiving external radiation to the neck for cancer of the larynx. Which is the most likely expected effect? ✓ Sore throat 586) A cervical radiation implant is placed in a client who is undergoing treatment of cervical cancer. The nurse should initiate which activity prescription as the most appropriate for this client? ✓ Bed rest 587) The client reports to the nurse that while performing testicular self-examination, he found a lump the size and shape of a pea. Which statement is the most appropriate response to the client? ✓ "That's important to report even though it might not be serious." 588) The nurse is admitting a client with laryngeal cancer to the nursing unit. What should the nurse assess for as the most common risk factor for this type of cancer? ✓ Cigarette smoking 589) A client receiving chemotherapy is experiencing mucositis. The nurse should advise the client to use which item as the best substance to rinse the mouth? ✓ Weak salt and bicarbonate mouth rinse 590) The nurse is reviewing the preoperative prescriptions for a client with a colon tumor who is scheduled for abdominal perineal resection and notes that the health care provider has prescribed neomycin for the client. After discussing a prescription for neomycin with the nursing student who is caring for the client, the nurse determines that the student understands the rationale for administration if which statement is made? ✓ "It will help to decrease the bacteria in the bowel." 591) The nurse is caring for a client who has undergone a radical neck dissection and creation of a tracheostomy because of laryngeal cancer and is providing discharge instructions to the client. Which should be included in the instructions? Select all that apply. ✓ Protect the stoma from water. ✓ Use a humidifier if dryness is a problem. ✓ Keep powders and sprays away from the stoma site. ✓ Apply a thin layer of non–oil-based ointment to the skin around the stoma to prevent cracking. 592) Which statement made by a client who will undergo cytoreductive (debulking) surgery for ovarian cancer indicates that teaching by the nurse was effective? ✓ "The surgery will help to reduce the size of the tumor." 593) The nurse is caring for a client with prostate cancer who is being treated with a hormone therapy. What should the nurse monitor for in order to evaluate the effect of this treatment? ✓ A decline in the amount of circulating androgens 594) The nurse is caring for a client with cancer of the prostate who has undergone a prostatectomy. Which action should the nurse include in discharge instructions? ✓ Avoid lifting objects heavier than 20 lb (9 kg) for at least 6 weeks. 595) The oncology nurse is providing a teaching session for a group of nursing students regarding the risks and causes of bladder cancer. Which statement by a student would indicate a need for further teaching? ✓ "Bladder cancer most often occurs in women." 596) The nurse is caring for a client after intravesical instillation of an alkylating chemotherapeutic agent for the treatment of bladder cancer. What should the nurse instruct the client to do after the instillation? ✓ Change position every 15 minutes. 597) The community nurse is conducting a health promotion program, and the topic of the discussion relates to the risk factors for gastric cancer. Which item, if identified as a risk factor by a client, indicates a need for further discussion? ✓ A low-fat diet 598) A client with leukemia is receiving busulfan and allopurinol. The nurse should tell the client that the purpose of the allopurinol is to prevent which symptom? ✓ Hyperuricemia 599) A 67-year-old man is receiving outpatient radiation treatments for carcinoma of the oropharynx and has developed dysphagia. The nurse develops a teaching plan regarding dysphagia and includes which interventions in the plan? Select all that apply. ✓ Teach the man to examine his oral mucosa daily. ✓ Encourage the man to use artificial saliva to manage dryness. 600) A client with a medical diagnosis of breast cancer is undergoing chemotherapy. The client complains to the nurse about losing her hair and severe fatigue from the treatment. Which interventions should the nurse implement for this client? Select all that apply. ✓ Review side effects of chemotherapy and treatment with the client. ✓ Teach the client to pace activities with rest so as to maintain strength. ✓ Offer information on available counseling services and support groups. ✓ Inquire how the cancer diagnosis and treatment affect the client's normal routine. 601) The nurse is caring for a client undergoing external radiation. The client has developed a dry desquamation of the skin in the treatment area, and the nurse is teaching about management of the skin reaction. Which comment made by the client suggests understanding of the instructions? ✓ "When bathing I will use lukewarm water on the affected area." 602) The nurse is monitoring a client with chronic lymphocytic leukemia (CLL). Which sign should the nurse specifically monitor for and report to the health care provider? ✓ Lymphadenopathy 603) A client with bladder cancer has undergone surgical removal of the bladder with creation of an ileal conduit. Which assessment findings indicate that the client is developing complications? Select all that apply. ✓ Dusky appearance of the stoma ✓ Stoma protrusion from the skin ✓ Sharp abdominal pain with rigidity 604) A client who is receiving chemotherapy for breast cancer develops myelosuppression. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply. ✓ Avoid contact sports. ✓ Wash hands frequently. ✓ Avoid crowded places such as shopping malls. ✓ Avoid people who have received live attenuated vaccines. 605) A client with laryngeal cancer has undergone laryngectomy and is now receiving external radiation therapy to the head and neck. The nurse should monitor the client for which side and adverse effects of external radiation? Select all that apply. ✓ Stomatitis ✓ Dysgeusia ✓ Xerostomia 606) The nurse in the health care provider's office is performing a postoperative assessment of a client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. The nurse should provide which information to the client about her complaint? ✓ These sensations dissipate over several months and usually resolve after 1 year. 607) The nurse has instructed the client in the correct technique for breast self-examination (BSE). For a portion of the examination, the client will lie down. The nurse should teach the client to put the pillow in which location for self-examination of the right breast? ✓ Under the right shoulder 608) The nurse has conducted a cancer prevention seminar for clients in an ambulatory setting. The nurse determines that teaching was effective if the clients select which food item on the menu? ✓ Broccoli, baked fish, mashed potato 609) The nurse has provided teaching for an adult client about screening for a colon cancer. Which statement by the client indicates that education was effective? ✓ "I should have an annual fecal occult blood test." 610) A 27-year-old client is undergoing evaluation of lumps in her breasts. In determining whether the client could have fibrocystic breast disorder, the nurse should ask her whether the breast lumps seem to become more prominent or troublesome at which time? ✓ Before menses 611) The nurse is performing an admission assessment of a client with a possible right colon tumor. Which sign or symptom should the nurse anticipate the client may report? ✓ Dull abdominal pain exacerbated by walking 612) A client has undergone abdominal perineal resection for a bowel tumor. The nurse interprets that the client's colostomy is beginning to function if which sign is noted? ✓ The passage of flatus 613) The nurse monitoring an oncological client assesses for which early sign of vena cava syndrome? ✓ Periorbital edema 614) The nurse has conducted an educational session about risk factors for bladder cancer with clients in the ambulatory care center. Which statements by the clients indicate that teaching was effective? Select all that apply. ✓ "Quitting smoking will help to reduce my risk." ✓ "I have to consider natural alternatives to dye my hair." ✓ "I have to consult with my health care provider about long-term use of cyclophosphamide medications." 615) A client with liver cancer who is receiving chemotherapy tells the nurse that some foods taste bitter. The nurse would try to limit which food that is most likely to cause this bitter taste for the client? ✓ Pork 616) A client is having a diagnostic workup for colorectal cancer. Which factors in the client's history place the client at increased risk for this type of cancer? Select all that apply. ✓ A diet high in fats ✓ A diet high in carbohydrates ✓ A history of inflammatory bowel disease 617) The nurse is teaching a group of adults about the warning signs of cancer. Which signs and symptoms should the nurse mention to the group? Select all that apply. ✓ Sores that do not heal ✓ Nagging cough or hoarseness ✓ Indigestion or difficulty swallowing ✓ Change in bowel or bladder habits 618) The nurse is reviewing the record of a client who arrives at the health care clinic. The nurse notes that the client is taking letrozole. The nurse should suspect that the client has which disorder? ✓ Advanced breast cancer 619) The nurse is monitoring a client with acute lymphocytic leukemia for toxic effects of asparaginase. The nurse should notify the health care provider if monitoring reveals which finding? ✓ Prolonged blood clotting times 620) A client with testicular cancer is receiving cisplatin. The nurse assesses for which finding as a toxic effect of this medication? ✓ Tinnitus 621) The nurse transcribes a medication prescription for ifosfamide for a client with a diagnosis of germ cell cancer of the testes. The nurse reviews the client's history and looks for another prescription for which medication, which usually is administered with the antineoplastic medication? ✓ Mesna 622) A client with squamous cell carcinoma is receiving bleomycin. What is the priority assessment of the nurse when monitoring for side and adverse effects of bleomycin? ✓ Lung sounds 623) The nurse caring for a client receiving vincristine is monitoring the client for toxicity. The nurse interprets that the client is experiencing a toxic effect of this medication on the basis of which assessment finding? ✓ Weakness and sensory loss in the legs 624) A client with cancer is receiving a continuous intravenous infusion of morphine sulfate. The nurse monitoring the client for adverse effects would become most concerned about which vital sign? ✓ Respirations of 10 breaths/minute 625) A client is receiving intravesical chemotherapy for cancer of the bladder. The nurse should plan to take which action after the completion of each treatment? ✓ Encourage increased intake of oral fluids. 