front 1 A NURSE IS CARING FOR A CLIENT WHO HAS BEEN APPLYING SILVER SULFADIAZINE CREAM TO A DEEP PARTIAL THICKNESS ARM BURN FOR THE PAST 2 WEEKS. THE NURSE SHOULD MONITOR THE CLIENT FOR WHICH OF THE FOLLOWING ADVERSE EFFECTS? | back 1 LEUKOPENIA AN ADVERSE EFFECT OF SILVER SULFA. THE NURSE SHOULD MONITOR THE CLIENTS ALLERGIC REACTION CAUSING A DECREASE IN THE CLIENTS WBC COUNT |
front 2 A NURSE IS CONTRIBUTING TO THE PLAN OF CARE FOR A CLIENT WHO HAS BEEN ADMITTED FOR TREATMENT OF A MALIGNANT MELANOMA OF THE UPPER LEG WITHOUT METASTASIS. THE NURSE SHOULD EXPECT THE PROVIDER TO PERFORM WHICH OF THE FOLLOWING PROCEDURES? | back 2 SURGICAL EXCISION THE TREATMENT OF CHOICE FOR SMALL, SUPERFICIAL LESIONS. DEEPER LESIONS REQUIRE WIDE LOCAL EXCISION, FOLLOWED BY SKIN GRAFTING |
front 3 A NURSE IS CARING FOR A CLIENT WHOSE WOUNDS ARE COVERED WITH A HETEROGRAFT DRESSING. IN RESPONSE TO THE CLIENT'S QUESTIONS ABOUT THE DRESSING, THE NURSE EXPLAINS THAT IT IS OBTAINED FROM WHICH OF THE FOLLOWING SOURCES? | back 3 PIG SKIN HETEROGRAFTS ARE OBTAINED FROM AN ANIMAL, USUALLY A PIG |
front 4 A NURSE IS CARING FOR A CLIENT WHO HAS A LESION ON THE BACK OF HIS RIGHT HAND. THE CLIENT ASKS THE NURSE WHICH TYPE OF SKIN CANCER IS THE MOST SERIOUS. WHICH OF THE FOLLOWING RESPONSES SHOULD THE NURSE MAKE ? | back 4 MELANOMAS. MALIGNANT NEOPLASMS WITH ATYPICAL MELANOCYTES IN BOTH THE EPIDERMIS, THE DERMIS, AND SOMETIMES THE SUBQ CELLS. IT IS THE MOST LETHAL TYPE OF SKIN CANCER. OFTEN CAUSING METASTASES IN THE BONE, LIVER, LUNGS, SPLEEN , CNS AND THE LYMPH NODES. |
front 5 A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO HAS BURN INJURIES TO HIS TRUNK ABOUT WHAT TO EXPECT FROM THE PRESCRIBED HYDROTHERAPY. WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT INDICATES AN UNDERSTANDING OF THE TEACHING? | back 5 " I WILL BE ON A SPECIAL SHOWER TABLE" HYDROTHERAPY IS A SPECIAL SHOWER TABLE THAT FACILITATES THE EXAMINATION AND DEBRIDEMENT OF THE WOUND. ADVANTAGES: THE WATER CAN BE KEPT AT A CONSTANT TEMPERATURE AND THERE IS A LOWER RISK OF WOUND INFECTION. |
front 6 A NURSE IS ASSISTING WITH THE ADMISSION OF A CLIENT WHO IS BEDRIDDEN AND WAS ADMITTED FROM HOME. THE NURSE NOTES A SHALLOW CRATER IN THE EPIDERMIS OF THE CLIENTS SACRAL AREA. THE NURSE SHOULD DOCUMENT THAT THE CLIENT HAS A PRESSURE ULCER AT WHAT OF THE FOLLOWING STAGES? | back 6 STAGE 2 - PARTIAL THICKNESS SKIN LOSS - VISIBLE AND SUPERFICIAL - CAN APPEAR AS A BLISTER, ABRASION, OR SHALLOW CRATER - EDEMA PERSISTS AND THE ULCER CAN BECOME INFECTED. - MIGHT REPORT PAIN AND DRAINAGE |
front 7 A NURSE IS ASSISTING WITH THE CARE OF A CLIENT WHO IS IN THE RESUSCITATION PHASE FOLLOWING A MAJOR BURN. WHICH OF THE FOLLOWING LABORATORY FINDINGS SHOULD THE NURSE EXPECT. | back 7 SODIUM 132 MEq/L SHOULD ANTICIPATE CLIENT TO HAVE A LOW SODIUM LEVEL BECAUSE SODIUM IS TRAPPED IN INTERSTITIAL SPACE |
front 8 A NURSE IS COLLECTING DATA FROM A CLIENT WHO SUSTAINED SUPERFICIAL PARTIAL THICKNESS AND DEEP PARTIAL THICKNESS BURNS 72 HOURS AGO. WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE REPORT TO THE PROVIDER? | back 8 TEMPERATURE OF 39.1 (102.4) - ELEVATED TEMP INDICATES INFECTION - SEPSIS IS CRITICAL FINDING FOLLOWING A MAJOR BURN |
front 9 A NURSE IS ASSISTING WITH THE DEVELOPMENT OF A PROGRAM TO EDUCATE CLIENTS ABOUT MEASURES TO REDUCE THE RISK OF SKIN CANCER. WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD THE NURSE INCLUDE. | back 9 AVOID EXPOSURE TO THE MIDDAY SUN - AVOID CONTACT BETWEEN 1100 AND 1500 BECAUSE SUN RAYS ARE THE STRONGEST DURING THAT TIME |
front 10 A NURSE IN A PROVIDERS OFFICE IS CARING FOR A CLIENT WHO HAS A NEW DIAGNOSIS OF HERPES ZOSTER. THE NURSE SHOULD ANTICIPATE A PRESCRIPTION FOR WHICH OF THE FOLLOWING MEDICATIONS? | back 10 ACYCLOVIR - ANTIVIRAL MEDICATION - INHIBITS REPLICATION OF THE VIRUS THAT CAUSES HERPES ZOSTER |
front 11 A NURSE IS ASSISTING WITH THE DEVELOPMENT OF AN EDUCATION SESSION ABOUT MALIGNANT MELANOMA FOR A GROUP OF CLIENTS. THE NURSE SHOULD INCLUDE THAT WHICH OF THE FOLLOWING CLIENTS HAS AN INCREASED RISK FOR DEVELOPING MALIGNANT MELANOMA | back 11 A CLIENT WHO HAS A LIGHT COMPLEXION - A LIGHT COMPLEXION HAS LESS PIGMENTATION |
front 12 A NURSE IS COLLECTING DATA FROM A CLIENT WHO HAS AN ARM LESION. WHICH OF THE FOLLOWING CHARACTERISTICS IS A CLINICAL MANIFESTATION OF A MALIGNANT MELANOMA | back 12 IRREGULARLY SHAPED WITH BLUE TONES - MALIGNANT MELANOMAS ARE IRREGULARLY SHAPED AND CAN BE BLUE, RED, OR WHITE IN TONE. - OFTEN OCCUR ON UPPER BACK AND LOWER LEGS |
front 13 A NURSE IS REINFORCING DISCHARGE TEACHING WITH A CLIENT WHO IS POSTOPERATIVE FOLLOWING A SURGICAL EXCISION OF A BASAL CELL CARCINOMA. WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE INCLUDE AS AN INDICATION OF MALIGNANCY OF A MOLE? | back 13 ULCERATION - BLEEDING , EXUDATION ARE INDICATIONS OF A MOLES POTENTIAL MALIGNANCY - INCREASING IN SIZE - FOLLOW UPS AND PROPER TECHNIQUES FOR SELF EXAMINATION |
front 14 A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO IS WHEELCHAIR BOUND AND HIS CAREGIVER ABOUT WAYS TO REDUCE THE RISK OF PRESSURE ULCER FORMATION. WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD THE NURSE INCLUDE? | back 14 SHIFT YOUR WEIGHT IN THE WHEELCHAIR EVERY 15 MINUTES - THIS RESPONSE ADDRESSES THE SAFETY ISSUE OF PRESSURE ULCER RISK - MOST LIKELY TO DEVELOP IF THE CLIENT DOES NOT SHIFT POSITION FREQUENTLY TO RELIEVE PRESSURE |
front 15 A NURSE ON A SURGICAL UNIT IS CARING FOR FOUR CLIENTS WHO HAVE HEALING WOUNDS. WHICH OF THE FOLLOWING WOUNDS SHOULD THE NURSE EXPECT TO HEAL BY PRIMARY INTENTION? | back 15 SURGICAL INCISION A WOUND THAT HEALS BY PRIMARY INTENTION |
front 16 PRIMARY INTENTION | back 16 A CLEAN WOUND THAT IS CLOSED MECHANICALLY WITH WELL APPROXIMATED EDGES AND MINIMAL SCARRING |
front 17 A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO HAS A LARGE WOUND HEALING BY SECONDARY INTENTION. THE NURSE SHOULD INSTRUCT THE CLIENT THAT WHICH OF THE FOLLOWING NUTRIENTS PROMOTES WOUND HEALING? | back 17 VITAMIN C |
front 18 A NURSE IS CARING FOR AN ADOLESCENT CLIENT WHO HAS BURN WOUNDS ON HER FACE AND HANDS. WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT INDICATES THAT SHE HAS ADAPTED TO HER CHANGED BODY IMAGE? | back 18 " MAY I GO WITH MY FAMILY TO THE VISITORS LOUNGE?" |
front 19 A NURSE IS OBSERVING THE SKIN OF A CLIENT WHO HAS FROSTBITE. THE CLIENT HAS A SMALL BLISTER THAT CONTAIN BLOOD AND THE SKIN OF THE AFFECTED AREA DOES NOT BLANCH. THE NURSE SHOULD CLASSIFY THIS INJURY AS WHICH OF THE FOLLOWING? | back 19 3 DEGREE FROSTBITE
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front 20 A NURSE IN A PROVIDERS OFFICE IS COLLECTING DATA FROM A CLIENT WHO HAS SKIN LESIONS. THE NURSE NOTES THAT THE LESIONS ARE 0.5CM (0.20IN) IN SIZE, ELEVATED, AND SOLID, WITH VERY DISTINCT BORDERS. THE NURSE SHOULD DOCUMENT THE FINDINGS AS WHICH OF THE FOLLOWING SKIN LESIONS? | back 20 PAPULES
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front 21 A NURSE IN AN URGENT CARE CLINIC IS CARING FOR A CLIENT WHO HAS A SNAKEBITE ON HER ARM. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE? | back 21 IMMOBILIZE THE LIMB AT THE LEVEL OF THE HEART
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front 22 THE HEALTH CARE PROVIDER HAS ORDERED ORAL GRISEOFULVIN OF TINEA CAPITIS. THE PATIENT'S MOTHER ASKS THE NURSE WHY AN ORAL MEDICATION IS USED RATHER THAN A CREAM. WHAT INFORMATION SHOULD BE PROVIDED BY THE NURSE? | back 22 TOPICAL CREAMS DO NOT REACH THE ROOT OF THE HAIR TO KILL FUNGUS |
front 23 THE NURSE IS CARING FOR A PATIENT WITH AN OPEN SKIN LESION. WHAT IS THE PATIENT GOAL WITH HIGH PRIORITY? | back 23 THE PATIENT DOES NOT DEVELOP AN INFECTION OF THE LESION |
front 24 WHAT ASSESSMENT SHOULD THE NURSE REPORT TO THE HEALTH CARE PROVIDER IMMEDIATELY FOR AN ADULT PATIENT WITH PARTIAL THICKNESS BURNS OVER 25% OF HIS BODY? | back 24 HOURLY URINARY OUTPUT OF 10 TO 15 ML |
front 25 A PATIENT HAS A RASH ON HER BACK THAT BEGAN ABOUT 10 DAYS AGO WITH A RAISED, SCALY BORDER AND A PINK CENTER. NOW SHE HAS A SIMILAR ERUPTION ON BOTH SIDES OF HER BACK. WHAT CONDITION MIGHT SHE HAVE? | back 25 PITYRIASIS ROSEA |
front 26 A PATIENT COMPLAINS OF A BURMNING PAIN ON HIS LOWER THORACIC AREA. ON INSPECTION, THE AREA IS FOUND TO BE ERYTHEMATOUS AND EDEMATOUS WITH A CLUSTER OF VESICLES. WHAT CONDITION IS MOST LIKELY TO BE DIAGNOSED? | back 26 HERPES ZOSTER |
front 27 A PATIENT STATES THAT HE HAS BASAL CELL CARCINOMA AND IS GOING TO DIE. WHEN PLANNING THE BEST RESPONSE TO MAKE, THE NURSE SHOULD INCLUDE WHAT KNOWLEDGE? | back 27 BASAL CELL CARCINOMA IS RARELY TERMINAL |
front 28 IT IS IMPORTANT TO TEACH A PATIENT THE WARNING SIGNS OF SKIN CANCER. WHICH CHARACTERITICS OF A NEVUS IS A WARNING SIGN OF SKIN CANCER? | back 28
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front 29 A PATIENT HAS AN INHALATION BURN INJURY. WHICH IS A MEDICAL EMERGENCY? | back 29 RESPIRATORY STRIDOR |
front 30 WHAT METHOD OF ASSESSING BURN SIZE APPLIES ONLY TO ADULTS? | back 30 RULE OF NINES |
front 31 THE NURSE JUST FINISHED AN ASSESSMENT FOR A PATIENT WITH SYSTEMIC LUPUS E. WHAT CLINICAL MANIFESTATION WOULD THE NURSE EXPECT TO FIND? | back 31
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front 32 THE HEALTH CARE PROVIDER HAS SCHEDULED A DEBRIDEMENT FOR A PATIENT WHO HAS PARTIAL THICKNESS BURNS ON HIS CHEST AND RIGHT UPPER LEG. WHICH NURSING INTERVENTION IS MOST IMPORTANT? | back 32 ADMINISTER AN OPIOIOD ANALGESIC INTRAVENOUSLY BEFORE THE DEBRIDEMENT |
front 33 A PATIENT IS ADMITTED WITH PARTIAL AND FULL THICKNESS BURNS ON HIS RIGHT LOWER EXTREMITY. WHAT IS LIKELY TO BE INCLUDED IN THE PLAN OF CARE INITIALLY? | back 33 CLOSED DRESSING CHANGE EVERY 3 HOURS |
front 34 A PATIENT IS ADMITTED WITH PARTIAL THICKNESS BURNS ON HIS UPPER CHEST AND FACE. WHAT IS THE MOST IMPORTANT THING FOR THE NURSE TO MONITOR IN THE PATIENT ON ADMISSION? | back 34 RESPIRATORY PROBLEMS |
front 35 WHAT SHOULD BE INCLUDED IN THE ASSESSMENT OF A PATIENT WITH AN ELECTRICAL BURN? | back 35 CARDIAC IRREGULARITIES |
front 36 A PATIENT IS ADMITTED WITH HERPES ZOSTER. THE HEALTH CARE PROVIDER ORDERS AN ANTIVIRUL MEDICATION TO SLOW THE PROGRESSION OF THE VIRUS. WHICH MEDICATION WITH THE NURSE ADMINISTER? | back 36 ACYCLOVIR (ZOVIRAX) |
front 37 A PATIENT HAS BEEN DIAGNOSED WITH SCABIES. WHAT WILL THE NURSE ANTICIPATE TO ASSESS WITH THIS PATIENT? | back 37
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front 38 AN ADOLESCENT PATIENT IS SEEN IN THE CLINIC WITH A MILD CASE OF ACNE. WHAT DOES THE NURSE EXPECT TO ASSESS? | back 38 THE PATIENT REPORTS A SENSE OF LOW SELF ESTEEM |
front 39 A PATIENT WITH THERMAL BURNS OVER 30% OF HIS BODY HAS MAINTAINED A URINARY OUTPUT OF 250 ML FOR THE PAST 8 HOURS. WHAT CAN THE NURSE INFER FROM THIS INFORMATION? | back 39 STAGE OF HYPOVOLEMIC BURN SHOCK IS RESOLVING |
front 40 A PATIENT TELLS THE NURSE SHE HAS NOT GONE OUT OF THE HOUSE FOR WEEKS BECAUSE SHE COULD NOT COVER LESIONS ON HER FACE WITH MAKEUP. WHAT WOULD BE AN APPROPRIATE PATIENT PROBLEM? | back 40 DISTORED BODY IMAGE, RELATED TO CHANGE IN PERSONAL APPEARANCE |
front 41 WHEN TEACHING A PATIENT TO CARE FOR HERPES ZOSTER LESIONS AT HOME, WHAT IS THE MOST IMPORTANT INSTRUCTION FOR THE NURSE TO PROVIDE? | back 41 WHAT HANDS BEFORE AND AFTER APPLYING MEDICATION |
front 42 THE NURSE IS REVIEWING THE HISTORY FOR A PATIENT WHO HAS BEEN ADMITTED WITH CELLUITIS. WHAT CONDITIONS WOULD PREDISPOSE THE PATIENT TO CELLULITIS? | back 42
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front 43 A PARENT TELLS THE DERMATOLOGISTS THAT HER DAUGHTER SEEMS TO BE LOOSING INTEREST IN SCHOOL/ WHICH MEDICATION COULD HAVE CAUSED THE PATIENTS CHANGE IN BEHAVIOR | back 43 ISOTRETINOIN |
front 44 AN AFRICAN AMERICAN PATIENT IS SEEN WITH IMPENDING SHOCK AFTER AN ACCIDENT. HOW WOULD THE NURSE EXPECT THE SKIN TO APPEAR DURING THE ASSESSMENT OF THE PATIENT? | back 44 ASHEN, GRAY, OR DULL |
front 45 THE NURSE PLANNING THE CARE FOR A PATIENT WHO HAS IMPETIGO EXPECTS TO ADMINISTER WHAT TOPICAL DRUG TO THE PATIENT ? | back 45 RETAPAMULIN |
front 46 WHEN TEACHING HOME CARE TO A PATIENT WITH RECURRENT GENITAL HERPES INFECTION. IT IS IMPORTANT TO INCLUDE WHAT INFORMATION? | back 46
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front 47 A NURSE IN A DEMATOLOGY CLINCIC IS USING THE ABCDE METHOD WHILE SCREENING SEVERAL OF A CLIENTS SKIN LESIONS FOR SKIN CANCER. WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE REPORT TO THE PROVIDER | back 47 COLOR VARIATION WITHIN A LESION |
front 48 A NURSE IS ASSISTING WITH THE DEVELOPMENT OF A PROGRAM TO EDUCATE CLIENTS ABOUT MEASURES TO REDUCE RISK OF SKIN CANCER. WHAT INSTRUCTIONS SHOULD THE NURSE INCLUDE ? | back 48 AVOID EXPOSURE TO THE MIDDAY SUN |
front 49 A NURSE IN A PROVIDER'S OFFICE IS COLLECTING DATA FROM A CLIENT WHO HAS SKIN LESIONS. THE NURSE NOTES THAT THE LESIONS ARE 0.5 (0.20 IN) IN SIZE, ELEVATED, AND SOLID WITH DISTINCT BORDERS. THE NURSE SHOULD DOCUMENT THESE FINDINGS AS WHICH OF THE FOLLOWING SKIN LESIONS ? | back 49 PAPULES |
