A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of thefollowingactions should the nurse take?
A
... [Show More] nurseisreinforcingteachingaboutanesophagogastroduodenoscopy withaclientwhohasuppergastricpain.Whichofthefollowingstatements
shouldthenurseincludeintheteaching?
A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following ageneralized tonic-clonic seizure. Which of the
following descriptions should the nurse use when documenting this finding in the medical record?
A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopiccholecystectomy. Which of the following statements
should the nurse make?
A nurse is checking the suction control chamber of a client's chest tube and notes that there is nobubbling in the suction control chamber. Which
of the following actions should the nurse take?
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of thefollowing actions should the nurse take?(Selectall that
apply.)
A nurse is assisting with the care of a client who is postoperative following surgical repair of a fracturedmandible. The client’s jaw is
wired shut to repair and stabilize the fracture. The nurseshould recognize which of thefollowing is thepriority action?
A nurse is collecting data from a client who has scleroderma. Which of the following findings should thenurse expect?
A nurse is caring for an older adult client who has dysphagia and left-sided weakness following astroke. Which of the following actions should the
nurse take?
A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, andchest. The nurse shouldrecognize which of
thefollowing is the priority risk tothe client?
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the
following instructions should the nurse include in the teaching?
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary
catheter with continuous irrigation. The nurse notes there hasnot been any urinary output in the last hour. Which of the following actions should the
nurse perform first?
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will
hurt. Which of the following responses should the nursemake?
pH 7.22
PaCO2 68 mm Hg
Base excess -2
PaO2 78 mm Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG
values should the nurse make
A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke.
Which of the following interventions should the nurse include in the plan?
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the
client for which of the following manifestations?
A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of
7/min. The arterial blood gas (ABG) values include:
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurseshould recognize that which of the following
statements by the client indicates a need for further teaching?
A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the
nurse approaches him. Which of the following actionsshould the nurse plan totake?
A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The
nurse should recognize this is a manifestation of which of thefollowing?
A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3
. Which of the following food items brought by the family
should the nurse prohibit from being given to the client?
A nurse is contributing to the plan of care for an older adult client who is postoperative following a righthip arthroplasty. Which of the following
interventions should the nurse include in the plan?
A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actionsshould the nurse take first?
A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longercertain he wants to have the procedure. Which
A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight onthe operative foot. The nurse enters the room
to discover the client hopped on one foot to the bathroom, using an IVpole for support. Which of the following actions should the nurse take?
A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainagesystem in place. Which of the following actions
should thenurse take?
A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the followingstatements by the client indicates an understanding
of the teaching?
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosedwith emphysema. Which of the following
instructions should be included in the teaching?
A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of thefollowing manifestations should thenurse
monitor?
a nurse is is reinforcing teaching with a client who has HIV and is being discharged to home.Whichof the following
instructions should the nurse include inthe teaching?
Following admission, a client with a vascular occlusion of the right lower extremity callsthe nurse and reports
difficulty sleeping because of cold feet. Which of the following nursing actions should thenurse taketopromote
the client's comfort?
A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate
(TURP). Which of the following is the priority finding for thenurse report to the provider?
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a
hypothermia blanket. The nurse should monitor the client for which ofthefollowing adverseeffects of the
hypothermia blanket?
A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following
statements by the client indicates an understanding of theteaching?
A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After
calling for assistance, which of the following actions should thenurse take first?
A nurse is collecting data from a client who has alcohol use disorder and is experiencingmetabolicacidosis.
Whichof the following manifestations should thenurseexpect?
A nurse is reinforcingdischargeteaching withaclient followingacataractextraction.Which of the following
should thenurse include in the teaching?
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mgdaily. The client refuses
breakfast and reports nausea. Which of the following actions should thenurse takefirst?
A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. Thenurse suspects the client's
wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should
the nurse report as the type of drainage found?
A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative
complications which of the following actions should be reinforcedduringtheteaching?
A nurse is collecting data from a client who has emphysema. Which of the followingfindings should the nurse
expect?
A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse
notices a thin stream of clear drainage coming from out oftheclient's rightnostril. Which of thefollowing actions
should thenursetake first?
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client
is at risk for autonomic dysreflexia. Which of the followinginterventions should the nurse take toprevent
autonomic dysreflexia?
A nurse is caring for a client who is being evaluated for endometrial cancer. Which of thefollowing findings should
thenurseexpect theclient to report?
nurse is caring for a client following an open reduction and internal fixation of afractured femur. Which
of the following findings is thenurse's priority?
A nurse is assisting in the care of a client who is 2 hours postoperative following a wedgeresection of the left lung
and has a chest tube to suction. Which of the following is the priority finding the nurseshould report to the
provider?
A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which
of the following instructions should the nurse include in theteaching?
A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland.Which of the following
actions should thenurse include in theplan?