626) A female client with a diagnosis of breast cancer is taking cyclophosphamide. The client calls the health care clinic and tells the nurse that the medication is upsetting her stomach. Which instruction should the nurse provide to the client? ✓ Take the medication with food. 627) The nurse is preparing a plan of care for a client who will be receiving intravenous mitomycin for the treatment of cancer. In developing the plan of care, the nurse includes monitoring which as the priority? ✓ White blood cell count 628) The nurse is monitoring a client with leukemia who is receiving doxorubicin by intravenous infusion. The nurse should monitor for which finding that would indicate doxorubicin toxicity? ✓ Electrocardiogram (ECG) changes 629) The nurse is collecting subjective and objective data from a client and notes that the client is taking capecitabine. The nurse determines that this medication has been prescribed to treat which condition? ✓ Metastatic breast cancer 630) Capecitabine has been prescribed for a client, and the client asks the nurse about the action of the medication. The nurse formulates a response based on which mechanism of action of this medication? ✓ Interferes with protein synthesis 631) The health care provider (HCP) writes a prescription for capecitabine for a client who was admitted to the hospital. The nurse should contact the HCP to verify the prescription if which condition is noted in the assessment data? ✓ Chronic kidney disease 632) Capecitabine has been prescribed for a client. The nurse should tell the client that which blood test will be done periodically while the client is taking this medication? ✓ Complete blood count (CBC) 633) Capecitabine has been prescribed for a client, and the client asks the nurse about the side effects of the medication. The nurse responds that a frequent side effect of this medication is which finding? ✓ Diarrhea 634) A client admitted to the hospital is taking capecitabine. The nurse should monitor the client for which symptom that is a side or adverse effect of the medication? ✓ Dyspnea 635) Capecitabine has been prescribed, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further instruction? ✓ "I need to be sure to go to the clinic to receive my yearly flu vaccine." 636) A female client with carcinoma of the breast is admitted to the hospital for treatment with intravenously administered doxorubicin. The client tells the nurse that she has been told by her friends that she is going to lose all her hair. What is the most appropriate nursing response? ✓ "Hair loss may occur, and it will grow back, but it may have a different color or texture." 637) The clinic nurse prepares instructions for a client who developed stomatitis after the administration of a course of antineoplastic medications. The nurse should provide the client with which instruction? ✓ Rinse the mouth with a diluted solution of baking soda or saline. 638) A health care provider prescribes cisplatin and vincristine to a client with bladder cancer. The nurse should explain to the client that 2 medications are administered together for which reason? ✓ To increase the therapeutic response 639) A client with lung cancer is receiving a high dose of methotrexate. A health care provider also prescribes leucovorin to the client. The nurse should explain to the client that leucovorin is prescribed for which reason? ✓ "It helps to preserve normal cells." 640) The nurse is caring for a client receiving combination chemotherapy. Which nursing intervention is the most appropriate? ✓ Avoid giving agents with the same nadirs and toxicities at the same time. 641) A client with cancer has received a course of chemotherapy with fluorouracil. The nurse should tell the client to report which finding immediately? ✓ Stomatitis and diarrhea 642) The nurse is reviewing medical record notes of a client with bladder cancer who is prescribed concentrations of methotrexate followed by leucovorin (citrovorum factor, folic acid). The nurse should include in the client's education which information about the anticipated therapeutic effect of leucovorin? ✓ "It will help to preserve normal cells." 643) The nurse is caring for a client who is receiving asparaginase. The nurse should monitor the client for improvement of which condition? ✓ Acute lymphocytic leukemia 644) The nurse is caring for a client on the oncology unit who has developed stomatitis during chemotherapy. The nurse should plan which measure to treat this complication? ✓ Rinse the mouth with diluted baking soda or saline. 645) A client who has been diagnosed with cancer is to receive chemotherapy with both cisplatin and vincristine. The client asks the nurse why both medications must be given together. The nurse should explain to the client that the combination of 2 chemotherapeutic medications is used for which reason? ✓ Increase the destruction of tumor cells. 646) The nurse tells a client with leukemia who is receiving chemotherapy that allopurinol has been added to the medication list. When the client asks the purpose of the new medication, the nurse responds that the allopurinol is intended to prevent which problem? ✓ Hyperuricemia 647) The client with breast cancer has been given a prescription for cyclophosphamide. The nurse determines that the client understands the proper use of the medication if the client states to take which measure? ✓ Increase fluid intake to 2 to 3 L/day. 648) The nurse should be prepared to institute bleeding precautions in the client receiving antineoplastic medication if which result was reported from the laboratory? ✓ Platelet count 50,000 mm3 (50 × 109/L) 649) A client with cancer is about to be started on mitomycin. The nurse should contact the health care provider after noting that the client is also taking which medication? ✓ Warfarin 650) The nurse is assigned to care for a client with metastatic breast cancer who is taking tamoxifen citrate. The nurse plans to monitor for which changes in laboratory values for this client? Select all that apply. ✓ Increase in serum calcium level ✓ Decrease in low-density lipoprotein levels 651) The nurse is monitoring a client who has just returned from surgery after a transurethral resection of the prostate (TURP). The client has a 3-way Foley catheter in place for ongoing bladder irrigation. The nurse is observing the color of the client's urine and should expect which urine color during the immediate postoperative period? ✓ Pale pink urine 652) A client who has had a prostatectomy has been instructed in perineal exercises to gain control of the urinary sphincter. The nurse determines that the client demonstrates a need for further teaching when he states that he will perform which movement as part of these exercises? ✓ Bearing down as if having a bowel movement 653) A client has developed acute kidney injury (AKI) as a complication of glomerulonephritis. Which should the nurse expect to observe in the client? ✓ Hypertension 654) The nurse is planning discharge teaching for a client newly diagnosed with chronic kidney disease (CKD). Which factor will enhance the educational process? ✓ Presence of family 655) The nurse is analyzing the posthemodialysis laboratory test results for a client with chronic kidney disease. The nurse interprets that the dialysis is having an expected but nontherapeutic effect if which value is decreased? ✓ Red blood cell (RBC) count 656) A client diagnosed with chronic kidney disease (CKD) is scheduled to begin hemodialysis. The nurse determines that which neurological and psychosocial manifestations, if exhibited by this client, are related to the CKD? Select all that apply. ✓ Agitation ✓ Depression ✓ Withdrawal ✓ Labile emotions 657) A client with chronic kidney disease (CKD) has been taking aluminum hydroxide gel. On the basis of this information, the nurse determines that the client is most at risk for which problem? ✓ Constipation 658) The nurse is working with a client newly diagnosed with chronic kidney disease (CKD) to set up a schedule for hemodialysis. The client states, "This is impossible! How can I even think about leading a normal life again if this is what I'm going to have to do?" The nurse determines that the client is exhibiting which problem? ✓ Anger 659) A client with an arteriovenous fistula in the left arm who is undergoing hemodialysis is at risk for infection. Which should the nurse formulate as the best outcome goal for this client problem? ✓ The client's white blood cell (WBC) count remains within normal limits. 660) The nurse is giving general instructions to a client receiving hemodialysis. Which statement would be most appropriate for the nurse to include? ✓ "Several types of medications should be withheld on the day of dialysis until after the procedure." 661) A client with chronic kidney disease (CKD) has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now presents with mental cloudiness, dementia, and complaints of bone pain. The nurse determines that these assessment data are compatible with which condition? ✓ Aluminum intoxication 662) A client undergoing hemodialysis is at risk for bleeding from the heparin used during the hemodialysis treatment. The nurse assesses for this occurrence by periodically checking the results of which laboratory test? ✓ Partial thromboplastin time (PTT) 663) The nurse is monitoring the fluid balance of an assigned client. The nurse determines that the client has proper fluid balance if which 24-hour intake and output totals are noted? ✓ Intake 1800 mL, output 1750 mL 664) The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder, if noted on the client's record, should the nurse identify as a risk factor for this disorder? ✓ Diabetes mellitus 665) A client with chronic kidney disease (CKD) is prescribed aluminum hydroxide. Which information should the nurse include while instructing the client regarding the action of this medication? ✓ It combines with phosphorus and helps eliminate phosphates from the body. 666) The registered nurse is instructing a new nursing graduate about hemodialysis. Which statement made by the new nursing graduate indicates an understanding of the procedure for hemodialysis? Select all that apply. ✓ "Heparin sodium is administered during dialysis." ✓ "Dialysis cleanses the blood of accumulated waste products." ✓ "Warming the dialysate increases the efficiency of diffusion." 667) The nurse is caring for a client with acute kidney injury (AKI) experiencing metabolic acidosis. When performing an assessment, the nurse should expect to note which breathing pattern? ✓ Kussmaul respirations 668) The nursing student is assigned to care for a client with a diagnosis of acute kidney injury (AKI), diuretic phase. The nursing instructor asks the student about the primary goal of the treatment plan for this client. Which goal, if stated by the nursing student, indicates an adequate understanding of the treatment plan for this client? ✓ Prevent loss of electrolytes. 669) The nurse instructs a client about continuous ambulatory peritoneal dialysis (CAPD). Which statement by the client indicates an accurate understanding of CAPD? ✓ "No machinery is involved, and I can pursue my usual activities." 670) Which client is most at risk for developing a Candida urinary tract infection (UTI)? ✓ A young woman on antibiotic therapy 671) A cystectomy is performed for a client with a diagnosis of bladder cancer, and a Kock pouch is created for urinary diversion. In creating a discharge teaching plan for the client, the nurse should include which instruction in the plan? ✓ Technique of catheterization 672) A client is having difficulty coughing and deep- breathing because of pain after a nephrectomy. Which action by the nurse is helpful in promoting optimal respiratory function? ✓ Assisting the client to splint the incision during respiratory exercise 673) A client being discharged home after renal transplantation has a risk for infection related to immunosuppressive medication therapy. The nurse determines that the client needs further teaching on measures to prevent and control infection if the client states that it is necessary to take which action? ✓ Monitor urine character and output at least 1 day each week. 674) A client with a bladder injury has had surgical repair of the injured area with placement of a suprapubic catheter. Which is the most appropriate nursing action to prevent complications of this procedure? ✓ Ensure that the catheter tubing is not kinked. 