front 50 A NURSE IS SCREENING A CLIENT FOR SKIN CANCER. WHEN REINFORCING TEACHING WITH THE CLIENT ABOUT SKIN CANCER RISK, WHICH OF THE FOLLOWING RISK FACTORS SHOULD THE NURSE INCLUDE ? | back 50 EXCESSIVE EXPOSURE TO ULTRAVIOLET LIGHT |
front 51 A NURSE IS REINFORCING TEACHING WITH A GROUP OF CLIENTS ABOUT SKIN CANCER. THE NURSE SHOULD EXPLAIN THAT BASAL CELL CARCINOMA ORIGINATES FROM WHICH OF THE FOLLOWING TISSUES? | back 51 EPIDERMIS |
front 52 A NURSE IS CARING FOR AN ADOLESCENT CLIENT WHO HAS BURN WOUNDS ON HER FACE AND HANDS. WHAT STATEMENT BY THE CLIENT INDICATES THAT SHE HAS ADAPTED TO HER CHANGED BODY IMAGE? | back 52 MAY I GO WITH MY FAMILY TO THE VISITORS LOUNGE? |
front 53 A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO HAS A LARGE WOUND HEALING BY SECONDARY INTENTION. THE NURSE SHOULD INSTRUCT THE CLIENT THAT WHICH OF THE FOLOOWING NUTRIENTS PROMOTES WOUND HEALING | back 53 VITAMIN C |
front 54 A NURSE IS ASSISTING WITH THE ADMISSION OF A CLIENT WHO IS BEDRIDDEN AND WAS ADMITTED FROM HOME. THE NURSE NOTES A SHALLOW CRATER IN THE EPIDERMIS OF THE CLIENTS SACRAL AREA. THE NURSE SHOULD DOCUMENT THAT THE CLIENT HAS A PRESSURE ULCER AT WHICH OF THE FOLLOWING STAGES? | back 54 2 |
front 55 A NURSE IS CARING FOR A CLIENT WHO HAS BEEN APPLYING SILVER SULFADIZINE CREAM TO A DEEP PARTIAL THICKNESS ARM BURN FOR THE PAST 2 WEEKS. THE NURSE SHOULD MONITOR THE CLIENT FOR WHICH OF THE FOLLOWING ADVERSE EFFECTS | back 55 LEUKOPENIA |
front 56 A NURS EIN A PROVIDERS OFFICE IS CARING FOR A CLIENT WHO HAS A NEW DIAGNOSIS OF HERPES ZOSTER. THE NURSE SHOULD ANTICIPATE A PRESCRIPTION FOR WHICH OF THE FOLLOWING MEDICATIONS | back 56 ACYCLOVIR |
front 57 A NURSE IS CARING FOR A CLIENT WHO HAS A DEEP PARTIAL AND FULL THICKNESS BURN AND REQUIRES A TOPICAL ANTIMICROBIAL DRUG. THE GOAL OF THIS MEDICATION THERAPY IS TO REDUCE WHICH OF THE FOLLOWING OUTCOMES | back 57 BACTERICAL GROWTH |
front 58 A NURSE IS CARING FOR A CLIENT WHO WOUNDS ARE COVERED WITH A HETEROGRAFT DRESSING. IN RESPONSE TO THE CLIENTS QUESTIONS ABOUT THE DRESSING THE NURSE EXPLAINS THAT IT IS OBTAINED FROM WHICH OF THE FOLLOWING SOURCES | back 58 PIG SKIN |
front 59 A NURSE IS CONTRIBUTING TO THE PLAN OF CARE FOR A CLIENT WHO HAS BEEN ADMITTED FOR THE TREATMENT OF A MALIGNANT MELANOMA OF THE UPPER LEG WITHOUT MESTASIS. THE NURSE SHOULD EXPECT THE PROVIDER TO PERFORM WHICH OF THE FOLLOWING PROCEDURES ? | back 59 SURGICAL EXCISION |
front 60 A NURSE IS ASSISTING WITH THE CARE OF A CLIENT WHO IS IN THE RESUSCITATION PHASE FOLLOWING A MAJOR BURN. WHICH OF THE FOLLOWING LAB FINDINGS SHOULD THE NURSE EXPECT | back 60 SODIUM 132 MeQ/l |
front 61 A NURSE IS COLLECTING DATA FROM A CLIENT WHO IS 3 DAYS POST OP FOLLOWING ABDOMINAL SURGERY. THE CLIENTS INCISION I SLIGHTLY EDEMATOUS, APPEARS PINK WTH CRUSTING ON THE EDGES AND IS DRAINING SERISANGUINOUS FLUID. WHICH OF THE FOLLOWING STATEMENTS DESCRIBES THIS INCISION? | back 61 THE INCISION IS SHOWING SIGNS OF HEALING WITHOUT COMPLICATIONS |
front 62 A NURSE IS ASSISTING WITH PLANNING CARE FOR A CLIENT WHO HAS DEEP PARTIAL THICKNESS AND FULL THICKNESS THERMAL BURNS OVER 40 PERCENT OF HIS TOTAL BODY SURFACE. THE FOLLOWING INTERVENTIONS SHOULD SHOULD THE NURSE INCLUDE IN THE PLAN | back 62 INITIATE RANGE OF MOTION EXERCISES |
front 63 A NURSE IS CARING FOR A CLIENT WHO HAS SMOKE INHALATION AND FULL THICKNESS BURNS COVERING 63 PERCENT OF HER BODY. WHICH OF THE FOLLOWING NURSING ACTIONS IS THE NURSES PRIORITY ? | back 63 MONITOR RESPIRATORY STATUS |
front 64 A NURSE IS COLLECTING DATA FROM A CLIENT WHO SUSTAINED SUPERFICIAL PARTIAL THICKNESS AND DEEP PARTIAL THICKNESS BURNS 72 HOURS AGO WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE REPORT TO THE PROVIDER | back 64 TEMP 39.1 (102.4) |
front 65 A NURSE IN AN URGENT CARE CLINIC IS CARING FOR A CLIENT WHO HAS A SNAKEBITE ON HER ARM. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE? | back 65 IMMOBILIZE THE LIMB AT THE LEVEL OF THE HEART |
front 66 A NURSE IS CARING FOR A CLIENT WHO HAS A LESION ON THE BACK OF HIS RIGHT HAND. THE CLIENT ASKS THE NURSE WHICH TYPE OF CANCER IS THE MOST SERIOUS. WHICH OF THE FOLLOWING RESPONSES SHOULD THE NURSE MAKE? | back 66 MELANOMAS |
front 67 A NURSE IS REINFORCING DISCHARGE TEACHING WITH A CLIENT WHO IS POST OP FOLLOWING SURGICAL EXCISION OF A BASAL CELL CARCINOMA. WHICH OF THE FOLLOWING FINDINGS SHOULD THE NURSE INCLUDE AS AN INDICATION OF MALIGNANCY OF A MOLE | back 67 ULCERATION |
front 68 A NURSE IS COLLECTING DATA FROM A CLIENT WHO HAS AN ARM LESION. WHICH OF THE FOLLOWING CHARACTERISTICS IS A CLINICAL MANIFESTATION OF MALIGNANT MELANOMA | back 68 IRREGULARLY SHAPED BLUE TONES |
front 69 A NURSE ON A SURGICAL UNIT IS CARING FOR 4 CLIENTS WHO HAVE WOUND HEALING WHICH OF THE FOLLOWING WOUNDS SHOULD THE NURSE EXPECT TO HEAL BY PRIMARY INTENTION | back 69 SURGICAL INCISION |
front 70 A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO HAS BURN INJURIES TO HIS TRUNK ABOUT WHAT TO EXPECT FROM THE PRESCRIBED HYDRO THERAPY. WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT INDICATES UNDERSTAND OF THE TEACHING | back 70 I WILL BE ON A SPECIAL SHOWER CHAIR |
front 71 A NURSE IS OBSERVING THE SKIN OF A CLIENT WHO HAS FROSTBITE. THE CLIENT HAS SMALL BLISTERS THAT CONTAIN BLOOD AND THE SKIN OF THE AFFECTED AREA DOES NOT BLANCH. THE NURSE SHOULD CLASSIFY THIS INJURY AS WHICH OF THE FOLLOWING | back 71 THIRD DEGREE FROSTBITE |
front 72 A NURSE IS REINFORCING TEACHING WITH A CLIENT WHO IS WHEELCHAIR BOUND AND HIS CAREGIVER ABOUT WAYS TO REDUCE THE RISK OF PRESSURE ULCER FORMATION. WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD THE NURSE INCLUDE ? | back 72 SHIFT YOUR WEIGHT IN THE WC EVERY 15 MINUTES |
front 73 A NURSE IN AN URGENT CARE CLINIC IS COLLECTING DATA FROM A CLIENT WHO HAS EXTENSIVE BURNS, INCLUDING ON HER FACE . WHICH OF THE FOLLOWING DATA SHOULD THE NURSE COLLECT | back 73 RESPIRATORY RATE |
front 74 A NURSE IS CARING FOR A CLIENT WHO HAS REGULAR OCCUPATIONAL EXPOSURE TO SUN LIGHT AND PRESENTS TO THE CLINIC FOR EVAL OF SEVERAL SKIN LESIONS WHICH OF THE FOLLOWING FINDINGS SHOULD ALERT THE NURSE TO THE FOLLOWING FINDINGS SHOULD ALRET THE NURSE TO THE POSSIBILITY OF MALIGNANT MELANOMA? | back 74 AN IRREGULARLY SHAPED BROWN LESION WITH LIGHT BLUE AREAS ON THE NECK |
front 75 A COMMUNITY HEALTH NURSE IS TEACHING ABOUT MELANOMA WITH A GROUP OF CLIENTS. WHICH OF THE FOLLOWING CHARACTERISTICS OF LESIONS ASSOCIATED WITH MELANOMA SHOULD THE NURSE INCLUDE INT HE TEACHING? | back 75 IRREGULAR BORDER |
front 76 A NURSE IS REINFORCING DISCHARGE TEACHING ABOUT FOOT CARE WITH A CLIENT WHO HAS DIABETES. WHICH OF THE FOLLOWING INSTRUCTIONS SHOULD THE NURSE INCLUDE IN THE TEACHING ? | back 76 TEST WATER TEMP WITH THE WRIST |
front 77 A NURSE IS ASSESSING A PATIENT'S INDWELLING URINARY CATHETER DRAINAGE AT THE END OF THE SHIFT AND NOTES THE OUTPUT IS CONSIDERABLY LESS THAN THE FLUID INTAKE. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE FIRST? | back 77 CHECK THE CATHETER FOR KINKS |
front 78 A NURSE IS LIKELY TO RECIEVE AN ORDER FOR URINARY CATHETERIZATION OF A NEWLY ADMITTED PATIENT WHO | back 78 IS IN THE ICU FOR GASTROINTESTINAL BLEED |
front 79 A NURSE IS PREPARING TO INSERT AN INDWELLING URINARY CATHETER FOR A FEMALE PATIENT. WHEN BEGINNNING THE INSERTION PROCEDURE, THE NURSE SHOULD INSTRUCT THE PATIENT TO | back 79 BEAR DOWN |
front 80 WHEN PROVIDING PERINEAL CARE FOR A FEMALE PATIENT WHO HAS AN INDWELLING URINARY CATHETER. WHAT AREA SHOULD THE NURSE CLEAN LAST | back 80 THE ANUS |
front 81 A NURSE IS PLANNING ON OBTAINING A URINARY SPECIMEN FROM A PATIENTS CLOSED URINARY SYSTEM. IDENTIFY THE SEQUENCE OF STEPS THE NURSE SHOULD TAKE | back 81
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front 82 A NURSE IS APPLYING A CONDOM CAT FOR AN OLDER ADULT PATIENT WHO IS UNCIRCUMCISED. WHAT IS AN APPROPRIATE STEP IN THE PROCEDURE ? | back 82 LEAVING A SPACE BETWEEN THE PENIS AND THE CATHETERS TIP |
front 83 A NURSE WHO IS PREPARING TO INSERT A STRAIGHT URINARY CAT FOR A MALE PATIENT SHOULD | back 83 APPLY LIGHT TRACTION TO THE PENIS |
front 84 A NURSE IS CARING FOR A PATIENT WHO HAS A TRACH TUBE WITH AN INNER CANNULA IN PLACE. WHAT SUPPLIES SHOULD THE NURSE USE TO DY THE INNER CANNULA OF THE PATIENTS TRACH TUB AFTER CLEANING IT | back 84 FOLDED PIPE CLEANERS |
front 85 A NURSE IS PREPARING TO SUCTION SECRETIONS FORM THE MOUTH OF A PATIENT WHO HAS DYSPHAGIA. WHAT IS THE APPROPRIATE SUCTION DEVICE OR METHOD FOR THE NURSE TO USE? | back 85 YANKAUER CATHETER |
front 86 A NURSE IS CARING FOR A PATIENT WHO HAS A TRACHEOSTOMY TUBE IN PLACE. DURING TRACH CARE, WHAT SHOULD THE NURSE PLACE UNDERNEATH THE FLANGES OF THE OUTER CANNULA | back 86 COMMERCIALLY PREPARED FENESTRATED DRESSING - DOES NOT UNRAVEL AND HAS FENESTRATION SLITS DESIGNED TO FIT AROUND THE TRACHOSTOMY TUBE UNDER THE FLANGES |
front 87 A NURSE IS CARING FOR A PATIENT WHO HAS CUFFED ENDOTRACHEAL TUBE IN PLACE. WHAT IS AN APPROPRIATE COMPONENT OF ET TUBE CARE FOR THIS PATIENT | back 87 REPOSITIONING THE ET TUBE IN THE PATIENTS MOUTH EVERY 12 HOURS |
front 88 A NURSE IS PREPARING TO PERFORM ENDOTRACHEAL TUBE CARE AND PLANS TO USE TAPE TO SECURE THE TUBE. WHAT IS AN APPROPRIATE PREP ACTION FOR THIS PROCEDURE ? | back 88 HAVE TINCTURE OF BENZOIN READY TO APPLY TO THE PATIENTS FACE |
front 89 A NURSE IS SUCTIONING A PATIENTS AIRWAY USING IN LINE SUCTIONING. WHEN USING THIS METHOD IT IS APPROPRIATE FOR THE NURSE TO | back 89 REUSE THE CATHETER REPEATEDLY |
front 90 A NURSE IS PERFORMING CHEST PHYSIOTHERAPY FOR A PATIENT WHO NEEDS HELP MOBILIZING AND EXPECTORATING THICK PULMONARY SECRETIONS. TO INCREASE THE TURBULENCE OF THE AIR THE PATIENT EXHALES THE NURSE SHOULD USE WHICH TECHNIQUE | back 90 VIBRATION USED DURING OR AFTER PERCUSSION TO INCREASE THE TURBULENCE OF EXHALED AIR AND LOOSEN SECRETIONS |
front 91 A NURSE IS CARING FOR A PATIENT WHO SUSTAINED TRAUMA TO HIS HEAD AND NECK AND WILL REQUIRE LONG TERM AIRWAY SUPPORT. WHAT DEVICE WILL BE REQUIRED FOR HOME HEALTH CARE FOR THIS PATIENT? | back 91 TRACHEOSTOMY TUBE |
front 92 STANDARD PRECAUTIONS MANDATE | back 92 DISINFECTING HANDS IMMEDIATELY AFTER REMOVING GLOVES |
front 93 AFTER COMPLETING A PROCEDURE THAT REQUIRED DONNING PERSONAL PROTECTIVE EQUIPMENT CONSISTING OF A GOWN, N95, A FACE SHIELD AND GLOVES. WHAT SHOULD THE NURSE REMOVE FIRST WHEN REMOVING PPE SEPARATELY | back 93 GLOVES |
front 94 YOU ARE ABOUT TO IRRIGATE A PATIENTS OPEN WOUND. BESIDES GLOVES, WHICH OTHER ITEM OF PPE MUST YOU WEAR? | back 94 FACE SHIELD |
front 95 WHICH PRODUCT CAN AFFECT THE PERMEABILITY OF GLOVES | back 95 PETROLEUM BASED HAND LOTION |
front 96 A CLIENT HAS A HEALTHCARE ASSOCIATED INFECTION (HAI). WHAT BEST DESCRIBES HAI? | back 96 ACQUIRING THE INFECTION WHILE HOSPITALIZED |
front 97 YOU ARE CARING FOR A PATIENT DIAGNOSED WITH MYCOPLASMAL PNEUMONIA. DROPLET PRECAUTIONS HAVE BEEN INSTITUTED SO YOU MUST | back 97 PROTECT YOUR EYES |
front 98 CONTACT PRECAUTIONS WOULD BE MANDATED FOR A HOSPITALIZED ADULT PATIENT DIAGNOSED WITH | back 98 INFECTIOUS DIARRHEA |
front 99 you are washing your hands with non antimicrobial soap and water prior to repositioning a patient in a bed. during the handwashing procedure it is important to? | back 99 continue for at least 15 seconds |
front 100 to decontaminate your hands with an alcohol based gel, you rub them together until all of the gel has evaporated and your hands are dry. the primary reason you do this is that | back 100 drying provides the full antiseptic effect |
front 101 which of the following is an advantage of using alcohol based gel? | back 101 it use takes less time than washing with soap and water does |
front 102 after assisting a newly admitted patient in removing his shoes and outerwear you notice what appears to be soil or grime on your hands you | back 102 wash your hands with soap and water |
front 103 WHERE DOES HEMATOPOIESIS TAKE PLACE? | back 103 RED BONE MARROW |
front 104 THE NURSE IS REPOSITIONING A PATIENT. DURING THE MOVEMENT THE EXTREMITY IS PLACED IN A POSITION AWAY FROM THE MIDLINE OF THE BODY. TO DOCUMENT THIS POSITION, WHAT TERM IS MOST APPROPRIATE | back 104 ABDUCTION |
front 105 A PATIENT IS SUSPECTED OF HAVING RHEUMATOID ARTHRITIS. WHAT DIAGNOSTIC TESTS MAY BE USED TO SUPPORT THE DIAGNOSIS? | back 105
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front 106 THE NURSE IS REVIEWING THE ASSESSMENT FINDINGS AND MEDICAL HISTORY OF A PATIENT SUSPECTED OF HAVING GOUTY ARTHRITIS. WHAT FINDINGS SUPPORT THE DIAGNOSIS? | back 106 TOPHI |
front 107 A 55 YEAR OLD PATIENT MENTIONS THAT SHE IS POSTMENOPAUSAL AND IS NOT TAKING ESTROGEN SUPPLEMENTS. A REVIEW OF HER NORMAL DIETARY INTAKE INDICATES HIGH CONSUMPTION OF CAFFINE LIMITED DIETARY INGESTION OF CALCIUM. BASED ON HER HISTORY, SHE FACES AN INCREASED RISK FOR WHAT CONDITION? | back 107 OSTEOPOROSIS |
front 108 WHAT ARE APPROPRIATE NURSING INTERVENTION FOR A PATIENT SUFFERING FROM A FRACTURED HIP WITH A BIPOLAR HIP REPAIR? | back 108
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front 109 A PATIENT IS BEING DISCHARGED AFTER A PROSTHETIC HIP IMPLANT. SHE ASKS WHEN SHE CAN BEGIN TO BEAR WEIGHT ON THE AFFECTED LEG. WHAT WOULD THE NURSE RESPONSE BE? | back 109 " YOU WILL MOST LIKELY REQUIRE SOME DEGREE OF NON WEIGHT BEARING FOR 6 WEEKS TO 3 MONTHS " |