A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial
infarction. The nurse should instruct the client that aspirin is prescribedforclients whohavecoronaryarterydisease
for whichof thefollowingeffects?
A nurse is collecting data from a client who has open-angle glaucoma. Which of thefollowingfindings should
the nurse expect?
A nurse is collecting data from a client who has acute gastroenteritis. Which of thefollowingdata
collection findings should the nurse identifyas thepriority?
A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a
vaginal repair. Which of the following statements by the clientindicates aneed for further teaching?
A nurse is assisting with the care of a client who has a femur fracture and is in skeletaltraction. Whichof the
following actions should the nurse take?
A nurse in a provider’s office is reinforcing teaching with a client who has anemia and hasbeen taking ferrous
gluconate for several weeks. Which of the following instructions should thenurse include?
A nurse in a provider’s office is reinforcing teaching with a client who has anemia and hasbeen taking ferrous
gluconate for several weeks. Which of the following instructions should thenurse include?
A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of thefollowing interventions
should thenurse recommend?
A nurse is reinforcing teaching with a client who is postoperative after having an ileostomyestablished. Whichof the
following instructions should thenurseincludeintheteaching?
A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an
escharotomy and wants to know what the procedure involves. Which ofthe followingstatements is appropriate
for thenurseto make?
A nurse is collecting data from a client who has a possible cataract. Which of the followingmanifestations should the
nurse expect the client to report?
A nurse is contributing to the plan of care for a client who has an intestinal obstruction andis receiving continuous
gastrointestinal decompression using a nasogastric tube. Which of thefollowing interventions should the nurse
include in the plan ofcare?
A nurse is caring for a client who has Cushing's syndrome. Which of the following clinicalmanifestations should the
nurse expect to observe?(Select all that apply.)
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which ofthe following actions
should the nurse take?
A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client whohas upper gastric pain.
Which of the following statements should the nurse include in theteaching?
A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a
generalized tonic-clonic seizure. Which of the following descriptions shouldthe nurse use when documenting this
findingin the medical record?
A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopiccholecystectomy.
Whichof thefollowingstatementsshouldthenurse make?
A nurse is checking the suction control chamber of a client's chest tube and notes that thereis no bubbling in the
suction control chamber. Which of the following actions should the nursetake?
A nurse is assisting with the care of a client immediately following a lumbar puncture.Whichof the following
actions should thenursetake?(Selectall thatapply.)
A nurse is assisting with the care of a client who is postoperative following surgical repairof a fractured mandible.
The client’s jaw is wired shut to repair and stabilize the fracture. Thenurseshould recognize which of the
followingis the priorityaction?
A nurse is collecting data from a client who has scleroderma. Which of the followingfindings should the nurse
expect?
A nurse is caring for an older adult client who has dysphagia and left-sided weaknessfollowingastroke. Which
of the followingactions should the nursetake?
A nurse is caring for a client who has partial-thickness and full-thickness burns of his head,neck, and chest. The
nurse should recognize which of the following is the priority risk to theclient?
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start
taking neostigmine. Which of the following instructions should thenurse include inthe teaching?
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate
(TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any
urinary output in the last hour. Which ofthefollowing actions should the nurse perform first?
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fearabout the procedure and
asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make?
A nurse is assisting with planning care for a client who is recovering from a left- hemispheric stroke. Which of
the following interventions should the nurse include in theplan?
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse shouldmonitor the client for
whichof the following manifestations?
A nurse is reviewing the laboratory results of a client who is postoperative and has arespiratory rateof
7/min. The arterial blood gas (ABG) values include:
pH 7.22
PaCO2 68mm HgBase
excess -2 PaO2 78 mm
Hg
Oxygensaturation 80%
Bicarbonate28 mEq/L
Whichof thefollowing interpretations of the ABG valuesshould thenurse make?
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize
that which of the following statements by the client indicates aneed for further teaching?
A nurse is preparing to provide morning hygiene care for a client who has Alzheimer'sdisease. The client
becomes agitated and combative when the nurse approaches him. Which of the following actions should the
nurse plan to take?
A nurse is collecting data on a client’s wound. The nurse observes that the wound surfaceis covered with soft, red
tissue that bleeds easily. The nurse should recognize this is a manifestationof which of the following?
A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3
. Whichof thefollowing
fooditemsbroughtbythe familyshould thenurseprohibit from being given totheclient?
A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip
arthroplasty. Which of the following interventions should the nurseinclude in theplan?
A nurse is caring for a client who has heart failure and respiratory arrest. Which of thefollowingactions
should the nurse take first?
A nurse is caring for a client scheduled for coronary artery bypass grafting who reports heis no longer certain he
wants to have the procedure. Which of the following responses should the nurse make?
A nurse is caring for a client who is postoperative following foot surgery and is not to bearweight on the operative
foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for
support. Which of the following actions should thenurse take? [Show Less]