675) The nurse is caring for a client with acute kidney injury (AKI). The nurse should test the client's urine for proteinuria to determine which type of AKI? ✓ Intrinsic 676) The nurse is preparing to perform a discharge teaching with a client who is started on hemodialysis. Which information should the nurse provide regarding the hemodialysis schedule? ✓ 3 to 4 hours of treatment 3 days per week 677) A client is about to begin hemodialysis. Which measures should the nurse employ in the care of the client? Select all that apply. ✓ Using sterile technique for needle insertion ✓ Using standard precautions in the care of the client ✓ Giving the client a mask to wear during connection to the machine ✓ Wearing full protective clothing such as goggles, mask, gloves, and apron 678) A client is scheduled for surgical creation of an internal arteriovenous (AV) fistula on the following day. The client says to the nurse, "I'll be so happy when the fistula is made tomorrow. This means I can have that other hemodialysis catheter pulled right out." Which interpretation should the nurse make based on the client's statement? ✓ The client does not understand that the site needs to mature or develop for 1 to 2 weeks before use. 679) The nursing student is caring for a client with benign prostatic hyperplasia (BPH). The nursing instructor asks the student to identify the clinical manifestations associated with this condition. The student needs further teaching if the student states that which finding is an early symptom of BPH? ✓ Hematuria 680) A client with end-stage renal disease (ESRD) has the problem of ineffective coping. Which nursing interventions are appropriate in working with this client? Select all that apply. ✓ Acknowledge the client's feelings. ✓ Assess the client and family's coping patterns. ✓ Explore the meaning of the illness with the client. ✓ Give the client information when the client is ready to listen. 681) The nurse has administered a dose of meperidine hydrochloride to a client with renal colic as treatment for pain. The nurse carefully monitors this client for which side and adverse effect of this medication? ✓ Urinary retention 682) The nurse is assessing the renal function of a client at risk for acute kidney injury. After noting the amount of urine output and urine characteristics, the nurse proceeds to assess which as the best indirect indicator of renal status? ✓ Blood pressure 683) A client has been diagnosed with polycystic kidney disease. On assessment of the client, the nurse should observe for which most common manifestation of this disorder? ✓ Flank pain and hematuria 684) The nurse is performing an assessment on a client after a cystoscopy. Which assessment finding indicates a need to notify the health care provider (HCP)? ✓ Grossly bloody urine with clots 685) The nurse provides discharge instructions to a client after prostatectomy. What is the priority discharge instruction for this client? ✓ Increase fluid intake to at least 2.5 L/day. 686) A home care nurse is making home visits to an older client with urinary incontinence who is very concerned about the incontinent episodes. Which finding by the nurse indicates that the client has an environmental barrier to normal voiding? ✓ Bathroom located on the second floor, bedroom on the first floor 687) The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions should the nurse include in performing this procedure? Select all that apply. ✓ Explaining the procedure to the client ✓ Clamping the tubing of the drainage bag ✓ Aspirating a sample from the port on the drainage tubing ✓ Wiping the port with an alcohol swab before inserting the syringe 688) The nurse is teaching a client with nephrotic syndrome about managing the disorder. What should the nurse instruct the client to adjust according to the amount of edema present? ✓ Activity level 689) The nurse is caring for a client just after ureterolithotomy and is monitoring the drainage from the ureteral catheter hourly. Suddenly, the catheter stops draining. The nurse assesses the client and determines that which could be the cause of the problem? Select all that apply. ✓ Blood clots ✓ Mucous shreds ✓ Chemical sediment ✓ Catheter displacement 690) A client with renal cell carcinoma of the left kidney is scheduled for nephrectomy. The right kidney appears normal at this time. The client is anxious about whether dialysis will ultimately be needed. The nurse should plan to use which information in discussions with the client to alleviate anxiety? ✓ One kidney is adequate to meet the needs of the body as long as it has normal function. 691) The nurse is teaching a client with renal cancer who is scheduled for a renal artery embolization about the procedure. Which statement by the client indicates that the educational session was effective? ✓ "This will decrease the size of the tumor because its blood supply will be removed after placement of an absorbable gelatin sponge." 692) A client with renal cancer is being treated preoperatively with radiation therapy. What statement by the client demonstrates understanding of proper care of the skin over the treatment field? ✓ "I need to avoid skin exposure to direct sunlight and chlorinated water." 693) The nurse is urging a client to cough and deep breathe after nephrectomy. The client tells the nurse, "That's easy for you to say! You don't have to do this." The nurse interprets that the client's statement is most likely to be a result of which factor? ✓ Pain that is intensified because of the location of the incision near the diaphragm 694) A client is being evaluated as a potential kidney donor for a family member. The client asks the nurse why separate teams are evaluating donor and recipient. What is the most appropriate response by the nurse? ✓ Avoids a conflict of interest between the team evaluating the recipient and the team evaluating the donor 695) The nurse is caring for a client immediately after nephrectomy and renal transplantation. What is the most appropriate datum to use in planning administration of intravenous fluids to this client? ✓ The number of milliliters in the previous hour's urine output 696) A female client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which problem? ✓ The development of a vesicovaginal fistula 697) The nurse is preparing to teach ostomy care to a client who has just had a urinary diversion; the client expresses concern about body appearance. Which client action indicates that the best initial positive adaptation is being made? ✓ Agrees to look at the ostomy 698) The home health nurse is planning to make a home visit to a client who has undergone surgical creation of an ileal conduit. The nurse should include which information on ostomy care in discussion with the client? ✓ Cleanse the skin around the stoma, using gentle soap and water, and then rinse and dry well. 699) A client who is to have a cystectomy with creation of an ileal conduit asks the nurse why the bowel needs to be cleansed before surgery if the bladder is being removed. Which response by the nurse is the most appropriate? ✓ "A portion of the bowel will be used to create the conduit for urinary diversion." 700) A client with epididymitis is upset about the extent of scrotal edema. Attempts to reassure the client that this condition is temporary have not been effective. The nurse should plan to address which client problem? ✓ Altered body appearance related to change in the appearance of the scrotum 701) A client is diagnosed with epididymitis. The nurse checks the health care provider's prescriptions and expects that which measures will be prescribed? Select all that apply. ✓ Sitz bath ✓ Antibiotics ✓ Scrotal elevation ✓ Bed rest with bathroom privileges 702) The nurse is providing instructions regarding the complications of peritoneal dialysis. The nurse emphasizes that onset of peritonitis, a serious complication, is most likely to be associated with which clinical manifestation? ✓ Fever 703) A client who is performing peritoneal dialysis at home calls the clinic and reports that the outflow from the dialysis catheter seems to be decreasing in amount. The clinic nurse should ask which question first? ✓ "Have you been constipated recently?" 704) The nurse is assessing a client who has returned from the postanesthesia care unit after transurethral resection of the prostate (TURP). The nurse should assess for which color in the urinary drainage tubing that indicates proper irrigation and adequate functioning of the device? ✓ Pale pink 705) The nurse caring for a client immediately after transurethral resection of the prostate (TURP) notices that the client has suddenly become confused and disoriented. Which is the priority nursing action for this client? ✓ Notify the health care provider (HCP). 706) The nurse is participating in a prostate screening clinic for men. Which complaints by a client are associated with prostatism? Select all that apply. ✓ Inability to stop urinating ✓ Postvoid dribbling of urine ✓ Increased episodes of nocturia ✓ Hesitancy on initiating the urinary stream 707) A client has just had a Foley catheter removed and is to be started on a bladder retraining program. Which intervention will provide the most useful information about the client's ability to empty the bladder? ✓ Measuring postvoid residual using a bladder scan 708) The nurse is planning a teaching session with a client who has chronic kidney disease (CKD) about managing the condition between dialysis treatments. The nurse should plan to include the instruction that weight gain between dialysis treatments should be ideally what value? ✓ 2 to 3 lbs (1 to 1.5 kg) 709) A client undergoing hemodialysis begins to experience muscle cramping. What is the best action by the hemodialysis nurse in this situation? ✓ Decrease the ultrafiltration rate. 710) The nurse is admitting a client from the postanesthesia care unit who has had percutaneous nephrolithotomy for calculi in the renal pelvis. The nurse anticipates that the client's care will most likely involve monitoring which device? ✓ Nephrostomy tube 711) The nurse is preparing to care for a client after a renal scan. Which intervention should the nurse include in the post procedure plan of care? ✓ Wear gloves if contact with the client's urine will occur. 712) A client passes a urinary stone, and laboratory analysis of the stone indicates that it is composed of calcium oxalate. On the basis of these data, which should the nurse specifically include in the dietary instructions? ✓ Avoid green, leafy vegetables such as spinach. 713) The nurse checks the serum myoglobin level for a client with a crush injury to the right lower leg because the client is at risk for developing which type of acute kidney injury? ✓ Intrarenal 714) The nurse is creating a plan of care for a client with chronic kidney disease and uremia. The nurse is developing interventions to assist in promoting an increased dietary intake while at the same time maintaining necessary dietary restrictions. Which action should the nurse include in the plan of care? ✓ Maintain a diet high in calories with frequent snacks. 715) A client who is undergoing peritoneal dialysis calls the nurse at the renal unit and reports the presence of severe abdominal pain and diarrhea. The client also informs the nurse that the peritoneal dialysis returns are brown-tinged in color. Which would the nurse suspect? ✓ Bowel perforation 716) The nurse is providing dietary instructions to a client with an oxalate kidney stone. The nurse should instruct the client to avoid which food? ✓ Chocolate 717) A client with uric acid calculi is placed on a low- purine diet. The nurse instructs the client to restrict the intake of which food? ✓ Fish 718) The nurse has provided instructions regarding home care measures for a client with acute pyelonephritis. Which statement by the client indicates a need for further teaching? ✓ "I need to avoid alcohol and highly spiced foods but may continue to drink my coffee every day." 719) The nurse is creating a plan of care for a client with a diagnosis of nephrotic syndrome whose glomerular filtration rate (GFR) is normal. Which interventions should the nurse include in the plan of care? Select all that apply. ✓ Monitor daily weight. ✓ Maintain sodium restrictions. ✓ Monitor intake and output (I&O). ✓ Maintain bed rest when edema is severe. 