front 110 A PATIENT HAS BEEN SEEING THE HEALTH CARE PROVIDER FOR COMPLAINTS OF OSTEOARTHRITIS. TODAY THE PATIENT IS DISCUSSING CONCERNS ABOUT THEIR CONDITION AND ASKS WHAT HAS CAUSE THE OSTEOARTHRITIS. WHAT WOULD BE THE NURSES RESPONSE? | back 110 " WEAR AND TEAR OVER THE YEARS HAVE MOST LIKELY CAUSED THE JOINTS TO BEGIN TO DEGENERATE" |
front 111 WHEN PROVIDING CARE TO A PATIENT IN SKELETAL TRACTION WHAT ACTION WOULD BE INCLUDED IN THE NURSE'S PLAN OF CARE? | back 111 CLEANSE PIN SITES AND OBSERVE FOR SIGNS OF INFECTION |
front 112 AFTER A FRACTURE OF THE FOREARM OR TIBIA, COMPLAINTS OF SHARP, DEEP, UNRELENTING PAIN IN THE HAND OR FOOT UNRELIEVED BY ANALGESICS OR ELEVATION OF THE EXTREMITY INDICATE WHAT TYPE OF INFECTION? | back 112 COMPARTMENT SYNDROME |
front 113 A PATIENT SUFFERED A KNEE INJURY WHILE PLAYING FOOTBALL. THE PATIENT IS SCHEDULED FOR AN ARTHROSCOPIC EXAM AND ASKS THE NURSE TO EXPLAIN THE PROCEDURE. WHAT INFORMATION WILL BE GIVEN TO THIS PATIENT ? | back 113 " YOUR HEALTH CARE PROVIDER WILL INSERT A SMALL SCOPE INTO YOUR KNEE JOINT TO VISUALIZE THE JOINT FOR DAMAGED TISSUE |
front 114 A PATIENT WITH RA ASKS IF THERE IS A CURE. WHAT WOULD BE THE MOST APPROPRIATE RESPONSE BY THE NURSE ? | back 114 " NO, BUT NEW DRUGS CAN INTERFERE WITH THE BODYS REACTION TO INFLAMMATION AND BETTER CONTROL THE DISEASE PROCESS" |
front 115 A PATIENT IS SCHEDULED FOR ENDOSCOPIC SPINAL MICRO SURGERY TO CORRECT A HERNIATED DISK. WHAT IS THE MOST ACCURATE STATEMENT CONCERNING THIS TYPE OF SURGERY | back 115 " SPECIAL SCOPES ARE PLACED THROUGH SMALL INCISIONS CAUSEING MINIMAL DAMAGE TO SURROUNDING TISSUE" |
front 116 A PATIENT HAS OSTEOARTHRITIS OF THE KNNEE AND IS SEEKING INFORMATION ABOUT GLUCOSAMINE SUPPLEMENTS. WHAT WOULD BE AN APROPRIATE RESPONSE FROM THE NURSE ? | back 116 " STUDIES SUGGEST THAT GLUCOSAMINE SUPPLEMENTS MAY HAVE BE HELPFUL IN MAINTAING HEALTHY JOINT FUNCTION |
front 117 WHAT IS THE MOST APPROPRIATE NURSING ASSESSMENT FOR THE PATIENT PROBLEM OF INEFFECTIVE TISSUE PERFUSION, SECONDARY TO FRACTURED HIP? | back 117 ASSESS FOR DISTAL PULSES |
front 118 A PATIENT HAS JUST UNDERGONE TOTAL HIP REPLACEMENT. THE PATIENT ASKS WHY SHE CANNOT CROSS HER LEGS WHEN SITTING BUT MUST DO STRAIGHT LEG RAISING EXERCISES. WHAT IS THE MOST CORRECT RESPONSE? | back 118 " THE EXERCISES HELP STRENGTHEN THE LEG MUSCLES, CROSSING YOUR LEGS PUTS PRESSURE ON THE JOINTS AND COULD DAMAGE THE HIP PROSTHESIS |
front 119 WHICH OBJECTIVE SIGNS WILL THE NURSE FIND DURING THE ASSESSMENT OF A PATIENT WITH COMPARTMENT SYNDROME IN THE LOWER LEG? | back 119
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front 120 A PATIENT HAD A COMPOUND FRACTURE OF HIS RIGHT FEMUR 2 YEARS BEFORE THE PRESENT ADMISSION. HIS HCP SUSPECTS OSTEOPMYELITIS AND HAS INFORMED THE PATIENT THAT TESTS ARE NEEDED TO CONFIRM THE DIAGNOSIS. THE PATIENT WANTS TO KNOW WHAT TESTS CAN BE ORDERED TO DETERMINE OSTEOMYELITIS. AN APPROPRIATE RESPONSE WOULD BE ? | back 120
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front 121 A CONSTRUCTION WORKER SUFFERED A FRACTURE OF THE FEMUR 48 HOURS AGO. THE NURSE NOTICES THAT HE HAS PETECHIAE ON THE CONJUNCTIVA, CHEST , NECK AND AXILLAE. PETECHIAE IN THESE LOCATIONS ARE CONSISTENT WITH WHICH CONDITION? | back 121 FAT EMBOLISM |
front 122 A NURSE IS COLLECTING DATA FROM A CLIENT WHO IS 24 HR POST OP FOLLOWING AN ABOVE THE ELBOW AMPUTATION. WHAT SHOULD THE NURSE IDENTIFY AS PRIORITY? | back 122 REPORT OF MUSCLE SPASMS |
front 123 A NURSE IS CARING FOR A CLIENT WHO HAD A BELOW THE KNEE AMPUTATION FOR GANGRENE OF THE RIGHT FOOT. THE CLIENT REPORTS SENSATIONS OF BURNING, AND CRUSHING PAIN IN THE TOES OF THE RIGHT FOOT. WHAT STATEMENT SHOULD THE NURSE MAKE ? | back 123 AN ANTICONVULSANT MEDICATION CAN BE HELPFUL IN RELIEVING THIS TYPE OF PAIN. |
front 124 A nurses is caring for a client who is 4hr post-op following a laparoscopic cholecystectomy. which of the following findings should the nurse expect? | back 124 right shoulder pain |
front 125 nurse is assessing client who is experiencing perforation of a peptic ulcer. which of the following manifestations should the nurse expect? | back 125 border like abdomen |
front 126 A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred? | back 126 rigid abdomen |
front 127 A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray? | back 127 wheat toast |
front 128 A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? | back 128 clear liquids |
front 129 A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? | back 129 Diaphoreisis |
front 130 A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? | back 130 place the client in semi followers position |
front 131 A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching? | back 131 "A hepatitis B immunization is given to infants and children." |
front 132 A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? | back 132 liver transplant |
front 133 a nurse is collecting data from a client who is in the early stages of hep a. which of the following manifestions should the nurse expect? | back 133 anorexia |
front 134 A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention by the nurse? | back 134 the head of the bed elevated 20 degrees |
front 135 A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is used to do which of the following? | back 135 to detect ulcerations in the stomach |
front 136 a nurse is reinforcing teaching with a client who has diverticulitis about preventing acute attacks. what type foods should the nurse recommend? | back 136 foods high in fiber |
front 137 a nurse is assisting a client who has esophageal varices. the nurse might anticipate a prescription for what medication? | back 137 vasopressin |
front 138 A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? | back 138 "This procedure can determine how well the lower part of your esophagus works." |
front 139 A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? | back 139 night sweats |
front 140 A nurse is caring for an older client who has chronic obstructive pulmonary disease with pneumonia. The nurse should monitor the client for Which of the following acid-base imbalances? | back 140 respiratory acidosis |
front 141 A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? | back 141 the nurse ascultates coarse crackles in the lung field |
front 142 A nurse is providing teaching to a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? | back 142 total lung capacity |
front 143 A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? | back 143 tape all connections between the chest tube and drainage system. |
front 144 A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? | back 144 dry cough |
front 145 A nurse on a medical unit is assisting with the care of a client who has a possible closed pneumothorax and significant bruising of the left chest following a motor vehicle crash. The client reports severe left chest pain on inspiration. The nurse should hear which of the following findings when auscultating the clients lung sounds? | back 145 absence of breath sounds |
front 146 A nurse in a clinic is reinforcing teaching with a client who is to have a tuberculin skin test. Which of the following information should the nurse include? | back 146 You must return to the clinic to have the test read in 2 or 3 days |
front 147 A nurse is assisting with discharge teaching for a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? | back 147 Lie on you back with you head elevated 30 degrees when resting |
front 148 A nurse is reinforcing teaching with a client who has cystic fibrosis and a prescription for daily chest physiotherapy. The nurse should instruct the client that which of the following is the purpose of these treatments? | back 148 To mobilize secretions in the airways |
front 149 A nurse is reinforcing preoperative teaching with a client who is to undergo a pneumonectomy. The client states I am afraid it will hurt to cough after the surgery. Which of the following statements should the nurse make? | back 149 I will show you how to splint your incision while coughing |
front 150 A nurse is collecting data from a client who has a prescription for cisplatin IV to treat lung cancer. Which of the following client findings is an adverse effect of this medication? | back 150 tinnitus |
front 151 A nurse is reinforcing teaching about pursed lip breathing for a client who has COPD and emphysema. The nurse should explain that this breathing does which of the following? | back 151 Keeps the airways open on exhalation |
front 152 A nurse is assisting the provider to prepare a client for a thoracentesis. The nurse should instruct the client that which of the following positions will be used for this procedure? | back 152 Sitting while leaning forward over the bedside table |
front 153 A nurse is assisting with the development of a teaching plan about how to prevent an acute asthma attack for a young adult client. Which of the following points should the nurse plan to discuss first? | back 153 Determine the clients perception of the disease process and what might have triggered the current attack |
front 154 A nurse on a medical unit is assisting with the care of a client who aspirated gastric contents prior to admission. The provider prescribed 100% oxygen by nonrebreather mask after the client reported severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome? | back 154 PaO2 50 mmHg |
front 155 A nurse is assisting with the plan of care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? | back 155 eat high calorie food first |
front 156 A nurse on a medical surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. The nurse collects additional data from the client. Which of the following findings is an indication of pulmonary embolism? | back 156 sudden onset of dyspnea |
front 157 a nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. what actions should the nurse take to assist the client with smoking cessation? | back 157 Discuss ways the client can reduce the number of cigaretters smoked per day |
front 158 A nurse is caring for a client who has pneumonia and is experiencing thick oral secretions. what actions should the nurse take first? | back 158 encourage deep breathing and coughing |
front 159 a nurse is reinforcing preop teaching with a client who will undergo a total laryngectomy. what statements should the nurse identify as an indication that the client understands the impact of the surgery? | back 159 " I understand that I will have a permanent tracheostomy after the surgery " |
front 160 A nurse on a medical surgical unit is caring for 4 clients. what client should then urse monitor for crepitus? | back 160 a client who has a chest tube following a pneumothorax |
front 161 a nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. what actions should the nurse take first? | back 161 evaluate the client for stridor |
front 162 a nurse is reinforcing teaching about pursed lip breathing with a client who has COPD and emphysema. The nurse should explain that this breathing technique does which of the following | back 162 keeps the airways open on exhalation |
front 163 a nurse is caring for an older adult client who has COPD and pneumonia. the nurse should monitor the client for which of the following acid base imbalances? | back 163 respiratory acidosis |
front 164 a nurse is assisting with the plan of care for a client who is post op following a hip arthroplasty/ in the clients medical record, the nurse notes a history of COPD. What oxygen delivery methods should the nurse recommend to use for this client | back 164 nasal cannula |
front 165 a nurse is caring for a client is scheduled to have his chest tube removed. what action should the nurse take ? | back 165 auscultate the lungs after removal |
front 166 a nurse is reinforcing teaching with a client who has cystic fibrosis and a prescription for daily chest physiotherapy. what is the purpose of this treatment. | back 166 to mobile secretions in the airways |
front 167 a nurse is reinforcing discharge teaching with a client who had a pulmonary embolism. what statement should the nurse identify as an indication that the client understands the information? | back 167 I'll call the doctor if I see any blood in my urine or stool |
front 168 A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. what information should the nurse include in the teaching. | back 168 use pursed- lip breathing during periods of dyspnea (shortness of breath) |
front 169 a nurse is collecting data about the respiratory status of a client who has COPD. what manifestations should the nurse identify as an indication of the early onset of respiratory failure. | back 169 Tachycardia |
front 170 a nurse is collecting data from a client who has a positive TB skin test. which of the following findings should the nurse identify as an indication the the client has active TB ? | back 170 night sweats |
