A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the
following findings should the nurse identify as a
... [Show More] manifestation of this condition?
A. Bounding pedal pulse
B. Capillary refill less than 2 seconds
C. Pain that increases with passive movement
D. Areas of warmth on the cast C. Pain that increases with passive movement
A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which
of the following statements made by the client reflects an understanding of the teaching?
A. "I will need to take antibiotics for 1 year"
B. "My partner will need to take an antiviral medication"
C. "My joints ache because I have Lyme disease"
D. "I will bruise easily because I have Lyme disease" C. "My joints ache because I have
Lyme disease"
A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available
is oral solution 125 mg/5 mL. How many mL should the nurse administer? 24
A nurse is caring for a client who has an arterial line. Which of the following actions should the
nurse take?
A. Flush the line before administering antibiotics
B. Position the client in Trendelenburg to obtain measurements
C. Have the client bear down when readings are obtained
D. Place a pressure bag around the flush solution D. Place a pressure bag around the flush
solution
A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the
following findings should the nurse identify as the priority?
A. Report of sore throat
B. Report of memory loss
C. Alopecia
D. Mucositis A. Report of sore throat
A nurse is reviewing the medical record of a client who has systemic lupus erthematosus (SLE).
Which of the following findings should the nurse expect?
A. Facial butterfly rash
B. Bradycardia
C. Esophagitis
D. Interstitial fibrosis A. Facial butterfly rash
A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which
of the following actions should the nurse identify as the priority?
A. Use pillows to support the client's head and neck
B. Offer opioid medication
C. Place a tracheostomy tray at the bedside
D. Place the client in semi-Fowler's position C. Place a tracheostomy tray at the bedside
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should
the nurse expect?
A. Low urine specific gravity
B. Hypertension
C. Bounding peripheral pulses
D. Hyperglycemia A. Low urine specific gravity
A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for
brachytherapy. Which of the following instructions should the nurse include?
A. "You will have an implant placed twice each month for the duration of the treatment"
B. "You should remain at least 6 feet away from others between treatments"
C. "You should expect to have blood in your urine for a few days after treatment"
D. "You will need to stay still in the bed during each treatment session" D. "You will need to
stay still in the bed during each treatment session"
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following
interventions should the nurse include in the plan?
A. Encourage the client to take deep breaths after the procedure
B. Assist the client to hold their arms up during the procedure
C. Instruct the client to remain NPO after midnight prior to the procedure
D. Keep the client on bedrest for 8 hr following the procedure A. Encourage the client to
take deep breaths after the procedure
A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless,
dyspneic, and has crackles noted to the lung bases. Which of the following actions should the
nurse anticipate taking?
A. Administer an antihistamine
B. Slow the infusion rate
C. Give the client a corticosteriod
D. Elevate the client's lower extremities B. Slow the infusion rate
A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a
kidney transplant. Which of the following information should the nurse provide?
A. Kidney donation must come from a living donor
B. Immunosuppressive therapy is necessary until the donated kidney begins producing urine
C. Hemodialysis is sometimes required following surgery
D. Kidney transplant recipients can resume their regular diet following surgery C.
Hemodialysis is sometimes required following surgery
A nurse is caring for a client who has hypothyroidism. Which of the following manifestations
should the nurse expect?
A. Constipation
B. Insomnia
C. Tachycardia
D. Diaphoresis A. Constipation
A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy.
Which of the following statements should the nurse make?
A. "You should accept your body image change before discharge"
B. "It is important for you to look at the incisional site when the dressings are removed"
C. "I will refer you to community resources that can provide support"
D. "The scar will remain red and raised for many years after surgery" C. "I will refer you to
community resources that can provide support"
A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the
following findings should the nurse report to the provider?
A. The client's urinary output has increased
B. The client reports back pain
C. The client's urine color is red tinged
D. The client's BUN is 18 mg/dL B. The client reports back pain
A nurse is teaching a family about the care of a patient who has a new diagnosis of Alzheimer's
disease. Which of the following information should the nurse include in the teaching?
A. Position tabletop clocks with multi-colored backgrounds throughout the home
B. Explain how to complete a task while having the client do the task
C. Place a calendar on the wall with days and weeks included
D. Create complete outfits and allow the client to select one each day D. Create complete
outfits and allow the client to select one each day
A nurse is caring for a client who has breast cancer and tells the nurse that they would like to
have acupunture because it provides greater relief than pain medication. Which of the following
statements should the nurse make?
A. "Acupuncture is not an approved treatment for cancer pain"
B. "I can speak to the provider about incorporating acupuncture into your treatment plan"
C. "I will ask the provider to prescribe a stronger medication to help ease your pain"
D. "I can contact a family member or spiritual advisor for you to speak with" B. "I can
speak to the provider about incorporating acupuncture into your treatment plan"
A nurse is caring for a client following extubation of an edotracheal tube 10 min ago. Which of
the following findings should the nurse report to the provider immediately?
A. Stridor
B. Oral secretions
C. Hoarseness
D. Sore throat A. Stridor
A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The
nurse should identify which of the following findings as an indication of a myocardial infarction
(MI)?
A. Creatine kinase (CK-MB) 85 mg/dL
B. High-density lipoprotein (HDL) 65 mg/dL
C. Alanine aminotransferase (ALT) 28 units/L
D. Troponin I 8 ng/mL D. Troponin I 8 ng/mL
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the
following actions should the nurse take first?
A. Obtain the client's vital signs
B. Describe the blood transfusion procedure to the client
C. Check for the type and number of units of blood to administer
D. Initiate a peripheral IV line C. Check for the type and number of units of blood to
administer
A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the
following findings indicates a potential complication?
A. RBC count 5.2 million/mm^3
B. WBC count 2,000/mm^3
C. Platelets 380,000/mm^3
D. Potassium 4 mEq/L B. WBC count 2,000/mm^3
A nurse is providing discharge teaching to a client who is postoperative following a modifie [Show Less]