720) The nurse is reviewing the assessment findings for a client with a diagnosis of nephrotic syndrome. Which should the nurse expect to note in this client? ✓ Decreased serum albumin levels 721) The nurse is reviewing the urinalysis results for a client with glomerulonephritis. Which findings should the nurse expect to note? Select all that apply. ✓ Proteinuria ✓ Hematuria ✓ A dark and smoky appearance of the urine 722) The ambulatory care nurse is providing instructions to a client after a cystoscopy. Which statement by the client indicates a need for further teaching? ✓ "If I notice any pink-tinged urine, I should contact the health care provider." 723) The nurse is providing instructions to a client who is scheduled for cystoscopy and possible biopsy under general anesthesia. Which information should the nurse include? ✓ Intravenous fluids may be started on the day of the procedure. 724) The nurse is performing assessment on a client with acute kidney injury who is in the oliguric phase. Which should the nurse expect to note? Select all that apply. ✓ Increased serum creatinine level ✓ A low and fixed specific gravity ✓ Increased blood urea nitrogen (BUN) level ✓ Urine osmolarity of approximately 300 mOsm/kg (300 mmol/kg) 725) The nurse instructor is evaluating a nursing student for knowledge regarding care of a client with acute kidney injury. Which statement by the student demonstrates the need for further teaching about the diuretic phase of acute kidney injury? ✓ "The diuretic phase is characterized by an increase in urine output of about 500 mL in a 24-hour period." 726) The graduate nurse is caring for a client with decreased renal perfusion. The registered nurse determines that the graduate nurse demonstrates understanding of why this is occurring if which statement is made? ✓ "It may be a consequence of decreased dopaminergic receptor stimulation." 727) The nurse has provided dietary instructions to a client with renal calculi who must learn about the foods that yield an alkaline residue in the urine. The nurse determines that education was effective if the client chooses which selections from a diet menu? ✓ Spinach salad, milk, and a banana 728) The nurse has given instructions about Kegel exercises to a female client with a cystocele. The nurse determines that the client needs further instruction if she makes which statement? ✓ "I should begin voiding and then stop the stream, holding residual urine for an hour." 729) The spouse of a client with acute kidney injury secondary to heart failure asks the nurse how a heart problem can affect the kidneys. The nurse should formulate a response using what fact about the kidneys? ✓ The kidneys generally require and receive about 20% to 25% of the resting cardiac output. 730) The nurse is caring for a client who was prescribed furosemide. The nurse should monitor the client for damage of which kidney structure? ✓ Nephron 731) The nurse measures the cardiac output of a client and finds it to be 6 L/min. Which amount of kidney perfusion should the nurse anticipate? ✓ 1200 to 1500 mL/min 732) The nurse is caring for a client with a bladder infection. The nurse plans care understanding that the primary risk factor for spread of infection in this client is dysfunction of which structure? ✓ Ureterovesical junction 733) A client is experiencing the syndrome of inappropriate antidiuretic hormone (ADH) secretion. When explaining this disorder to the client and family, the nurse recalls that ADH works to reabsorb water in which parts of the nephron? ✓ The distal tubule and the collecting duct 734) The nurse is monitoring the urine output of a client with low serum protein level and urinary output less than 30 mL in the last hour. Based on these data, the nurse understands that low urinary output is caused by which force within the kidneys? ✓ Oncotic pressure 735) The nurse is caring for a client whose urine output was 25 mL per hour for 2 consecutive hours. The nurse reviews the health care provider's prescriptions and plans care, knowing that which client-related factor would increase the amount of blood flow to the kidneys? ✓ Release of low levels of dopamine 736) The nurse is caring for an older client. Which finding should the nurse expect to note in this client while evaluating renal function? ✓ The glomerular filtration rate (GFR) diminishes 737) The nurse provides instructions to a client about newly prescribed furosemide. Which information should the nurse use to provide instructions in this teaching session? ✓ The medication acts on the loop of Henle in the nephron. 738) The nurse is admitting a client who has an arteriovenous (AV) fistula in the right arm for hemodialysis. Which nursing intervention is the best way to prevent injury to the AV site? ✓ Placing a sign at the bedside that reads "No blood pressure measurements or venipunctures in the right arm" 739) A client is being discharged to home while recovering from acute kidney injury (AKI). Reduced dietary intake of which substance indicates to the nurse that the client understands the dietary teaching? ✓ Potassium 740) The nurse is working on a medical-surgical nursing unit and is caring for several clients with chronic kidney disease. The nurse interprets that which client is best suited for peritoneal dialysis as a treatment option? ✓ A client with severe heart failure 741) A client tells the nurse about a pattern of a strong urge to void, followed by incontinence before the client can get to the bathroom. Based on the data provided, which condition should the nurse suspect? ✓ Urge incontinence 742) The nurse has provided instructions to a client with a urinary tract infection regarding foods and fluids to consume that will acidify the urine. Which fluids should the nurse include in the client's teaching plan that will aid in acidifying the urine? Select all that apply. ✓ Prune juice ✓ Apricot juice ✓ Cranberry juice 743) A client has urinary calculi composed of uric acid. The nurse is teaching the client dietary measures to prevent further development of uric acid calculi. The nurse should inform the client that it is acceptable to consume which item? ✓ Cottage cheese 744) The nurse has performed a nutritional assessment on a client with cystitis. The nurse should tell the client to consume which beverage to minimize recurrence of cystitis? ✓ Water 745) A client with nephrolithiasis arrives at the clinic for a follow-up visit. Laboratory analysis of the stone that the client passed 1 week earlier indicates that the stone is composed of calcium oxalate. Based on these data, what food item does the nurse instruct the client to avoid? ✓ Spinach 746) Before providing care for a client in the late stages of chronic kidney disease (CKD), the nurse should review the results of which most relevant laboratory studies? ✓ Serum potassium, serum calcium 747) Which finding noted in the client on continuous ambulatory peritoneal dialysis (CAPD) should be reported to the health care provider (HCP)? ✓ Cloudy yellow dialysate output 748) A client experiencing end-stage kidney disease has an arteriovenous (AV) fistula placed surgically for hemodialysis. Which action is most appropriate for the nurse to document in the plan for care of the AV fistula? ✓ Teach the client to avoid carrying heavy objects that would compress the AV fistula and cause thrombosis. 749) In performing a physical assessment of a client with chronic kidney disease (CKD), which finding should the nurse anticipate? ✓ Crackles auscultated in the lungs 750) The client diagnosed with benign prostatic hyperplasia (BPH) is scheduled for a transrectal ultrasound examination and a test to measure the level of prostate- specific antigen (PSA). The client says to the nurse, "I can't remember . . . can you tell me again why I need these tests to be done?" The nurse responds, knowing that these tests are done for which purpose? ✓ Help to rule out the possibility of cancer 751) The client with a crush injury to the leg has a highly positive urine myoglobin level. The nurse should assess this client carefully for signs and symptoms of which problem? ✓ Acute tubular necrosis 752) The nurse has completed teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse should determine that education was effective if the client states to record which parameters daily? ✓ Intake and output (I&O) and weight 753) A client diagnosed with polycystic kidney disease has been taught about the treatment plan for this disease. The nurse should determine that the client needs further teaching if the client states that which is included in the treatment plan? ✓ Sodium restriction 754) The nurse is preparing to care for a client receiving peritoneal dialysis. Which should be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis? ✓ Maintain strict aseptic technique. 755) A client with chronic kidney disease has completed a hemodialysis treatment. The nurse should use which standard indicators to evaluate the client's status after dialysis? ✓ Vital signs and weight 756) The client with chronic kidney disease has an indwelling abdominal catheter for peritoneal dialysis. The client spills water on the catheter dressing while bathing. Which action should the nurse immediately take? ✓ Change the dressing. 757) A client with urolithiasis (struvite stones) has a history of chronic urinary tract infections. What should the nurse plan to teach the client to avoid? ✓ Wearing synthetic underwear and pantyhose 758) The nurse is planning teaching for a female client diagnosed with urethritis caused by chlamydial infection. Which information should the nurse plan to include in the teaching session? ✓ Keep follow-up appointments for repeat cultures in 4 to 7 days. 759) A client with chlamydial infection has received instructions on self-care and prevention of further infection. The nurse determines that the client needs further teaching if the client states that he or she will take which action? ✓ Take an antibiotic so as to prophylactically prevent symptoms of Chlamydia. 760) The nurse is reviewing the list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse should base the response on knowing that which is the action of the glucose in the solution? ✓ Increases osmotic pressure to produce ultrafiltration 761) A client with benign prostatic hyperplasia undergoes a transurethral resection of the prostate. Postoperatively the client is receiving continuous bladder irrigations. The nurse assesses the client for manifestations of transurethral resection syndrome. Which assessment data would indicate the onset of this syndrome? ✓ Bradycardia and confusion 762) A client with prostatitis following kidney infection has received instructions on management of the condition at home and prevention of recurrence. The nurse determines that education was effective if the client makes which statement? ✓ "I should use warm tub baths and analgesics to increase comfort." 763) A client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril. When should the nurse plan to administer this medication? ✓ On return from dialysis 764) A client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. Which is the priority nursing intervention? ✓ Ensure that small clamps are attached to the arteriovenous shunt dressing. 765) The nurse has taught the client with polycystic kidney disease about management of the disorder and prevention and recognition of complications. The nurse should determine that the client understands the instructions if the client states that which should be reported to the health care provider (HCP)? Select all that apply. ✓ Frequent urination ✓ Burning on urination ✓ A temperature of 100.6°F (38.1°C) ✓ New-onset shortness of breath 766) The nurse is caring for a client who has just returned from having a cystoscopy. The nurse should recognize which as an abnormal assessment finding for this client? ✓ The nurse notes bright red urine output. 767) The nurse provides home care instructions to a client undergoing hemodialysis with regard to care of a newly created arteriovenous (AV) fistula. Which client statement indicates that teaching was effective? ✓ "I should check the fistula every day by feeling it for a vibration." 