front 171 a nurse is helping the provider prepare a client for thoracentesis. the nurse should instruct the client that which of the following positions will be used for this procedure. | back 171 sitting while leaning forward over the bedside table |
front 172 a nurse is assisting with the care of a client who had a chest tube inserted 12 hours ago. the nurse notes a crackling sensation upon palpation of the skin on the right side of the clients chest. the nurse should notify the charge nurse that the client is demonstrating a clinical manifestation of which of the following complications? | back 172 Crepitus |
front 173 a nurse is preparing to assist a provider in withdrawing arterial blood from a clients radial artery for ABG measurement. what actions should the nurse plan to take? | back 173 check the circulation in the clients ulnar artery prior to obtaining the specimen |
front 174 a nurse is assisting with planning postop education for a client who will undergo radial neck dissection for cancer of the larynx. the nurse should suggest which of the following topics? | back 174
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front 175 a nurse is caring for a client who is post op following a rhinoplasty. what findings should be reported to the surgeon | back 175 frequent swallowing - can indicate posterior nasal bleeding and possibly hemorrhage |
front 176 a nurse is reinforcing teaching about breathing techniques with a client who has emphysema. which of the following statements should the nurse identify as an indication that the client understands the mechanics behind pursed lip breathing? | back 176 " when I breathe out through pursed lips, my airways don't collapse between breaths" - slows exhalation - maintains inflation of the distal airways - enhances respirations |
front 177 a nurse is reinforcing discharge instructions with a client who has a new laryngectomy. the nurse should tell the client to be careful while bathing to prevent what complication? | back 177 aspiration of water |
front 178 a nurse is reinforcing preop teaching with a client who has lung cancer and will undergo a pneumonectomy. which of the following pieces of information should the nurse include? | back 178
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front 179 a nurse on a med surg unit is caring for a client who is post op following a hip replacement. the client reports feeling apprehensive and restless. the nurse collects additional data from the client. what finding is an indication of pulmonary embolism. | back 179 sudden onset of dyspnea - rapid onset - dyspnea due to reduced blood flow to the lungs |
front 180 a nurse is caring for a client who has a chest tube. the nurse notes that the chest tube has become disconnected from the chest drainage system. what actions should the nurse take? | back 180 immerse the end of the chest tube in a bottle of sterile water |
front 181 a nurse in a providers office is collecting data from a client who reports recent exposure to TB. which of the following findings is a clinical manifestation of pulmonary TB ? | back 181 night sweats - fevers also clinical manifestation |
front 182 a nurse is caring for a client who had a left lowerr lobectomy to treat lung cancer. what factor has a significant impact on the plan of care for this client? | back 182 Lung cancer usually has metastasized before the client has symptoms |
front 183 a nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. which of the following findings is an indication of the prodromal stage of inhalation anthrax? | back 183 dry cough |
front 184 a nurse on a medical unit is assisting with the care of a client who has a possible closed pneumothorax and significant bruising of the left chest following a motor vehicle crash. the client reports sever left chest pain on inspiration. the nurse should hear what findings when auscultating the client's lung sounds | back 184 absence of breath sounds |
front 185 a nurse is reviewing the lab results of a client who has metabolic alkalosis. which of the following labs values should the nurse expect? | back 185 pH 7.49 HCO3 32 mEq/L PACO2 40 mmHG |
front 186 a nurse is reinforcing teaching with a client about pulmonary function tests. which of the following tests measures the volume of air the lungs can hold a the end of max inhalation ? | back 186 total lung capacity |
front 187 a nurse in a clinic is reinforcing teaching with a client who is scheduled to have a TB skin test. which of the following pieces of info should the nurse include? | back 187 "you must return to the clinic to have the test read in 2 or 3 days" |
front 188 a nurse is reinforcing discharge teaching with a client who has emphysema. which of the following instructions should the nurse take? | back 188 try to drink at least 2-3 liters of fluid per day ......... ..... |
front 189 a nurse is caring for a client who is experiencing acute opioid toxicity. which of the following actions should the nurse identify as priorty. | back 189 ensure an adequate airway |
front 190 a nurse is caring for a client following a right pleural thoracentesis. the nurse measures a total of 35 mL of purulent drainage. what findings indicate a tension pneumothorax? | back 190 - tracheal deviation to the left - absent breath sounds on the right side - neck vein distention |
front 191 a nurse on a med surg unit is collecting data from a client who recently transferred from the ICU following endotracheal extubation. which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the charge nurse | back 191 increased coughing |
front 192 a nurse is collecting data from a client who has pharyngitis. what finding is the nurses priority to report to the provider | back 192 inspiratory stridor |
front 193 a nurse is caring for a client who is extremely anxious and is hyperventilating. the clients ABG results are pH 7.50, PaCO2 27 mmHg and HCO3 - 25 mEq/L. the nurse should identify that the client has which of the following acid base imbalances. | back 193 respiratory alkalosis |
front 194 a nurse is reinforcing teaching with a client who has a chronic cough and is scheduled for a bronchoscopy. what statement indicates an understanding of the teaching? | back 194 " a tissue sample might be obtained during the procedure " |
front 195 a nurse is assisting with the plan of care for a client who has COPD and is malnourished. which of the following recommendations to promote nutritional intake should the nurse include in the plan of care. | back 195 Eat high calorie foods first |
front 196 a nurse is assisting a provider with a comprehensive physcial examination of a client. when the provider uses transillumination the nurse should explain to the client that this technique helps evaluate which of the following structures? | back 196 maxillary sinuses |
front 197 a nurse is collecting data from a client who has a precription for cisplatin IV to treat lung cancer. what is an adverse effect of this medication? | back 197 tinnitus |
front 198 a nurse is contributing to the plan of care for a client who is recieving mechanical ventaliation. which of the following recommendations should the nurse make? | back 198 maintain the head of the bed at 30 degrees |
front 199 a nurse on a medical unit is assisting with the care of a client who aspirated gastric contents prior to admission. the provider prescribed 100 percent oxygen by norebreather mask after the client reported severe dyspnea. what findings is a clinical manifestation of acute respiratory distress syndrome? | back 199 PaO2 50 mmHg |
front 200 a nurse is caring for a client who has a 20 year history of COPD and is recieving oxygen at 2 L/min via nasal cannula/ the client is shortness of breath and has O2 sat via pulse ox of 85%. what actions should the nurse take. | back 200 Increase the oxygen flow and request and ABG |
front 201 a nurse in a medical surgical unit is assessing a client . the nurse should identify that which of the following findings is a manifestation of pulmonary embolism. | back 201 stabbing chest pain |
front 202 a nurse is reinforcing preop teaching with a client who is scheduled to undergo pneumonectomy. the client states " I am afraid that coughing will hurt after the surgery" what response should the nurse make | back 202 " i will show you how to splint your incision while coughing |
front 203 a nurse is assisting with the plan of care for a client following placement of a chest tube 1 hour ago/ what action should the nurse include in the plan of care. | back 203 tape all connections between the chest tube and draingage system |
front 204 a nurse is assisting with discharge teaching for a client who is post op following a rhinoplasty. which of the following instructions should the nurse include? | back 204 lie on your back with your head elevated 30 degrees when resting |
front 205 a nurse is assisting with the care of a client who has a chest tube in place following a thoractomy. which of the following actions should the nurse take? | back 205 - place the drainage unit below the clients chest level |
front 206 a nurse is preparing a client for discharge following a bronchoscopy. what assesment is the nurses priority. | back 206 - confirming the gag reflex |
front 207 a nurse is caring for a client who has a tracheostomy with an inflated cuff in place. which of the following findings indicates that the nurse should suction the clients airway secretions? | back 207 the client has coarse crackles in the lung fields |
front 208 a nurse is assiting with preparing a client for a bronchoscopy. which actions should the nurse take? | back 208 - explain the client will recieve sedation and will not remember the procedure - verify that the client understands the purpose and nature of the procdure |
front 209 a nurse is caring for a client who is post op following a thoracic lobectomy. the client has 2 chest tubes in place. 1 in the lower portion of the thorax and the other higher up on the chest wall. when the family asks the nurse why the client has 2 chest tubes, which of the following responses should the nurse make? | back 209 the lower tube will drain blood, an the higher tube will remove air |
front 210 a nurse in the PACU is collecting data from a newly admitted client and observes intercoastal retractions and high pitched inspiratory sound. the nurse should identify that these findings are manifestations of which of the following complications? | back 210 respiratory obstruction |
front 211 a nurse is auscultating the lungs of a client who is having an acute asthma attack. which of the following sounds should the nurse expect to hear. | back 211 noisy wheezing |
front 212 a charge nurse recieves notification of the admission of a client who is coughing frequenly and whose sputum is pink, frothy, and copious . the client has a history of night sweats, anorexia, and weight loss. which of the following actions should the nurse take? | back 212 - assign the client to a private room with negative - pressure airflow - wear an respirator when entering the clients room |
front 213 a nurse is caring for a client who has COPD and is experiencing shortness of breath. what action should the nurse take first? | back 213 place the client in an upright position |
front 214 the nurse notes blanching, coolness, and edema at the peripheral IV site. on the basis of these findings, the nurse should implement which actin? 1. remove the iv 2. apply a warm compress 3. check for a blood return 4. measure the area for infiltration | back 214 remove the iv rationale: because infiltration can be damaging to the surrounding tissue, the appropriate action would be to remove the iv to prevent any further damage. |
front 215 the nurse has recieved the client assignment for the day. which client should the nurse attend to first? 1. the client who has a nasogastric tube attached to intermitten suction 2. the client who needs to receive subq insulin before breakfast 3. the client who is 2 days post op and is complaining of incisional pain 4. the client who has a blood glucose level of 50 mg/dL (2.85 mmol/L and complains of blurred vision | back 215 the client who has a blood glucose level of 50 mg/dL (2.85 mmol/L) and complains of blurred vision rationale: client is showing symptoms of hypoglycemia, treatment should be implemented first. |
front 216 the nurse preps to care for a client on contact precautions who has a hospital acquired infection caused by methicillin resistant staphylococcus aurues. the client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. the nurse should assemble which neccessary protective items before entering the clients room? 1. gloves and gown 2. gloves mask goggles 3. gloves mask gown goggles 4. gloves gown and shoe protectors | back 216 gloves mask gown goggles |
front 217 a nurse at an opthalmology clinic is collecting data from a client referred by the provider for a potential cataract. which of the following client reports should the nurse recognize is consistent with cataracts?
| back 217 halos when looking at lights |
front 218 a nurse is collecting data from an older client who states he is homeless. which of the following findings should the nurse document as comorbidities for the client ?
| back 218 dementia and tuberculosis |
front 219 a nurse is reinforcing teaching about calcium supplements with an older adult female client who has osteoporosis and a recent pair of a fracture in her right hip. what should the nurse include in the instructions? | back 219 you should take your calcium supplements with a large glass of water |
front 220 a nurse is reinforcing teaching with a group of healthy older adult clients about health screenings after age 50 years. what health screening should the nurse recommend that the clients complete annually? | back 220 visual acuity |
front 221 a nurse is participating on a committee that is developing age appropriate care standards for older adult clients. which of the following of erikson's developmental tasks should the nurse recommend as the focus? | back 221 integrity |
front 222 a nurse is reinforcing dietary teaching with an older adult who is on bedrest following development of DVT about methods to increase peristalsis. which of the following high fiber food choices should the nurse recommend?
| back 222 navy bean soup |
front 223 a nurs eat an assisted living center is conducting an orientation session for a group of newly hired AP. what instruction should the nurse include regarding clients who are hearing impaired? | back 223 maintain eye contact with the clients |
front 224 a nurse is assisting with planning care for an older adult client following abdominal surgery for a bowel obstruction. what information about pain management should the nurse include in the plan of care? | back 224 older adult clients are sensitive to the analgesic effect of opiates |
front 225 a nurse at a long term care facilitiy is assisting with planning care for a group of older adults. when planning care, the nurse should consider that older adult clients are most likely to exhibit a decrease in which of the following?
| back 225 short term memory |
front 226 a nurse in a long term care facility is promoting reminiscence among older adult clients. which of the following actions should the nurse take? | back 226 institute a daily storytelling hour |
front 227 a nurse is reinforcing teaching with a newly hired assistive personnel about her role in helping older clients witch adls. the nurse should explain that which of the following is the most common factor that affects a clients ability to perform ADLS?
| back 227 chronic physical disability |
front 228 a nurse is assisting with the admission of an older adult client who fell at home 3 days ago. the client has fractured hip, malnutrition, and dehydration. which of the following laboratory values, noted n admission, should indicate to the nurse prolonged manlnutrition?
| back 228 decreased albumin |
front 229 a nurse is caring for an older adult client who has a new onset of type 2 diabetes mellitus. which of the following physciologic changes contribute to the development of type 2 diabetes?
| back 229 decrease sensitivity to the circulating insulin |
front 230 a nurse is caring for an older adult client who has pneumonia. which of the following physiologic changes associated with aging places the client at a greater risk for pneumonia?
| back 230 decreased number of cilia |
front 231 a nurse is caring fora client who has alzheimers disease and refuses to take her morning antihypertensive med. the client is oriented to name and place and is able to perform adls' with minimal supervision. which of the following actions should the nurse take?
| back 231 ask the client to express her reasons for refusing the medication and document the event |
front 232 a nurse is collecting data from an older adult client for signs of dehydration. which of the following findings should the nurse consider an expected pat of the aging process?
| back 232 decreased creatinine clearance |
front 233 an older adult client tells a nurse at a health fair " I am always forgetting things. I cannot even remember where I parked my car ! Do you think I have alzheimer's disease?" what would be the therapeutic response by the nurse ? | back 233 " that must be very upsetting. can you tell me about your forgetfulness?" |
front 234 a nurse is reinforcing teaching with a group of older adult female clients who are postmenopausal about dietary requirments. what statement should the nurse make about folic acid? | back 234 " adequate folic acid intake is associated with a reduced risk for heart disease" |
front 235 a nurse is reinforcing teaching with an older adult client who has osteoarthritis of the right hip and lower lumber vertebrae. which of the following statements by the client indicates an understanding of the teaching?
| back 235 to relieve the pressure on my hip I can use a cane while ambulating |
front 236 a nurse is collecting data from an older adult client during an annual physical. which of the following findings should the nurse report to the provider ?
| back 236 fasting blood glucose level 160 mg/dL |
front 237 a nurse is reviewing the medical record of a client who is postmenopausal and has osteoporosis. the client has a new prescription for alendronate sodium. which of the following findings in the clients history should the nurse recognize is a contraindication to this medication?
| back 237 esophageal stricture |
front 238 a nurse is collecting data from an older adult client. which of the following actions should the nurse take to collect subjective data?
| back 238 allow sufficient time for the client to respond to the questions |
front 239 a nurse in the clinic is assessing an older adult client for the second time this week. the client reports a decreased energy level, insomnia, and anorexia. Diagnositic tests are withing the expected reference ranges. For which of the following conditions should the nurse screen the client?
| back 239 depression |
front 240 a nurse is contributing to the plan of care for a client who had a stroke. which of the following goals should the nruse identify as the priority for this client?
| back 240 the client's airway will remain clear, as evidenced by clear breath sounds. |
front 241 a nurse is planning to administer diphenydramine hydrochloride to an older adult client. which of the following actions should the nurse plan to take prior to administration
| back 241 review the medical record for a client history of glaucoma |
front 242 a nurse is assisting with the care of an older adult client who has dementia. the client becomes agitated and confused at night and wanders into the hallway. what action should the nurse take? | back 242 place the clients mattress on the floor |
front 243 a nurse is contributing to the plan of care for a client who had a recent stroke and a history of GERD. for which of the following disorders should the nurse plan to monitor this client.
| back 243 aspiration pneumonia |
front 244 a nurse is caring for an older adult client who has gout and refuses to eat. the client's provider has approved the family to bring food from home. what foods should the nurse recommend that the client not eat? | back 244 lentil soup |
front 245 a nurse is caring for an older adult client. which of the following physiologic changes associated with aging can affect medication dosage in this client?
| back 245 decreased gastric motility |
front 246 a nurse is reinforcing teaching with an older adult client who has anemia. which of the following foods should the nurse recommend to increase the clients iron intake?
| back 246 dried fruit |
front 247 a nurse is reviewing the medication list of an older adult client upon admission and notes that he is taking fluoxetine for depression. the nurse should identify that fluoxetine can increase the effects of which of the following medications that is also on the clients list
| back 247 warfarin |
front 248 a nurse is assisting with the admission of an older adult client who is scheduled for surgery. the nurse is completing a medication reconciliation with the clients new admission medication prescriptions. for which of the following situations should the nurse plan to repeat the medication reconcililation process?
| back 248 the client returns to the unit from the surgical suite |
front 249 a nurse is reviewing the medication list of an older adult client and notes that the client is taking simvastatin for hypercholesterolemia as we as multiple herbal supplements. which of the following supplements indicated on the clients medication list can decrease the effect of this medication?
| back 249 st. johns wort |
front 250 a nurse is reinforcing discharge teaching with an older adult client who is taking multiple medications. which of the following information should the nurse include in the teaching?
| back 250 " you should consult with your doctor before taking any herbal supplements" |
front 251 A nurse is reviewing the laboratory results of an older adult client who is taking multiple medications. which of the following findings could impact the clients ability to distribute medication throughout his system ?