768) The nurse assessing the ureterostomy of a postoperative client interprets that the stoma has normal characteristics if which is observed? ✓ Red and moist 769) A client with glomerulonephritis has developed acute kidney injury (AKI) as a complication. The nurse should expect to note which abnormal finding documented on the client's medical record? ✓ Hypertension 770) A client has been diagnosed with pyelonephritis. The nurse interprets that which health problem has placed the client at risk for this disorder? ✓ Diabetes mellitus 771) A client has chronic kidney disease (CKD) that does yet not require dialysis. Which client statement indicates the need for further teaching? ✓ "I will reduce the sodium in my diet, and I can use salt substitutes to spice my food." 772) A client with chronic kidney disease (CKD) is being managed by continuous ambulatory peritoneal dialysis (CAPD). During outflow, the nurse notes that only half of the 2-L dialysate has returned and the flow has stopped. Which interventions should the nurse take to enhance the outflow? Select all that apply. ✓ Reposition the client. ✓ Make sure the peritoneal catheter is not kinked. ✓ Check that the drainage bag is lower than the client's abdomen. ✓ Assess the stool history, and institute elimination measures if the client is constipated. 773) The health care provider writes prescriptions for a client with chronic kidney disease (CKD). Which prescription should the nurse question? ✓ Provide a high-protein diet. 774) Nitrofurantoin is prescribed for the client. The nurse checks the client's record, knowing that this medication is contraindicated in which disorder? ✓ Renal disease 775) Oral bethanechol chloride is prescribed for the client. The nurse should instruct the client to take this medication at which time? ✓ Two hours after meals 776) Epoetin alfa is prescribed for a client diagnosed with chronic kidney disease. The client asks the nurse about the purpose of the medication. Which response by the nurse is most appropriate? ✓ "It is used to treat anemia." 777) Tamsulosin hydrochloride is prescribed for a client. The nurse should suspect that this medication is prescribed to relieve which condition? ✓ Urinary obstruction 778) Tamsulosin hydrochloride has been prescribed for a client with benign prostatic hypertrophy (BPH). How should the nurse instruct the client to take the medication? ✓ Thirty minutes after a meal 779) A client who has had a prostatectomy is complaining of pain from bladder spasms. The nurse checks the health care provider's prescription sheet and expects to see which medication prescribed to treat the problem? ✓ Oxybutynin 780) A client with chronic kidney disease has a medication prescription for epoetin alfa. The nurse should plan to administer this medication by which method? ✓ Subcutaneously 781) A client with chronic kidney disease (CKD) who is receiving an antihypertensive medication is experiencing frequent hypotensive episodes. The nurse reviews the client's medication record, knowing that which medication would have the greatest tendency to cause hypotension? ✓ Methyldopa 782) Ciprofloxacin is prescribed for a client with a Pseudomonas aeruginosa infection of the urinary tract. The health care provider (HCP) should be questioned by the nurse about the prescription if which underlying condition is noted in the client's record? ✓ Myasthenia gravis 783) Nitrofurantoin is prescribed for an adult client to treat acute urinary tract infection (UTI). Based on the normal adult dose, how should the nurse instruct the client to take this medication? ✓ 50 mg every 6 hours 784) The nurse is providing teaching for a client prescribed ciprofloxacin for a urinary tract infection. Which statement made by the client indicates that there is a need for further teaching? ✓ "If I develop any tendon pain while taking ciprofloxacin, exercise should help to decrease the pain." 785) A client is receiving levofloxacin for treatment of urinary tract infection. Which finding warrants an immediate call to the health care provider (HCP)? ✓ Prolonged QT interval on electrocardiogram 786) Bethanechol chloride is prescribed for an adult client with postoperative bladder spasms. Based on the normal adult dose, how should the nurse plan to administer this medication? ✓ 10 to 50 mg 3 to 4 times a day 787) Parenteral bethanechol chloride is prescribed for a client with urinary retention. The nurse should plan to administer this medication by which route? ✓ Subcutaneously 788) Aluminum hydroxide is prescribed for a client with chronic kidney disease (CKD). The nurse should instruct the client to take this medication at what time? ✓ With meals 789) A client taking metronidazole telephones the home health nurse to report dark discoloration to the urine. The nurse interprets that the client's complaint warrants which nursing action at this time? ✓ Tell the client that this is a harmless medication side effect. 790) A client being admitted to the nursing unit has been taking bethanechol chloride at home. During the admission assessment, the nurse gives special attention to assessing the client for which side and adverse effect of this medication? ✓ Bradycardia 791) The nurse has a prescription to administer bethanechol chloride subcutaneously. Before giving this medication, the nurse checks to ensure that which condition is not noted in the client's history? ✓ Asthma 792) A client with acute pyelonephritis who was started on antibiotic therapy 24 hours earlier is still complaining of burning with urination. The nurse should anticipate that the health care provider will prescribe which medication? ✓ Phenazopyridine 793) The home health nurse is caring for a client who is taking probenecid. The client has been instructed to restrict the diet to low-purine foods. Which food item should the nurse instruct the client to avoid? ✓ Scallops 794) The nurse is planning to administer furosemide 40 mg by intravenous push (IVP) through an existing intravenous (IV) line. To deliver this medication safely, the nurse should perform which action? ✓ Pinch the IV tubing above the injection port, and inject slowly over 1 to 2 minutes. 795) A client is prescribed sulfamethoxazole for treatment of urinary tract infection. Identification of which other medication noted on the client's medical record requires further collaboration with the health care provider (HCP)? ✓ Phenytoin 796) Laboratory analysis of a urine sample for culture and sensitivity reveals a bacterial infection, and the client is diagnosed with cystitis. Nitrofurantoin is prescribed for the client. Which is the priority nursing assessment before administering this medication? ✓ Checking lung sounds 797) The nurse provides instructions regarding the administration of liquid oral cyclosporine solution to a client. Which statement, if made by the client, would indicate the need for further teaching? ✓ "I will purchase a dropper from the pharmacy to calibrate the amount of medication that I need." 798) Nitrofurantoin is prescribed for a client with urinary tract infection. The nurse is instructing the client regarding the administration of the medication. Which information about the best time to take this medication should be included in the client's education? ✓ With meals 799) Trimethoprim-sulfamethoxazole is prescribed to be administered by intravenous infusion to a client with a recurrent urinary tract infection. How should the nurse administer this medication? ✓ Over 60 to 90 minutes 800) Propantheline bromide is prescribed for a client with bladder spasms. Which disorder, if noted in the client's record, should alert the nurse to question the prescription for this medication? ✓ Glaucoma 801) A client is receiving oxybutynin. The nurse should suspect that this medication is prescribed to relieve which condition? ✓ Overactive bladder 802) The nurse is taking care of a client receiving oxybutynin. Which finding should the nurse expect to note if the client develops side or adverse effects of this medication? ✓ Dry mouth 803) A client is prescribed dutasteride. Which outcome indicates that the medication is effective? ✓ Decreased obstruction to outflow of urine through the urethra 804) The ambulatory care nurse is providing instructions to a client with a urinary tract infection (UTI) being started on nitrofurantoin. The nurse should provide the client with which information? ✓ If taken with meals, it will help decrease the risk for gastrointestinal (GI) upset. 805) A client is prescribed trimethoprim-sulfamethoxazole for a recurrent urinary tract infection (UTI). The nurse should give the client which instruction regarding this medication? ✓ Take each dose with 8 oz (235 mL) of water, and drink extra water each day. 806) A client with a urinary tract infection (UTI) is given a prescription for levofloxacin. The nurse should provide the client with which information about this medication? ✓ "Pain in the back of the leg should be reported." 807) The nurse is preparing a subcutaneous dose of bethanechol prescribed for a client with urinary retention. Before giving the dose, the nurse checks to see that which medication is available on the emergency cart for use if needed? ✓ Atropine sulfate 808) The nurse is administering a dose of a prescribed diuretic to an assigned client. The nurse should monitor the client for hypokalemia as a side effect of therapy if the client has been receiving which medication? ✓ Bumetanide 809) The community health nurse is preparing an educational class on ovarian cancer for a group of women. Which signs and symptoms should the nurse include in the presentation? Select all that apply. ✓ Having urinary urgency or frequency ✓ Experiencing pelvic or abdominal swelling 810) The nurse is interviewing a middle-aged woman with a history of fibrocystic disorder of the breasts. Which statements made by the client indicate a need for further teaching? Select all that apply. ✓ "My symptoms will decrease just before menstruation." ✓ "Taking oral contraceptives now will increase my symptoms." 811) The nursing student is asked to discuss information related to the uterus with female high school students. Which statements by the nursing student are accurate? Select all that apply. ✓ "The uterus is a pelvic organ when not pregnant." ✓ "The uterus weighs approximately 2.2 pounds (1000 g) at term pregnancy." ✓ "The uterus weighs approximately 2 ounces (60 g) in the nonpregnant state." ✓ "The uterus is composed of 3 layers: endometrium, myometrium, and perimetrium." 812) A preadolescent client asks the nurse about the onset of puberty. The nurse describes which changes as indicating puberty? Select all that apply. ✓ Mood swings occur. ✓ Pubic hair will develop. ✓ Breast development begins. ✓ Height will increase due to a growth spurt. 813) The nurse presents a seminar on sexually transmitted infections. Which information about syphilis should the nurse include in this presentation? Select all that apply. ✓ A blood test will confirm the diagnosis. ✓ Syphilis signs and symptoms are divided into stages. ✓ Syphilis can be spread through vaginal, anal, or oral sex. 814) The nurse is performing an assessment on a client admitted to the hospital who was diagnosed with toxic shock syndrome (TSS). Which assessment question would assist in eliciting the most specific data regarding the cause of this syndrome? ✓ "Do you use tampons during your menstrual period?" 815) The clinic nurse has provided instructions regarding home care measures to a female client diagnosed with pelvic inflammatory disease (PID). Which statement, if made by the client, indicates an understanding of these measures? ✓ "I need to avoid tight-fitting clothing." 816) A female client is suspected of having a vaginal infection caused by the organism Candida albicans. Which assessment question would elicit data associated with this infection? ✓ "Have you had any vaginal discharge?" 