| back 251 albumin 3.0 |
front 252 a nurse is caring for a client who is using a continuous passive motion device following a right total knee replacement. which of the actions should the nurse take when using the CPM device? | back 252 line up the frame joints of the COM device with the clients knee. rationale: to avoid damage to the operative knee |
front 253 a nurse is reinforcing teaching with an older adult client who is healthy and has chronic constipation about establishing bowel retraining program. which of the following statements should the nurse include in the teaching? | back 253 increase the fiber content of your diet rationale: purpose is to manipulate factors within the clients control to produce the elimination of a soft formed stool at regular intervals. |
front 254 a nurse is reviewing the medical record of an older adult client. for which of the following medications should the nurse request a hearing assessment of the client? | back 254 furosemide rationale: can cause ototoxicity. decrease medication metabolism in the kidneys. teach client s/s of ototoxicity: tinitus and difficulty hearing |
front 255 A nurse is reinforcing teaching with an older adult client who is to start taking warfarin. which of the following statements indicates the client understands the teaching? | back 255 I can continue to eat green salads |
front 256 a nurse is collecting data from an 85 year old client. which of the following findings should the nurse report to the provider? | back 256 difference in pulse strength between lower extremities rationale: difference can indicate vascular complication, assessment of the peripheral vascular system should also include temp, color, sensation, edema, skin integrity of bother the upper and lower extremities. identify any differences in symmetry of the findings and report them. |
front 257 a nurse at a long term care facility is reinforcing teaching with an older adult client about ambulating with a quad cane. which of the following statements should the nurse include in the teaching? | back 257 hold the cane in the hand on the stronger side of your body rationale: this actions allows for a more normal gait, with the ipsliateral arm and weaker leg moving at the same time |
front 258 a nurse is collecting data from an older adult female client. which of the following findings should the nurse identify as a priority ? | back 258 rales heard in the bases of the lungs |
front 259 a nurse is collecting data from an older adult client who reports feeling anxious about financial concerns and having difficulty sleeping for several months. which of the following actions should the nurse take? | back 259 determine the clients usual sleep habits |
front 260 a nurse is assisting in the care of a client who is in hypovolemic shock. while waiting for a unit of blood, the nurse should plan to administer which of the following IV solutions? | back 260 0.9% sodium chloride |
front 261 a nurse is caring for a client who has advanced heart failure. which of the following actions should the nurse take? | back 261 enforce fluid restrictions rationale: helps reduce fluid retention in the lungs and lower extremities |
front 262 a nurse is collecting data from a client who has an abdominal aortic aneurysm what manifestations should the nurse expect? | back 262 lower back discomfort rationale : back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots causing pain |
front 263 a nurse is contributing to the plan of care for a client who has pernicious anemia. which of the following interventions should the nurse recommend? | back 263 initiate weekly injections of vitamin B12 rationale: lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract |
front 264 a nurse is reiforcing discharge teaching with a client who has a new permanent pace maker. which of the following information should the nurse include in the teaching? | back 264 avoid lifting both arms above your head when dressing rationale : dislodgement of the pacer leads can occur |
front 265 a nurse is reinforcing teaching with a client who has anemia and a new prescription for epoetin alfa. what information should the nurse include in the teaching. | back 265 hypertension is a common adverse effect to this medication rationale: rise in the prodction of erythrocytes |
front 266 a nurse is caring for a client who is post op following a vein ligation and stripping for varicose veins. which of the following actions should the nurse take ? | back 266 position the client supine with his legs elevated when in bed? rationale: promotes venous return to the heart |
front 267 a nurse is assisting in the care of a client who has abdominal aortic aneurysm and is scheduled for surgery. the clients vital signs are BP 160/98, HR 102/min, RR 22/min and SPO2 95% which of the following actions should the nurse take? | back 267 administer antihypertensive medication for blood pressure |
front 268 a nurse is collecting data from a client who has a history of peripheral arterial disease. which of the following findings on the clients lower extremities should the nurse expect? | back 268 cool, pale skin with minimal body hair |
front 269 a nurse is collecting data from a client who has a manifestation of aplastic anemia. what findings should the nurse expect? | back 269 petechiae and eccymosiss |
front 270 a nurse is administering a loop diuretic to a client who has a 3+ pitting edema in the lower extremities. what action should the nurse take? | back 270 monitor the client for ototoxicity |
front 271 a nurse is assiting the plan of care for an older adult client who is to recieve a unit of packed RBC. what action should the nurse recommend? | back 271 verify the information on the packed RBCś with another nurse |
front 272 a nurse is caring for a client who has a late stage heart failure and is experiencing fluid volume overload. what findings should the nurse expect? | back 272 weight gain of 1 kg (2.2 lbs) in 1 day |
front 273 a nurse is assisting in the preparation of a unit of packed red blood cells for a client who has anemia. which of the following actions should the nurse take first? | back 273 witness the informed consent |
front 274 a nurse is collecting data from a client who has a fluid volume overload resulting from a cardiovascular disorder. which of the following manifestations should the nurse expect? | back 274 jugular vein distension moist crackles postural hypotension |
front 275 a nurse is evaluating a clients repeat laborartory results 4 hours after administering fresh frozen plasma. what labs should the nurse review? | back 275 prothrombin time |
front 276 a nurse is caring for a client who has hemophilia. the client reports pain and swelling in a joint following an injury, | back 276 prepare for replacement of the missing clotting factor |
front 277 a nurse is assisting in collecting data from a client who has a history of unstable angina. what should the nurse expect? | back 277 the client reports chest pain when at rest |
front 278 a nurse is reinforcing teaching about lifestyle changes with a client who had a myocardial infarction and has a new prescription for a beta blocker. what statement indicates the client understand the teaching? | back 278 before taking my medication, i will check my blood pressure and radial pulse rate |
front 279 a nurse is collecting data from a client who has RS HF. what finding should the nurse expect? | back 279 dependent edema |
front 280 a nurse is caring for a client who has heart failure and is lethargic with muscle weakness. the clients telemetry displays dyrhythmias. which of the following lab results should the nurse anticipate? | back 280 potassium 2.8 mEq/L |
front 281 a nurse is checking lab values for an adult who has sickle cell anemia and is in crisis. which complication should the nurse monitor? | back 281 elevated bilirubin rationale: hemolysis of the abnormal red blood cells occurs |
front 282 a nurse is assisting in the plan of care for a client who is percutaneous transluminal coronary angioplasty with stent placement. what actions should the nurse anticipate in the postop plan of care? | back 282 initiate an aspirin regimen |
front 283 a nurse is collecting data from a client who reports using fish oil as a dietary supp. which of the following substances in fish oil should the nurse recognize as a health benefit to the client? | back 283 omega 3 fatty acids |
front 284 a nurse is monitoring a client who is recieving a unit of packed red blood cells following surgery. the client reports itching and has hives 30 minutes after the infusin begins. what action should the nurse take first ? | back 284 stop the infusion of blood |
front 285 a nurse is assisting in monitoring a client who had a myocardial infarction. what complication should the nurse monitor the first 24 ? | back 285 ventricular dysrhythmias |
front 286 a nurse is checking for cardiac tamponade on a client who has pericarditis. which of the following actions should the nurse take? | back 286 auscultate bp for pulsus paradoxus |
front 287 a nurse is collecting data from a client who has pericaditis. what should the nurse expect? | back 287 dyspnea |
front 288 a nurse caring for a patient who has gastric cancer is initiating an infusion of parenteral nutrition via the patients implanted port. which of the following is an appropriate action for the nurse ? | back 288 cover the device and the needle with a sterile tranparent dressing |
front 289 A nurse is caring for a patient who has a central venous catheter. when flushing the catheter, the nurse uses a 10 mL syringe to prevent what complication is associated with central vascular access devices | back 289 catheter rupture |
front 290 a nurse is caring for a patient who has a central venous access device in place. what routine measure should the nurse use specifically to prevent lumen occlusion? | back 290 clamping the extension tubing while removing a syringe from the injection cap |
front 291 an older adult patient who adheres to a regular cardio rehab schedule that includes water aerobics and swimming requires long term central venous access. what cva device is the best choice for allowing him to continue his aquatic program? | back 291 an implanted port |
front 292 a nurse is preparing to obtain a blood sample from a patient who has a triple lumen central catheter in place for multiple therapies. what would be an appropriate action for the nurse to take? | back 292 turn off the distal infusions for 1 to 5 minutes before obtaining the blood sample |
front 293 a nurse is caring for a patient who has a central venous catheter and suddenly develops dyspnea, tachycardia and dizziness. the nurse suspects air embolism and clamps the catheter immediately. what position should the patient be placed in? | back 293 on his left side in trendelenburg position |
front 294 a patient who sustained trauma from a motor vehicle crash is transported to an emergency department. the provider determines the need for immediate central venous access for fluid and blood replacement and prophyactic antibiotic therapy. what is the appropriate cva device for this patient? | back 294 nontunneled percutaneous central catheter |
front 295 a nurse is preparing to flush a patients peripherally inserted central catheter (PICC) because the patients catheter has a valved tip, the nurse . . . | back 295 use non heparinized saline solution for the flush |
front 296 a nurse finds a patients iv inserting site red, wam and slightly edamtous, which of the following actions should the nurse perform first | back 296 discontinue the IV line |
front 297 a nurse has just initiated a new peripheral IV infusion with 5% dextrose in water continuous infusion. how often should the nurse plan to replace the primary tubing? | back 297 every 96 hours |
front 298 a nurse who has just initiated an IV infusion explains to the patient that complications are possible and that she will monitor the infusion regularly. the nurse should teach the patient that which of the following findings is an indication of early infiltration? | back 298 coolness |
front 299 a nurse is initiating a peripheral iv infusion punctures the skin and selected vein and observes blood return in the flashback chamber of the IV catheter. what action should the nurse perform next? | back 299 lower the catheter until it is almost flush with the skin |
front 300 which of the following is an important nursing action when converting an IV infusion to a saline lock? | back 300 flush the IV cat to confirm patency |
front 301 a nurse has just inserted a peripheral IV catheter for a continuous infusion. To secure the cat. the nurse should ? | back 301 leave the connection between the hub and the tubing uncovered |
front 302 a patient in early stage renal failure is prescribed an infusion of 0.45% sodium chloride. This type of solution is appropriate because it . . . | back 302 dilutes extracellular fluid and rehydrates the cells |
front 303 a nurse is removing an IV cat from a patient who IV infusion has been discontinued. what action is appropriate? | back 303 pull the cat straight back from the insertion site |
front 304 a nurse is discontinuing an iv infusion. for which of the following reasons is it important to verify and document the integrity and condition of the IV cat? | back 304 a broken off cath. tip indicates the risk for an embolus. |
front 305 a nurse is caring for a client who has a new prescription for verapamil to treat atrial fibrillation. the nurse should instruct the client to avoid drinking grapefruit juice while taking verapamil because it can cause the client to experience which of the following conditions? | back 305 hypotension |
front 306 a nurse is providing teaching to a client who has a new prescription for losartan to treat hypertension. the nurse should instruct the client that which of the following findings could indicate an adverse to the drug and needs to be reported | back 306 facial edema |
front 307 a nurse is caring for a client who is taking a diuretic. the nurse should instruct the client to include which of the following foods in their diet to increase potassium intake? | back 307 raisins |
front 308 a nurse is teaching a client who has a new prescription for nitroglycerin. the nurse should instruct the client that which of the manifestations is a potential adverse effect of this drug? | back 308 headache |
front 309 a nurse is caring for a client who has a new prescription for dobutamine. the nurse should clarify the prescription with the provider if the client receiving which of the following types of drugs ? | back 309 MAOI general anesthetic tricyclic antidepressant beta blocker |
front 310 a nurse is caring for a client who has a new prescription for propranolol to treat tachydysrhthmia. the nurse should instruct the client to avoid taking which of the following types of OTC drugs while taking propranolol | back 310 NSAIDS |
front 311 a nurse is teaching a client who has a new prescription for quinidine. which of the following statements should the nurse include. | back 311 monitor your pulse rate and report changes |
front 312 a nurse is assessing a client who is taking a loop diuretic and is experiencing a thready, irregular pulse, orthostatic hypotension and confusion. the nurse should identify that these manifestations indicate which of the following adverse effects ? | back 312 hypokalemia |
front 313 a nurse is caring for a client who will begin using transdermal NTG to treat angina pectoris. when speaking to the client about the drug, which of the following instructions should the nurse include? | back 313
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front 314 a nurse should recognice that milrinone is contraindicated for a client who has which of the following conditions? | back 314 acute myocardial infarction |
front 315 a nurse is teaching a client who has a new prescription for gemfibrozil. which of the following instructions should the nurse include? | back 315
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front 316 a nurse is caring for a client who has glomerular filtration rate of 10 mL/min and a reduced urine output. the nurse should clarify a prescription for hydrocholorthiazide for this client because of which of the following characteristics of the drug? | back 316 the drug does not promote diuresis for clients who have renal insufficiency |
front 317 a nurse is caring for a client who is taking atorvastatin and has a new prescription for gemfibrozil. the nurse should recognize that this drug combo places the client at an increased risk for which of the following adverse effects. | back 317 myopathy |
front 318 a nurse is reviewing new prescriptions with a client who has heart disease . the nurse should instruct the client that which of the following drug is prescribed to treat hypercholesterolemia? | back 318 simvastatin |
front 319 a nurse is caring for a client who is taking amiodarone to treat a fib. which of the following should the nurse instruct the client to avoid while taking this drug? | back 319 grape fruit juice |
front 320 a nurse is caring for a client who is about to begin captopril therapy. which of the following adverse effects should the nurse instruct the client to report because it can indicate a need to discontinue drug therapy? | back 320
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front 321 a nurs eis caring for a client who is taking spironolactone to treat hypertension. the nurse should recognize that which of the following client lab values requires immediate intervention | back 321 potassium 5.2 mEq/L |
front 322 a nurse is administering hydrochlorothiazide to a client who has gouty arthritis. the nurse should monitor the client for which of the following findings that indicates an adverse effect of this drug? | back 322 hyperuricemia |
front 323 a nurse is caring for a client who has a new prescripition for aliskiren to treat hypertension. the nurse should monitor the client for which of the following findings as an adverse effect of the drug | back 323
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front 324 a nurse is caring for a client who is taking carvedilol and has a prescription for an oral antidiabetic drug to manage their new diagnosis of type 2 diabetes mellitus. By taking both drugs concurrently, the nurse should identify that the client is at an increased risk for which of the following conditions ? | back 324 hypoglycemia |
front 325 a nurse is caring for a client who has a new prescription for verapamil. the nurse should clarify the prescription with the provider if the client has a history of which of the following conditions? | back 325 second degree av block |
front 326 a nurse should identify that which of the following drugs is used only for the short term treatment of cardiac dysrhthmia because of the serious adverse effects associated with long term use? | back 326 procainamide |
front 327 a nurse is caring for a client who is taking digoxin and develops changes on their ECG tracing and other manifestations that indicate the client has severe digoxin toxcity. which of the following drugs should the nurse expect to administer to treat this complication | back 327 antigen binding fragments |
front 328 a nurse is providing teaching to a client who is taking simvastatin. the nurse should instruct the client to report which of the following manifestations as an indication of a serious adverse reaction that could require discontinuing drug therapy? | back 328 muscle pain |
front 329 the provider talks with the client about clomiphene therapy. what instruction should the provider include? | back 329 begin 5 days after menstruation begins and take it every day for next 5 days |
front 330 what adverse effects does clomiphene cause ? | back 330 - blurred vision - hot flashes breast engorgement - nausea |
front 331 recognizing the adverse effects of terbutaline, the nurse should monitor the client for what? | back 331 tachycardia |
front 332 what drug should the nurse have available to reverse the adverse effects of terbutaline? | back 332 propanolol |
front 333 the health care provider instructs the client to monitor for what when a taking conjugated estrogen and medroxyprogesterone acetate to treat postmenopausal vasomotor symptoms? | back 333 - swelling or pain in calf |
front 334 combination oral contraceptives such as ethinyl estradiol and drospirenone, should be used with caution when a patient has what disorder? | back 334 diabetes |
front 335 a client is prescribed testosterone to treat testicular failure. the nurse instructs the client to monitor and report what symptom? | back 335 weight gain |
front 336 a client is prescribed finasteride to treat bph. when providing instruction about finasteride, the nurse should include which of the following information? | back 336 allow 6 to 12 months to see improvement |
front 337 what medication should a health care provider question the use of when using sildenafil to treat erectile dysfunction? | back 337 nitroglycerin as needed for chest pain |
front 338 a client is prescribed clomiphen for infertility. the hcp instructs the client to monitor for what? | back 338 pelvic pain |
front 339 for rapid relief of urinary obstruction due to prostatic enlargment, the hcp should choose what drug? | back 339 tamsulosin |
front 340 the hcp administers oxytocin for induction of labor. the hcp should monitor what order to assess for an adverse effect to oxytocin | back 340 - urine output - bp duration of contractions - fetal heart rate |
front 341 a nurse is caring for a male client who has hyperthyroidism and is not responding to treatment. the nurse should identify that hyperthyroidism is a contraindication of what drug? | back 341 Bethanechol |
front 342 a nurse is caring for a client who missed a dose for her oral contraceptive. what instruction should the nurse give? | back 342 take missed dose as soon as possible |
front 343 a nurse is caring for a client who is taking a combo oral contaceptive ehtinyl estradiol and drospirenone and is about to begin taking rifampin to treat TB . what instruction should the nurse give the client do to possible drug interactions ? | back 343 use additional birth control methods |
front 344 a provider has prescribed a dinoprostone vaginal insert to promote cervical ripening in a client who is 40 weeks gestation. when administering dinoprostone, what actions should the nurse take | back 344 - urinate prior to insertion - remove the pouch when active labor begins - moniter for uterine hyperstimulation - monitor the patients temperature |
front 345 after administering terbutaline to a client to inhibit preterm labor, the nurse should asses what? | back 345 Heart Rate |
front 346 a nurse is providing teaching to a client about using leuprolide to treat endometriosis. what instruction should the nurse include? | back 346 perform weight bearing activities |
front 347 a nurse is assessing a client who has a new prescription for the combo oral contraceptive ethinyl estradiol and drospirenone. what findings should the nurse identify as a contraindication to use of this medication? | back 347 client smokes half a pack of cigarettes a day |
front 348 a nurse is caring for a client who is about to begin taking cabergoline to treat infertility. the nurse should explain that the client needs to monitor which of the following labs ? | back 348 prolactin level |
front 349 a nurse is caring for a client who received human menopausal gonadotropin what should the nurse expect to find? | back 349 follicular maturation |
front 350 a nurse is providing safety education to a client who is scheduled to begin treatment for BPH. what instructions should the nurse include in the teaching? | back 350 change positions slowly |
front 351 a nurse is providing teaching to a client about sildenafil to treat erectile dysfunction. what instruction should the nurse include? | back 351 do not take the drug with high fat foods |
front 352 a nurse is caring for a client who has a new prescripition for transdermal conjugated estrogen and medroxyprogesterone to treat postmenopausal symptoms. what therapeutic effects should the nurse explain to the client | back 352 - reduces the risk of ovarian cancer - relieves hot flashes - prevents osteoporosis |
front 353 a nurse is caring for aclient who has a new prescription for conjugated equine estrogen. the nurse should instruct the client to report which indication of a serious adverse reaction? | back 353 vaginal bleeding |
front 354 a nurse is preparing to administer finasteride to a client who has bph. what precaution should the nurse plan to take when administering this drug? | back 354 wear gloves when handling the table |
front 355 a nurse is assessing a client who has a new prescription to oxybutynin to treat neurogenic bladd. what assessment finding should the nurse identify as an adverset effect? | back 355 - dilated pupils - dizziness - distended bladder - fever |
front 356 a nurse is caring for a client who is about to begin cloiphene therapy to treat infertility. the nurse should monitor the client for which of the following adverse effects ? | back 356 ovarian hyperstimulation syndrome |
front 357 a nurse should question the use of conjugated equine estrogen by a client who has a history of what? | back 357 blood clots |
front 358 a nurse is providing teaching to a client who is taking bethanechol for urinary retention. what instructions should the nurse include | back 358 - avoid driving and activities that require alertness - increase fluid intake - stay close to a bathroom after taking the drug |
front 359 a nurse is teaching a client about conjugated estrogen and medroxyprogesterone. what instructions should the nurse include? | back 359 have blood pressure checked regularly |
front 360 a nurse is teaching a client who has a prescription for a testosterone transdermal patch. what statement indicates the client understand the teaching ? | back 360 i should apply the medications to a different site each time |
front 361 the nurs eis caring for a client who is about to begin taking finasteride to treat BPH the nurse should explain to the client that monitoring which lab is important? | back 361 prostate specific angtigen |
front 362 a nurse is teaching a client about receiving leuprolide to treat endometriosis. the nurse should instruct the client to expect what side effect? | back 362 vaginal dryness |
front 363 a nurse is caring for a client who has BPH and is taking tamsulosin. the nurse should question the use of the drug if the client also has | back 363 erectile dysfunction for which he takes sildenafil |
front 364 a nurse should question the use of estadiol and drospirenone by a client who has a renal disease due to increased risk of what? | back 364 hyperkalemia |
front 365 a nurse is reinforcing teaching for a client who has angina pectoris and a new prescription to apply a nitroglycerin transdermal patch daily at home. what instruction should the nurse give the client? | back 365 fold used patch with medication area to the inside and discard in a closed receptacle |
front 366 a nurse is talking with a client who is about to start taking NTG oral, sustained release capsuls. what should the instructions include? | back 366 swallow the capsules whole |
front 367 a nurse is caring for a client who has a prescription for metoprolol. the nurse measures the clients vital signs and notes that the apical hr is 49/min the nurse should prepare to administer which of the following ? | back 367 atropine |
front 368 a nurse is caring for a client who has heart failure notices that the client did not receive his scheduled dose of furosemide. when filling out an incident report about the occurrence, which oft he followig information should the nurse include? | back 368 - clients breath sounds clear bilaterally - the nurse documents the clients status as a result of the occurrence - the clients statement about the occurrence |
front 369 a nurse is reinforcing teaching a client who has a new prescription for transfermal NTG to treat angina. the nurse should include what instructions? | back 369 apply patch to a hairless area apply a new patch each morning remove patch for 10 to 12 hours daily |
front 370 a nurse is reinforcing discharge teaching with a client prescribed verapamil to treat angina what should be the nursing instructions | back 370 monitor for increased heart rate while taking this medication |
front 371 a nurse at a providers office is assessing a client who has been taking hydrocortisone for adrenal insufficiency. the client reports fatigue and feeling overwhelmed by personal responsibilities. which of the following findings should the nurse identify as an indication the provider might need to increase the clients dosage? | back 371 hypotension |
front 372 a nurse is providing teaching to a client who is about to begin exenatide therapy to treat type 2 diabetes mellitus. which of the following instructions should the nurse include? | back 372
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front 373 a nurse caring for a client who is about to begin taking pioglitazone to treat type 2 diabetes mellitus. the nurse should explain to the client about the need to monitor which of the follow laboratory values | back 373 ALT LDL |
front 374 a nurse is caring for a client who is about to begin taking Propulthiouracil PTU to treat hyperthyroidism. the nurse should instruct the instruct the client to report which of the following adverse effects | back 374 sore throat joint pain bradycardia rash |
front 375 a nurse is teaching a client about self administering regular insulin. the nurse should instruct the client to rotate injection sites to prevent which of the following | back 375 lipohypertrophy |
front 376 a nurse is caring for a client who is taking metformin and is scheduled to undergo angiography using iodine containing contrast dye. the nurse should identify that an interaction between metformin and the IV contrast dye increases the clients risk for which of the following conditions? | back 376 acute renal failure |
front 377 a nurse is providing teaching to a client about taking fludrocoritsone to treat adrenocortical insufficiency. which of the following instructions should the nurse include? | back 377
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front 378 a nurse should recognize that a provider will prescribe a lower dose of sitagliptin for a client who has type 2 diabetes and who also has what? | back 378 renal impairment |
front 379 a nurse is teaching a client who is about to begin levothyroxine therapy to treat hypothyroidism. which of the following instructions should the nurse include? | back 379 expect life long therapy with the drug |
front 380 a nurse is caring for a client taking PTU and reports weight gain, drowsiness and depression. the nurse should identify that the client is experiencing which of the following adverse reactions | back 380 hypothyroidism |
front 381 a nurse is speaking with a client who is taking glipizide to treat type 2 diabetes mellitus and has called to report feeling shaky, hungry, and fatigued. which of the actions should the nurse instruct the client to take? | back 381 perform a fingerstick blood glucose check |
front 382 a nurse is assessing a client who has a new prescription for levothyroxine the nurse should identify which of the following findings as a contraindication | back 382 recent MI |
front 383 a nurse is educaton the parent of a child who has Prader willi syndrome and has been prescribed somatropin. which of the following statements by a parent indicates understanding of the teaching? | back 383 we will use a different spot for injection each time we give the medication |
front 384 a nurse is teaching a client who has a prescription for glipizide what instruction should the nurse include | back 384 avoid alcohol |
front 385 a nurse is teaching a client about acarbose to treat 2 diabetes. which of the following instructions should the nurse include? | back 385 eat more iron rich foods |
front 386 a nurse is caring for a client who is about to begin insulin glargine therapy. the nurse should identify the need for additional precautions because the client also takes which drugs ? | back 386 beta blockers |
front 387 a nurse is caring for a client who is begin taking somatropin. the nurse should explain the need to monitor which of the following lab values? | back 387 urine calcium blood glucose |
front 388 a nurse is caring for a client who takes repaglinide 15 to 30 minutes before each meal to treat type 2 DM. the client asks if i skip a meal what should i do? which of the following responsese should the nurse make? | back 388 skip the dose |
front 389 a nurse is teaching a client who has a prescripiton for pramlinitide therapy to treat type 1 DM. which of the following instructions should the nurse include? | back 389 administer before meals |
front 390 which of the following drugs should a nurse have available for a client who is experiencing insulin toxicity? | back 390 glucagon |
front 391 a nurse is caring for a client who is taking metformin to treat type 2 dm and reports muscle pain. which of the following adverse reactions should the nurse suspect? | back 391 lactic acidosis |
front 392 a nurse is caring for a client who is taking desmopressin. the nurse should make whihc of the following assessments to evaluate the drugs effectiveness? | back 392 urine output |
front 393 when considering replacement therapy options for a client who has chronic adrenocoritcal insufficiency, a nurse should recognize the provider will choose which drug? | back 393 hydrocortisone |
front 394 a nurse administers pramlintide at 0800 to a client who has type 1 DM. at which of the following times should nurse expect the drug to exert its peak ? | back 394 0820 |
front 395 a nurse is caring for a client who is taking pioglitazone to treat type 2 dm. the nurse should monitor for which of the following findiings ? | back 395 weight gain |
front 396 a nurse is caring for a male client who has an upper urinary tract infection. the nurse should identify that the infection is in which of the following portions of the urinary tract | back 396 kidney |
front 397 a nurse is reinforcing teaching with a client who has a urinary tract infection and a prescription for cipro. which of the following instructions should the nurse include? | back 397 ¨ you should not take an antacid within 2 hours of taking cipro " |
front 398 a nurse is assisting with the development of plan of care for a client who has cystitis. which of the following interventions should the nurse include in the plan of care? | back 398 provide the client with a warm sitz baths |
front 399 a nurse is reviewing the medical record of an older adult male client. the nurse should identify that which of the following findings place the client at risk for developing a uti? | back 399 the client has prostate disease |
front 400 a nurse is collecting data from a client who has urosepsis. which of the following findings should the nurse expect? | back 400 decreased urinary output |
front 401 a nurse is caring for a client who has a new prescription for maraviroc therapy. the nurse should instruct the client to report which of the following adverse effects? | back 401 Paresthesia |
front 402 a nurse should recognize that realtegravir is used to treat clients who have which of the following conditions? | back 402 Resistant HIV disease |
front 403 a nurse is caring for a client who has a prescription for cisplatin to treat testicular cancer. the nurse should instruct the client to report which of the following adverse effects? | back 403 Paresthesias |
front 404 a nurse is teaching a client about recommended immunizations. which of the following immunizations should the nurse recommend the client receive starting 50 years of age? | back 404 herpes zoster |
front 405 a nurse is assessing a client following a trastuzumab infusion to treat metastatic breast cancer. which of the following findings should the nurse recognize as an indication that the client is experiencing an adverse reaction to the drug? | back 405 wheezing dysrhythmias hypotension fever |
front 406 a nurse is teaching a client about maraviroc. which of the following instructions should the nurse include? | back 406 "it is important to report any noticeable rash immediately as it might indicate an issue with your liver" |
front 407 a nurse is teaching a guardian of a child about the recommended age range to recieve the hpv vaccine which of the following age ranges should the nurse include? | back 407 11 to 12 |
front 408 A nurse is teaching a client who has a new prescription for mercaptopurine to treat leukemia. Which of the following instructions should the nurse include? | back 408 Use contraception if pregnancy is a risk |
front 409 A nurse is instructing a client how to self- administer enfuvirtide. Which of the following instructions should the nurse include? | back 409 Allow the vial to sit until the solution is completely clear and without particulates |
front 410 a nurse is teaching about immunizations . which of the following information should the nurse include in the teaching? | back 410 you should receive a tetanus booster every 10 years |
front 411 a nurse is teaching a client who has a new prescription imatinib to treat chronic myeloid leukemia. which of the following instructions should the nurse include? | back 411 clean fruits and veggies thoroughly weigh yourself daily perform hand hygiene avoid grapefruit and grapefruit juice |
front 412 a nurse should recognize that enfuvirtide can be prescribed to clients who have which of the following conditons? | back 412 advanced HIV |
front 413 a nurse is caring for a client who has a new prescription for ritonavir and zidovudine is prescribed with ritonavir for which of the following reasons? | back 413 to prevent drug resistance |
front 414 a nurse is preparing to administer enfuvirtide to a client. which of the following actions should the nurse plan to perform? | back 414 -Administer the drug subcutaneously. |
front 415 a nurse is caring for a client who has a new prescription for delavirdine therapy to treat HIV 1. the nurse should instruct the client to report which oft he following adverse reactions to the drug? | back 415 rash |
front 416 A nurse is preparing to administer paclitaxel IV to a client who has ovarian cancer. Which of the following actions should the nurse take. (Select all that apply). | back 416 -Give the patient an antihistamine. |
front 417 A nurse is teaching the guardian of a 4- month- old infant about recommended immunizations for the infant. Which of the following immunizations should the nurse include? | back 417 Haemophilus influenza type B vaccine (Hib) |
front 418 A nurse is caring for a client who has a new prescription for intrathecal cytarabine therapy to treat meningeal leukemia. The nurse should inform the client that they will also receive which of the following drugs to reduce the risk of neurotoxicity? | back 418 Dexamethasone |
front 419 A nurse is caring for a client who is receiving vincristine to treat lung cancer. The nurse should monitor the client and recognize which of the following manifestations as an indication that the client is experiencing an adverse reaction to the drug. | back 419 Weak hand grasps. |
front 420 A nurse is caring for a client who is prescribed zidovudine. Which of the following laboratory values should the nurse report to the provider? | back 420 hemoglobin 7.1 |
front 421 A nurse is preparing to administer the measles, mumps, and rubella (MMR) vaccine to a child. The nurse should recognize that the MMR vaccine provides which of the following types of immunity? | back 421 Artificial active immunity |
front 422 A nurse is teaching a client who has a new diagnosis of breast cancer about the drug tamoxifen. The nurse should tell the client that which of the following conditions is a contraindication for taking tamoxifen? | back 422 Deep-vein thrombosis |
front 423 A nurse is caring for a client who has a new prescription for topotecan therapy to treat resistant, small-cell lung cancer. The nurse should advise the client against taking which of the following types of over-the-counter drugs while receiving the therapy? | back 423 ibuprofen |
front 424 A nurse should recognize that maraviroc is used in the treatment of which of the following conditions? | back 424 Chemokine receptor 5 (CCR5)-tropic HIV-1 |
front 425 A nurse is considering drug therapy options for a client who has metastatic breast cancer that is positive for human epidermal growth factor receptor 2 (HER2). Which of the following drugs should the nurse expect the provider to prescribe? | back 425 Trastuzumab |
front 426 THE LPN IS OBSERVING THE CLIENTS CARDIAC RHYTHM ON THE MONITOR SCREEN AND NOTES THAT THERE IS AN ADDITIONAL PROMINENT WAVE FOLLOWING EACH T WAVE AND SUSPECTS THE PRESCENCE OF U WAVES. WHAT ACTIONS SHOULD THE LPN TAKE? | back 426 no data |
front 427 what are some causes of Fluid Volume Deficit ? | back 427 Vomiting
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front 428 suspected data for a client with fluid volume deficit? | back 428
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front 429 interventions for fluid volume deficit? | back 429
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front 430 a client with kidney damage or failure is at high risk for what? | back 430 fluid volume excess |
front 431 possible causes of fluid volume excess ? | back 431
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front 432 Objective and Subjective data collection for a client who is experiencing fluid volume excess? | back 432
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front 433 interventions for a client who is experiencing fluid volume excess? | back 433
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front 434 what type of diet should a person experiencing fluid volume excess be on? | back 434 low sodium |
front 435 HYPOkalemia | back 435 potassium values less than 3.5mEq/L life threatening |
front 436 food sources for potassium | back 436
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front 437 causes of hypokalemia | back 437
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front 438 s/s of HYPOkalemia | back 438
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front 439 a nurse is caring for a group of clients who have mobility issues. which of the following clients is at the greatest risk for a complication?