817) The nurse employed in a fertility clinic is providing information to a couple considering in vitro fertilization. The nurse's explanation should most appropriately include which information? Select all that apply. ✓ A fertilized ovum is transferred into the woman's uterus. ✓ Mild spotting or cramping may occur following egg removal. ✓ A medication protocol for follicle development will be prescribed. 818) The nurse is performing an assessment on a client who asks how she might recognize when she is ovulating. The nurse should explain that which occurs at ovulation? Select all that apply. ✓ Breast tenderness ✓ Small amount of vaginal spotting ✓ Lower abdominal pain known as Mittelschmerz ✓ Presence of spinnbarkeit–thin and clear mucous discharge 819) An adolescent seen in the health care clinic has been diagnosed with endometriosis. The client asks the clinic nurse to describe this condition. Which response should the nurse provide? ✓ "It is the presence of tissue outside the uterus." 820) The nurse is providing teaching to a transgender female to male client who will be started on testosterone therapy. Which information should the nurse include in the teaching session? Select all that apply. ✓ Expect the clitoris to enlarge. ✓ Liver enzymes and cholesterol levels will need to be monitored. 821) The instructor asks a nursing student to identify the phases of the ovarian cycle. Which phases identified by the nursing student indicate an understanding of the ovarian cycle? Select all that apply. ✓ Luteal phase ✓ Follicular phase ✓ Ovulatory phase 822) A client with a history of ovarian cysts is seen by the health care provider (HCP). The client has had 2 previous surgeries related to this condition. Her HCP recommends an exploratory laparoscopic procedure for the current ovarian cyst, which has persisted for several months. The client states that the prior ovarian cysts were benign and questions the need for this procedure. Which response is best for the nurse to provide? ✓ "A prolonged ovarian abnormality should be evaluated thoroughly." 823) The client has a regular 32-day cycle. She asks on which day she most likely ovulates. How should the nurse reply? ✓ Day 18 824) A nursing student is doing a presentation on human papillomavirus (HPV) for a young adult group aged 18 to 20 years old. What information should the nursing student include in this presentation? Select all that apply. ✓ "Some forms of HPV can lead to cervical cancer." ✓ "HPV is most commonly spread during vaginal or anal sexual contact." ✓ "In some types, HPV will go away on its own and does not cause health issues." 825) The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action? ✓ Perform a focused respiratory assessment. 826) The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? ✓ A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg 827) The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate? ✓ Continue to monitor the client. 828) The nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement? ✓ Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. 829) The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action? ✓ Hyperoxygenate the client. 830) The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction? ✓ Suctioning the client every hour 831) The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed? ✓ The nurse places 1 finger loosely between the tie and the neck. 832) The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider with this procedure, which is the initial nursing action? ✓ Suction the ET tube. 833) The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. ✓ Water or a kink in the tubing ✓ Biting on the endotracheal tube ✓ Increased secretions in the airway 834) The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is tolerating the procedure if which observation is made? ✓ Coughing occurs with suctioning. 835) A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status? ✓ Respiratory rate of 16 breaths/minute 836) The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. Which co- existing condition in the client may cause an inaccurate pulse oximetry reading? ✓ Hypotension 837) The nurse is monitoring the function of a client's chest tube that is attached to a drainage system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring? ✓ Tidaling is present. 838) A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate? ✓ "That isn't done because people often would develop pneumonia from the constricting effect on the lungs." 839) The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema? ✓ Lung crackles in the remaining lung 840) The nurse reads that a client's tuberculin skin test is positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation? ✓ Exposure to tuberculosis 841) The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which intervention as the best strategy to assist the client in coping with the illness? ✓ Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease. 842) A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client? ✓ This is expected, and the client should gradually increase activity as tolerated. 843) The nurse is assessing a client with the typical clinical manifestations of tuberculosis (TB). During history-taking the nurse anticipates that the client will report presence of cough and fatigue for what period of time? ✓ Several weeks to months 844) The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions for this procedure? Select all that apply. ✓ Keeping a supply of suction catheters at the bedside ✓ Auscultating breath sounds to determine the need for suctioning ✓ Hyperoxygenating the client before, during, and after suctioning 845) The clinic nurse administers a tuberculin skin test to a client. The nurse tells the client to return to the clinic for the results in how long? ✓ 48 to 72 hours 846) A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply. ✓ Suctioning the client as needed ✓ Encouraging coughing every 2 hours ✓ Supporting the neck incision when the client coughs ✓ Monitoring the respiratory status frequently as prescribed 847) The clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse provides which instruction to the client? ✓ Eat foods that are highly seasoned in moderation. 848) A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action? ✓ Assist the client to a sitting position with the head tilted forward. 849) The nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction? ✓ "I should use diluted alcohol on the stoma to clean it." 850) The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? ✓ Aspiration of gastric contents occurs during suctioning. 851) The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm? ✓ Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device. 852) The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? ✓ Displacement of the endotracheal tube 853) The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high- pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication? ✓ A kink in the ventilator circuit 854) A health care provider (HCP) writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The registered nurse determines that the new graduate nurse understands this modality of weaning if which statement is made? ✓ "The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." 855) The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a component of the plan of care with this type of weaning process? Select all that apply. ✓ The T-piece is connected to the client's artificial airway. ✓ The client is removed from the mechanical ventilator for a short period of time. ✓ Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen (FiO2) that is 10% higher than a ventilator setting. 856) The nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 700 mL. How does the nurse interpret this setting? ✓ It is the amount of air delivered with each set breath. 857) The nurse is providing an educational session to community members regarding histoplasmosis. The nurse should provide which information about this disease? ✓ It can be caused by the inhalation of spores from bird droppings. 858) A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse should include which measures in the care of this client? Select all that apply. ✓ Monitor the client's temperature. ✓ Use sterile technique when suctioning. ✓ Use the closed-system method of suctioning. ✓ Monitor sputum characteristics and amounts. 859) A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the HCP's use? ✓ Petrolatum gauze and sterile 4 × 4 gauze 860) The nurse enters a client's room with a pulse oximetry machine and tells the client that the health care provider (HCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry? ✓ It is painless and safe. 861) A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client? ✓ "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation." 862) The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder? ✓ Dyspnea 863) The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water seal chamber has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence? ✓ The chest tube may be obstructed. 864) The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement made by the client indicates a need for further teaching? ✓ "I should remove the chest tube site dressing as soon as I get home." 865) A nursing student is developing a plan of care for a client with a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student? ✓ Instruct the client to avoid coughing and deep breathing. 866) The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat? ✓ Inflate the cuff on the tracheostomy tube. 867) The nurse has provided discharge instructions to the client who has had a pneumonectomy. Which statement, if made by the client, indicates an understanding of appropriate home care measures? ✓ "I should perform arm exercises 2 or 3 times a day." 868) A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse determines that the pain is most likely of a respiratory origin if the client makes which statement about the pain? ✓ "It hurts more when I breathe in." 869) A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies? ✓ Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure 870) The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding? ✓ Accumulation of respiratory secretions 871) The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding? ✓ Disconnection of the ventilator tubing 872) A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. Which response by the nurse is most appropriate? ✓ "Blocked nasal passages impair the sense of smell." 873) A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the health care provider (HCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation? ✓ "It will enter the right main bronchus if inserted too far." 874) A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose? ✓ Humidifies the oxygen that is bypassing the client's nose 875) The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? ✓ Maintain inflation of the alveoli. 876) The nurse and an unlicensed assistive personnel (UAP) are assisting the respiratory therapist to position a client for postural drainage. The UAP asks the nurse how the respiratory therapist selects the position to be used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which primary areas? ✓ Lobes 877) A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client? ✓ Adjust the oxygen depending on SpO2. 878) A client who is experiencing respiratory difficulty asks the nurse, "Why it is so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses? ✓ The respiratory muscles relax 879) A client who has been diagnosed with pleurisy tells the nurse that it is painful to inhale. The nurse responds that this is an expected finding because of which physical response to this disorder? ✓ The inflamed pleurae cannot glide against each other as they normally do. 880) The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The health care provider (HCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence? ✓ Collapse of alveoli and decreased compliance 881) The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur? ✓ The client's arterial blood gas results will reflect acidosis. 882) The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation? ✓ A shunt unit exists. 883) The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action? ✓ Moves downward and out 884) The nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. How does the nurse correctly interpret these findings? ✓ It is at the bifurcation of the right and left main bronchi. 885) The nurse is told that a client will have an arterial blood gas sample drawn on room air. The nurse is asked to complete the laboratory requisition. The nurse documents on the requisition that the client was receiving how much oxygen for the procedure? ✓ 21% 886) The nurse is teaching a client with pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse explains that gas exchange occurs through which process? ✓ Diffusion 887) The nurse is caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse should assess for which characteristic of wound drainage expected in the immediate postoperative period? ✓ Serosanguineous 888) The nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement? ✓ "I will discard used tissues in a plastic bag." 889) The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority? ✓ Contact the health care provider (HCP). 890) A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented? ✓ The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site. 891) The nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment should the nurse plan to have at the bedside when the client returns from surgery? ✓ Obturator 892) The nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse should plan to perform which action? ✓ Suction the client. 893) The nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube drainage system. Which nursing action is appropriate? ✓ Document the findings. 894) The nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate? ✓ Notify the health care provider (HCP). 895) The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette- Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation should the nurse make? ✓ The client's test result will be positive, and a chest x-ray study will be required for evaluation. 896) A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action? ✓ Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed. 897) A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding? ✓ Absence of dyspnea 898) A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse should assess the client for which signs and symptoms associated with this problem? ✓ Pleural pain and fever 899) A client with long-standing empyema undergoes decortication of the affected lung area. Postoperatively the nurse should place the client in which position? ✓ Semi Fowler's 900) A client who experiences allergic rhinitis asks the nurse about a nasal corticosteroid. How should the nurse reply? ✓ "The medication works locally and decreases inflammation." 901) The nurse assesses for one-sided chest movement on the right while a client is being intubated by the health care provider. Which could occur with the endotracheal tube? ✓ It could enter the right main bronchus if inserted too far. 902) The nurse is assisting a radiologist to facilitate a thoracentesis. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area? ✓ Pleural space 903) A client's baseline vital signs are as follows: temperature 98.8°F (37.1°C) oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103°F (39.4°C). Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status? ✓ Respiratory rate of 22 breaths/min 904) The nurse is caring for a dyspneic client with decreased breath sounds. The nurse should carry out which intervention to decrease the client's work of breathing? ✓ Administer the prescribed bronchodilator. 905) The nurse is instructing a client in diaphragmatic breathing. To reinforce the need for this technique, the nurse teaches the client that in normal respiration, which is an action of the diaphragm? ✓ Moves downward and out as it contracts 906) Which are possible causes of upper airway obstruction? Select all that apply. ✓ Laryngeal edema ✓ Head and neck cancer ✓ Foreign body aspiration ✓ Lymph node enlargement 907) A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location? ✓ Just under the left clavicle 908) A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. Which item(s) should the nurse place at the client's bedside? ✓ Intubation tray 909) A client begins to experience drainage of small amounts of bright red blood from the tracheostomy tube 24 hours after a supraglottic laryngectomy. Which is the best nursing action? ✓ Notify the health care provider (HCP). 910) The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action should the nurse perform prior to reinserting the inner cannula? ✓ Allow the inner cannula to dry after washing it with sterile water. 911) An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse would expect to note which assessment findings in this client? Select all that apply. ✓ Anosmia ✓ Chronic cough ✓ Purulent nasal discharge 912) A clinic nurse notes that large numbers of clients present with flulike symptoms. Which recommendations should the nurse include in the plan of care for these clients? Select all that apply. ✓ Get plenty of rest. ✓ Increase intake of liquids. ✓ Take antipyretics for fever. ✓ Eat fruits and vegetables high in vitamin C. 913) The nurse is providing care for a client recently admitted with new onset pleurisy. Upon auscultation of the client's lungs, the nurse notes the absence of the pleural friction rub, which was documented on previous assessments. What is the most likely indication for this change in the client's lung sounds? ✓ Accumulation of pleural fluid in the inflamed area 914) The nurse is performing a cardiovascular assessment on a client. Which parameter would the nurse assess to gain the best information about the client's left-sided heart function? ✓ Breath sounds 915) The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? ✓ A 73-year-old woman who has just had pinning of a hip fracture 916) The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation? ✓ Rapid, shallow respirations 917) The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client with this goal. Which client statement indicates that further instruction is needed? ✓ "I will lie on the affected side for an hour." 918) The client is admitted to the hospital with a diagnosis of Legionnaires' disease. The nurse is providing information on the disease and treatment expectations. Which statement by the client indicates an understanding of the disease and treatments? ✓ "I cannot give Legionnaires' disease to other people." 919) The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate? ✓ Provide nasotracheal suctioning as needed to remove secretions. 920) A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority? ✓ Inability to clear the airway related to inability to expectorate sputum 921) The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing? ✓ Lying on the back in a low Fowler's position 922) The nurse should provide which home care instructions to a client who had a laryngectomy and has a stoma? Select all that apply. ✓ Increase the humidity in the home. ✓ Obtain and wear a MedicAlert bracelet. ✓ Stay away from people who have a respiratory infection. ✓ Be careful with showering to avoid water entering the stoma. 923) The client is returned to the nursing unit following thoracic surgery with a chest tube in place. During the first few hours postoperatively, the nurse assesses for drainage and expects to note which characteristics? ✓ The drainage is bloody. 924) The client who has had radical neck dissection begins to hemorrhage at the incision site. Which immediate actions should the nurse take? Select all that apply. ✓ Monitor the client's airway. ✓ Call the Rapid Response Team. ✓ Call the health care provider (HCP). ✓ Apply manual pressure over the site. 925) The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which is the most appropriate action? ✓ Document the findings. 926) The nurse is caring for the client who is suspected of having lung cancer. The nurse should assess the client for which most frequent early symptom of lung cancer? ✓ Cough 927) The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What should the nurse expect to note in the client? ✓ Low arterial PaO2 928) The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply. ✓ Cough ✓ Dyspnea ✓ Chills and night sweats 929) A client with silicosis is being monitored yearly at the health care clinic. On assessment, the nurse should ask the client about which manifestations of the disorder? Select all that apply. ✓ Fatigue ✓ Malaise ✓ norexia 930) A client tells the nurse that the health care provider (HCP) has stated a diagnosis of silicosis. The nurse determines that which finding is consistent with this respiratory disorder? ✓ The client has reduced lung volume and fibrosis on chest x-ray. 931) The nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How should the nurse interpret the result? ✓ Negative 932) A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism? ✓ Dyspnea 933) The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate? ✓ Increase to 3 L/min and titrate until the SpO2 is 88%. 934) The nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse should determine that which client on the nursing unit is at the lowest risk for infection with tuberculosis? ✓ A man who is an inspector for the U.S. Postal Service 935) The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The health care provider has recommended nicotine gum. When reviewing this treatment with the client, the nurse should provide which instruction? ✓ Hold the gum between the cheek and teeth periodically. 936) A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse should take which action? ✓ Determine if there are any disconnections in the ventilator tubing. 937) A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action should the nurse take to eliminate the problem? ✓ Empty excess accumulated water from the ventilatory circuit tubing. 938) The nurse determines that the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this? ✓ Continuous bubbling is observed in the water seal chamber during inspiration and expiration. 939) Which should the nurse do when caring for a client with a chest tube attached to a chest drainage system? ✓ Ensure the water level in the water seal chamber is at the 2- cm level. 940) The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted? ✓ Rhonchi are auscultated. 941) A client is returning from surgery after a pulmonary lobectomy. Which pieces of equipment should the nurse have at the bedside? Select all that apply. ✓ Clamp ✓ Vaseline gauze ✓ Suction equipment 942) A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? ✓ Plan short sessions with the client to obtain data. 943) Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. ✓ Teach the client techniques of chest physiotherapy. ✓ Encourage alternating activity with rest periods. ✓ Teach diaphragmatic and pursed-lip breathing. 944) A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. ✓ Dyspnea at rest ✓ Clubbed fingers ✓ Muscle retractions ✓ Prolonged expiratory breathing phase 945) Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)? ✓ Tripod position 946) A client with an endotracheal tube attached to mechanical ventilation begins to cough, and the client's face appears flushed. Which action should the nurse take first? ✓ Suction the client through the endotracheal tube. 947) The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation? ✓ The chest tube is functioning as expected. 948) The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? ✓ Call the health care provider. 949) The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly? ✓ The client breathes out slowly through the mouth. 