| back 439 an 80 year old client who has a fractured hip |
front 440 a nurse manager has established staff nurse committees to address unit issues, instituted an open door policy for talking about concerns, and supported the professional development of all staff members. which of the following leadership is this nurse manager?
| back 440 democratic |
front 441 an experienced nurse is serving as a mentor to a newly licensed nurse. which of the following actions should the mentor perform?
| back 441 serve as a guide and teacher for the newly licensed nurse in an established relationship |
front 442 a nurse on a medical surgical unit is planning for a group of clients. which of the following clients should the nurse attend to first?
| back 442 a client who has a cast newly applied on the forearm and reports tingling of the fingers rationale : use ABC's to collect data |
front 443 a nurse is a member of a quality improvement committee seeking to reduce the risk of adverse events in a health care facility. when reviewing recently submitted incident reports, which of the following incidents should the nurse identify as a sentinel event? \
| back 443 paralysis of the clients lower extremeties occurred following epidural anesthesia |
front 444 a nurse in an urgent care facility is preparing to administer a stat dose of medication to a toddler who is accompanied by their parent. the child is not wearing an identification band. How should the nurse identify the client?
| back 444 ask the parent to identify the child by name |
front 445 a nurse is reviewing a new prescription by a provider. the nurse should verify that which of the following components of a prescription are present? Select all that apply
| back 445 Date and time dosage of medication route of administration generic name of medication providers signature |
front 446 A nurse receives a telephone prescription from a provider. The provider states " administer three-tenths of a milligram of nitroglycerin orally to the client." How should the nurse trasncribe "three-tenths of a milligram" on the MAR?
| back 446 0.3 |
front 447 a nurse is preparing to administer medication to the client. which of the following should the nurse use to identify the client? select all that apply
| back 447 telephone number name photograph assigned id number |
front 448 a nurse is asked to administer a medication to a client because a coworker must help with an emergency. the coworker gives the nurse a syringe labeled furosemide 20 mg. the label also includes the client's name and hospital id number. which of the following responses by the nurse is appropriate?
| back 448 I'll go help with the emergency situation while you administer the medication |
front 449 a nurse is administering medications to a client. which of the following actions should the nurse perform during the planning step of the nursing process?
| back 449 calculate the dose verify the dose |
front 450 a charge nurse is explaining her understanding of quality improvement to a newly hired LVN. which of the following statements by the newly hired nurse requires further teaching?
| back 450 quality improvement measures the degree to which an agency has met a criterion rationale: quality improvement promotes quality care and focuses on prevention. quality assurance measures the degree to which an agency has met a criterion |
front 451 magnet recognition program | back 451 healthcare organizations that participate in this program must collect data about nursing sensitive outcomes |
front 452 which of the following is an iatrogenic risk factor that can increase a client's risk for falls ?
| back 452 type and number of medications prescribed for the client rational: prescription medications are iatrogenic risk factors, which are related to the treatment regimen |
front 453 a charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. the client has a history of night sweats, anorexia, and weight loss. which ofthe following actions should the nurse take?
| back 453 assign the client to a private room with negative pressure airflow wear an n95 when entering the clients room rationale: history and status suggests TB. communicable infection, airborne precautions |
front 454 a nurse is assisting with the plan of care for a client who has cushings syndrome due to chronic corticosterioid use. which of the folllowing actions should the nurse include in the plan of care?
| back 454 check for hypertension rationale: the nurse should check for hypertension which can indicate fluid volume overload |
front 455 a nurse is collecting data from a client who has pericarditis. which of the following manifestations should the nurse expect?
| back 455 dyspnea rationales: pericarditis clients will experience dyspnea, hiccups and nonproductive cough which may indicate heart failure |
front 456 a nurse collecting data from a client who has a closed head injury and is receiving mannitol for manifestations of increase intracranial pressure. which of the following findings indicates the medication is having a therapeutic effect?
| back 456 the clients urine output is 250 mL/hour rationale: mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water from the brain tissue. |
front 457 a nurse is reinforcing discharge teaching with a client who is postoperative following a right mastectomy for breast cancer. the client will be going home with 2 jackson pratt drains. which of the following peices of information should the nurse include in the teaching?
| back 457 avoid wearing deodorant until the drains are removed and the incision heals rationale: avoid deodorant and talcum powder until healed |
front 458 a nurse is caring for a client who has just returned from the surgical suite following a right nephrectomy. which of the following indicates that the client is meeting successful short term goal following this procedure ?
| back 458 urinary output is 35 to 50 mL/hr rationale: less than 30 mL indicates inadequate blood flow to the remaining kidney |
front 459 a nurse is collecting data from a client who is postop following ESWL. the nurse should identify that which of the following findings is the priority?
| back 459 report palpations rationale: think of ABC's |
front 460 a nurse is collecting data from a client who is admitted to the facility for observation following a closed head injury. which of the following data is the priority for the nurse to collect to detect a change in the client's neurological status?
| back 460 Level of consciousness rationale : change in LOC can be first indication of a change in neurologic status |
front 461 A nurse is reinforcing teaching about hypoglycemia with a client who has DM. which of the following manifestations should the nurse include?
| back 461 diaphoresis, shakiness, palpitations |
front 462 a nurse is caring for a client who has lung cancer that has metastasized. which of the following findings indicates the client is developing superior vena cava syndrome?
| back 462 facial edema rationale: svc is partial occlusion of the superior vena cava leading to decreased blood flow through the vein the earliest manifestation is facial and upper extremity edema |
front 463 a nurse is caring for a client who has 20 year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. the client is dyspneic and has an oxygen sat via pulse ox of 85% which of the following actions should the nurse take ?
| back 463 increase the oxygen flow and request an arterial blood gas determination rationale: increase the flow and evaluate its effectivness with ABG results |
front 464 a nurse is preparing an automated external defib. for a client receiving CPR after a cardiac arrest. which of the following actions should the nurse perform first?
| back 464 apply the defib pads to the clients chest |
front 465 a nurse is reinforcing discharge teaching with a client who has aplastic anemia. which of the following statements should the nurse identify as an indication that the client understands instructions?
| back 465 I should eliminate uncooked foods from my diet for now rationale: eating thoroughly cooked foods can help prevent infections avoid raw fruits and veggies |
front 466 a nurse names 3 objects for the client to remember, asks the client to repeat them, and tells the client he will have to repeat them again in a few minutes. after 5 minutes, the nurse asks the client to name the objects. the nurse is using this strategy to test which type of memory? | back 466 immediate rationale: 3 object protocol involved |
front 467 a nurse is reinforcing discharge teaching with the partner of a client who has AIDS. which of the following statements by the clients partner indicates further teaching?
| back 467 I'll clean blood spills immediately with hot water rationale: clean with bleach and wear gloves |
front 468 during a neurological eval. a nurse asks how the client arrived at the appointment and with whom. which of the following types of memory is the nurse testing? | back 468 recall/ recent |
front 469 a nurse is reinforcing teaching about dietary modifications for a client with newly diagnosed with cirrhosis. which of the following foods should the nurse recommend ?
| back 469 grilled chicken |
front 470 A NURSE IS REINFORCING DISCHARGE TEACHING TO A CLIENT FOLLOWING OPEN RADICAL PROSTATECTOMY. THE CLIENT IS GOING HOME WITH AN INDWELLING URINARY CAT. WHICH OF THE FOLLOWING STATEMENTS BY THE CLIENT INDICATES UNDERSTANDING OF THE TEACHING ? 1. I WILL BE ABLE TO TAKE A TUB BATH IN 1 WEEK 2. i WILL TAKE ACETAMINOPHEN IF i HAVE ANY PAIN 3. i WILL USE SUPPOSITORIES TO PREVENT CONSTIPATION 4. i WILL REGAIN MY BLADDER CONTROL ONCE THE CATHETER IS REMOVED | back 470 TAKE ACETAMINOPHEN IF PAIN |
front 471 A NURSE IS COLLECTING A HEALTH HISTORY FROM A CLIENT WHO HAS SKIN CANCER. WHICH OF THE FOLLOWING CLIENTS HISTORY AT THE HIGHEST RISK FACTOR FOR DEVELOPING SKIN CANCER 1. AGE OVER 60 2. GENETIC PREDISPOSITION 3. LIGHT SKINNED RACE 4. OVER EXPOSURE TO SUNLIGHT | back 471 OVER EXPOSURE TO SUNLIGHT |
front 472 A NURSE IS CARING FOR A CLIENT WHO IS RECEIVING CHEMO TO TREAT CANCER. WHICH OF THE FOLLOWING EFFECTS SHOULD THE NURSE ANTICIPATE FROM THE CHEMO> 1. GINGIVAL HYPERPLASIA 2. HIRSUTISM 3. PANCYTOPENIA 4. WEIGHT GAIN | back 472 PANCYTOPENIA - BONE MARROW SUPPRESSION - DEFICIENCY OF WBCS, RBCS AND PLATELT COUNTS - ADVERSE EFFECT OF CHEMO |
front 473 A NURSE IS CARING FOR A CLIENT WHO HAS LUNG CANCER THAT HAS METASTASIZED. WHICH OF THE FOLLOWING INDICATES THE CLIENT IS DEVELOPING SUPERIOR VENA CAVA SYNDROME? 1. IRREGULAR CARDIAC RHYTHM 2. NUMBNESS IN THE HANDS 3. MUSCLE CRAMPS 4. FACIAL EDEMA | back 473 FACIAL EDEMA |
front 474 A NURSE IS COLLECTING DATA FROM A CLIENT WHO HAS CANCER AND IS RECEIVING CHEMOTHERAPY BY PERIPHERAL IV INFUSION. THE CLIENT REPORTS PAIN AT THE INSERTION SITE AND THE NURSE NOTES FLUID LEAKING AROUND THE CATHETER. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE FIRST? 1. TAKE A PHOTOGRAPH OF THE PERIPHERAL IV SITE 2. OBTAIN AN RECORD THE CLIENTS VITAL SIGNS 3. STOP THE INFUSION IDENTIFY ALL MEDICATIONS ADMINISTERED THROUGH THE IV SITE FOR THE PAST 24 HRS | back 474 STOP THE INFUSION |
front 475 A NURSE IS CARING FOR A CLIENT WHO HAS TESTICULAR CANCER AND IS EXPERIENCING PERIPHERAL NEUORPATHY AS AN ADVERSE EFFECT OF CHEMO. WHICH OF THE FOLLOWING CLIENT MANIFESTATIOS IS AN EXPECTED FINDING OF PERIPHERAL NEUROPATHY? 1. THINNING OF THE SCALP HAIR 2. TINGLING OF THE HANDS AND FEET 3. REDUCED ABILITY TO CONCENTRATE 4. SORES IN THE MUCOUS MEMBRANES | back 475 TINGLING IN THE HANDS AND FEET |
front 476 A NURSE IS COLLECTING DATA FROM A CLIENT. WHICH OF THE FOLLOWING FINDINGS IS THE HIGHEST RISK FACTOR FOR DEVELOPING BLADDER CANCER 1. THE CLIENT IS A HAIRDRESSER 2. THE CLIENT USES TOBACCO 3. THE CLIENT IS OVER 60 YEARS 4. THE CLIENT HAS FREQUENT UTIS | back 476 THE CLIENT USES TOBACCO |
front 477 A nurse is planning care for client who has cancer and has developed thrombocytopenia following chemotherapy. Which of the following precautions should the nurse offer to minimize the adverse effects of thrombocytopenia? 1. MONITOR VISITORS FOR MANIFESTATIONS OF INFECTION 2. REMIND THE CLIENT TO USE AN ELECTRIC RAZOR 3. ENCOURAGE FREQUENT REST PERIODS 4. INSTRUCT THE CLIENT TO RINSE MOUTH DAILY WITH NORMAL SALINE | back 477 REMIND THE CLIENT TO USE AN ELECTRIC RAZOR NEUTROPENIA PROHIBIT VISITORS, THROMBOCYTOPENIA DO NOT |
front 478 A nurse is collecting a health history from a female client who is undergoing screening for breast cancer. Which of the following factors should the nurse identify for placing the client at the greatest risk for developing breast cancer? 1. OBESITY 2. ORAL CONTRACEPTIVE USE 3. ALCOHOL USE 4. OVER 50 YEARS OF AGE | back 478 OVER 50 YEARS OF AGE |
front 479 A nurse is providing teaching to a client who has cancer and is receiving external radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? 1. I NEED TO PROTECT THE AREA FROM SUNLIGHT 2. IM GOING TO APPLY SKIN LOTION TO THE AREA EVERY DAY 3. ILL MASSAGE THE AREA ONCE PER DAY 4. ILL WASH THE MARKINGS OFF AFTER EACH THERAPY TREATMENT | back 479 I NEED TO PROTECT THE AREA FROM SUNLIGHT |
front 480 A nurse is providing postoperative discharge teaching to a client following a pan hysterectomy for uterine cancer. Which of the following information should the nurse include in the teaching? 1. YOU WILL NEED TO CONTINUE TO USE SOME FORM OF BIRTH CONTROL FOR 6 MONTHS 2. YOU MIGHT EXPERIENCE MANIFESTATIONS OF MENOPAUSE 3. DO NOT LIFT ANYTHING HEAVIER THAN 15 POUNTS 4. PAIN OR BURNING ON URINATION IS AN EXPECTED OUTCOME OF THIS SURGERY | back 480 YOU MIGHT EXPERIENCE MANIFESTATIONS OF MENOPAUSE |
front 481 A nurse is admitting a client who has multiple myeloma and a white blood cell count of 2,200/mm3. Which of the following foods should the nurse prohibit the family members from bringing to the client? 1. FRIED CHICKEN FROM A FAST FOOD RESTURAUNT 2. A CASE OF CANNED NUTRITIONAL SUPPLEMENTS 3. A FACTORY SEALED BOX OF CHOCOLATES 4. A FRESH FRUIT BASKET | back 481 A FRESH FRUIT BASKET |
front 482 A nurse is obtaining a health history from a client who has cancer of the cervix. Which of the following manifestations should the nurse expect? | back 482 VAGINAL BLEEDING |
front 483 A nurse in an oncology clinic is assessing a client who has early stage Hodgkin's lymphoma. Which of the following findings should the nurse expect? 1. BONE AND JOINT PAIN 2. ENLARGED LYMPH NODES 3. INTERMITTENT HEMATURIA 4. PRODUCTIVE COUGH | back 483 ENLARGED LYMPH NODES |