950) The nurse is performing an admission assessment on a client with tuberculosis (TB) and is collecting subjective and objective data. Which finding would the nurse expect to note? ✓ Complaints of night sweats 951) The nurse is performing a respiratory assessment on a client with a left lower lobe lung mass. Chest auscultation over the posterior left lower lobe reveals these breath sounds. The nurse would interpret this as which sound? Play Sound ✓ Bronchial breath sounds 952) An emergency department nurse is performing a respiratory assessment on a client who is complaining of painful breathing. On palpation the nurse notes a coarse grating sensation during inspiration, and on auscultation the nurse hears this breath sound. The nurse interprets these findings as characteristic of which condition? Play Sound ✓ Pleurisy 953) The nurse is auscultating breath sounds in a hospitalized client with emphysema and hears these sounds. The nurse should document this finding as which sound? Play Sound ✓ High-pitched wheezes 954) A client is experiencing severe dyspnea, and the nurse listens to the client's breath sounds and hears this sound. The nurse should document this finding as which sound? Play Sound ✓ Stridor 955) The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. The nurse determines that these breath sounds are usually caused by which condition? Stop Sound ✓ Opening of small airways that contain fluid 956) Which are warning signs of head and neck cancer? Select all that apply. ✓ Difficulty swallowing ✓ Lump in the mouth, neck, or throat ✓ Persistent or unexplained oral bleeding 957) The nurse providing instructions to a client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. What statement by the client indicates successful teaching? ✓ "It will keep the small airways open." 958) The nurse is providing education to a group of adolescents diagnosed with asthma. The nurse informs the group that which can be triggers for an asthma attack? Select all that apply. ✓ Dry air ✓ Exercise ✓ An upper respiratory infection (URI ✓ Nonsteroidal antiinflammatory drugs (NSAIDs 959) The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The health care provider states that because of fluid in the alveoli, surfactant production is falling. The nurse anticipates that insufficient surfactant will cause which effect? ✓ Collapse of alveoli and decreased compliance 960) The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings? ✓ pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L 961) The nurse is caring for a client with a dry suction chest drainage system. During assessment of the drainage system, what should the nurse expect to find? Select all that apply. ✓ The dry suction control regulation set to the prescribed amount ✓ The drainage in the collection chamber marked each shift to monitor the amount of drainage ✓ The nurse should determine that tracheal suctioning is needed if which is noted? ✓ Congested breath sounds in the lung fields 962) A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client? ✓ Hyperinflation of lungs documented by chest x-ray 963) The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching on positioning? ✓ Lying on the back in a low Fowler's position 964) The nurse is assisting the health care provider (HCP) with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse should take which action? ✓ Document the accurate functioning of the tube. 965) A health care provider (HCP) is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the health care provider should ask the client to perform which procedure? ✓ Take a deep breath and hold it. 966) The nurse is assisting in caring for a client after removal of an endotracheal tube. Which finding should be reported to the health care health care provider (HCP) immediately? ✓ Stridor 967) The nurse is doing volunteer work in a homeless shelter. The nurse should monitor the individuals for which initial signs and symptoms of tuberculosis? Select all that apply. ✓ Fatigue ✓ Lethargy ✓ Morning cough ✓ Low-grade fever 968) The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. How should the nurse interpret this finding? ✓ There is an air leak somewhere in the system. 969) The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. Which instructions should the nurse include? Select all that apply. ✓ Sit upright in the bed or in a chair. ✓ Place the mouthpiece in your mouth and seal your lips tightly around it. ✓ After maximum inspiration, hold the breath for 2 to 3 seconds and exhale. 970) The nurse is administering a dose of pirbuterol to a client. The nurse should monitor for which side or adverse effect of this medication? ✓ Increased pulse 971) Ribavirin is prescribed for a hospitalized child with severe respiratory syncytial virus (RSV). The nurse prepares to administer this medication via which route? ✓ Oxygen tent 972) Isoniazid is prescribed for a child with human immunodeficiency virus (HIV) infection who has a positive tuberculin skin test result. The mother of the child asks the nurse how long the child will need to take the medication. For how long should the nurse tell the mother the medication will need to be taken? ✓ 12 months 973) A client with an exacerbation of chronic obstructive pulmonary disease (COPD) has been on oral glucocorticoids and is currently being weaned to triamcinolone by inhalation. The nurse determines that the client understands the potential adverse effects to watch for during this medication change when the client states the need to report which signs and symptoms? ✓ Anorexia, nausea, weakness, and fatigue 974) A client diagnosed with active tuberculosis has been prescribed a combination of isoniazid and rifampin for treatment. The nurse teaches the client to perform which action? ✓ Take both medications together once a day. 975) A client with tuberculosis receiving cycloserine orally twice daily must have blood drawn in 1 week to measure the serum concentration of the medication. The nurse prepares the client for this test by providing which information to the client? ✓ Take the morning dose and have the blood drawn 2 hours after taking the dose. 976) A client with a documented exposure to tuberculosis is on medication therapy with isoniazid. The nurse is monitoring laboratory results and determines that which laboratory value indicates the need for follow-up? ✓ Aspartate aminotransferase (AST) 55 U/L (55 U/L 977) A client has begun a course of therapy with rifampin. The home care nurse instructs the client on which measure due to an anticipated side effect? ✓ Wear dark clothing to avoid staining. 978) A client is taking a prescribed course of therapy with ethambutol. The home health nurse assesses the client at each home visit for which adverse effect of this medication? ✓ Visual disturbances 979) The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving theophylline. The nurse monitors the serum theophylline level and concludes that the medication dosage may need to be increased if which value is noted? ✓ 5 mg/mL (20 mcmol/L) 980) The nurse is administering a dose of morphine sulfate to a client via an epidural catheter after nephrectomy. Before administering the medication, what should the nurse plan to do? ✓ Ensure that naloxone is readily available. 981) A client has been given a prescription for benzonatate. Which observation should the nurse look for to evaluate the effectiveness of the medication? ✓ Calming the client's persistent cough 982) A client has begun using a methylxanthine bronchodilator. What beverage should the nurse plan to teach the client to avoid while taking this medication? ✓ Coffee 983) A client taking albuterol by inhalation cannot cough up secretions. What should the nurse suggest that the client do to assist in expectoration of secretions? ✓ Drink increased amounts of fluids every day. 984) A client who has been receiving theophylline by the intravenous (IV) route has the medication prescription changed to an immediate-release oral form of the medication. After discontinuing the IV medication, when should the nurse schedule the first dose of the oral medication? ✓ 4 hours after discontinuing the IV form 985) A client has been taking pyrazinamide for 6 months. The nurse determines that the medication is effective if which cultures yield a negative result? ✓ Sputum 986) A client with a prescription to take theophylline daily has been given medication instructions by the nurse. What statement by the client indicates the need for further education regarding the prescription? ✓ "I will take the daily dose at bedtime." 987) A client with tuberculosis (TB) has a prescription for rifampin. What instruction should the nurse include in the client's teaching plan? ✓ Wearing glasses instead of soft contact lenses will be necessary. 988) Cromolyn sodium is prescribed for the client with allergic asthma. What goal does the nurse expect to achieve by administration of this medication? ✓ Inhibition of the release of mediators from mast cells after exposure to an antigen 989) A client has been taking pyrazinamide for 1 month. The client asks the nurse whether the therapy is due to be terminated soon. The nurse determines that the medication probably will be continued based on a positive finding in which report? ✓ Sputum culture 990) A client has a prescription to take guaifenesin. The nurse should conclude that the client understands the most effective use of this medication if the client states that they need to take which action? ✓ Take the tablet with a full glass of water. 991) The nurse is preparing to administer albuterol to a client. Which parameters should the nurse assess before and during therapy? ✓ Lung sounds and presence of dyspnea 992) A home care nurse has observed a client self-administer a dose of an adrenergic bronchodilator via metered-dose inhaler. Within a short time, the client begins to wheeze loudly. The nurse understands that this is the result of which occurrence? ✓ Paradoxical bronchospasm, which must be reported to the health care provider (HCP) 993) A client receiving oral theophylline is due to have a theophylline level drawn. The nurse should question the client to ensure that the client has not ingested which substance before the blood sample is drawn? ✓ Coffee 994) The nurse has administered a dose of salmeterol to a client. The client develops a generalized rash and urticaria, and the eyelids begin to swell. Which action should the nurse take? ✓ Call the health care provider (HCP) immediately. 995) A client taking rifampin reports, "My urine has blood in it." When the nurse assesses the urine, it is brown. Which is the nurse's best action? ✓ Chart the finding as a normal response to the rifampin. 996) A clinic nurse is assessing a client who has been on isoniazid for 6 months. Which client complaint should most concern the nurse? ✓ Difficulty tying shoes 997) The client questions the nurse as to why the health care provider switched the usual prescription from a metered-dose inhaler (MDI) to a dry powder inhaler (DPI). The nurse should respond correctly by providing which facts? Select all that apply. ✓ Dry powder inhalers pose no environmental risks. ✓ Dry powder inhalers deliver more medication to the lungs. ✓ Dry powder inhalers require less hand- to-lung coordination. 998) Which statement made by a client taking montelukast indicates the need for further teaching? ✓ "I will take the medication when I first notice I am having trouble breathing." 999) When evaluating an asthmatic client's knowledge of self-care, the nurse recognizes that additional instruction is needed when the client makes which statement? ✓ "I use my corticosteroid inhaler each time I feel short of breath." 1000) Which are risk factors for chronic obstructive pulmonary disease (COPD)? Select all that apply. ✓ Cigarette smoking ✓ Genetic risk factor ✓ Environmental factors ✓ Alpha-1 antitrypsin (AAT) deficiency 1001) Which is the nurse's priority assessment for monitoring for adverse effects for the client taking isoniazid? ✓ Urine color [Show More]

Last updated: 1 year ago

Preview 1 out of 159 pages