1. A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. Which of
... [Show More] the following findings should the nurse identify as a contraindication to receiving this alternative therapy? Lymphedema
2. A nurse is preparing to administer lactated Ringer's via continuous IV infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/mL. How many gtt/min should the nurse set the IV ump to administer?
33
3. A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching?
I should lie down when I take this medication
4. A nurse is providing discharge teaching to an older adult client following total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? Install a raised toilet seat in your bathroom
5. A nurse is planning care for a client following a cardiac catheterization. Which of the following actions should the nurse take?
Maintain the client's affected extremity in extension
6. A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change?
I will need to have my partner take over shopping for groceries and cooking the meals for us
7. A nurse is providing teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?
wash peri area two times each day with antimicrobial soup
8. A nurse is caring for a client who has a contusion and reports thirst. The client's urinary output was 4,000 ml over past 24 hr. the nurse should anticipate a prescription for which of the following IV medications?
Desmopressin
9. A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports nagging dry cough. Which of the following responses by the nurse is appropriate?
Sucking on a lozenge may reduce the frequency of your cough
10. A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a parenteral trigger for exacerbation of Raynaud's?
Using nicotine transdermal patch
11. A nurse is caring for a client who has a central venous device and notes the tubing has become disconnected. the client develops dyspnea and tachycardia. Which of the following actions should the nurse take first?
On his left side in Trendelenburg position
12. A nurse is completing an assessment of an older client and notes reddened areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include in the plan of care?
Support bony prominences with pillows
13. A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take?
List strategies for family coping when dealing with possible role changes
14. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? (click on the "exhibit" button for additional information about the client)
Initiate airborne precautions
15. A nurse is reviewing the medical record of a client to identify factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk?
History of Crohn's disease
16. A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make?
I can give you additional information about the procedure
17. A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow.
1. obtain venous access using a 19-gauge needle
2. Obtain the unit of a packed RBCs from blood bank 3. verify blood compatibility with another nurse
4. Initiate transfusion of the unit of packed RBCs
5. Remain with the client for the first 15 to 30 minutes
18. A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client
indicates an understanding of the teaching?
I should expect less than 25 ml of secretions per day in the drainage devices
19. A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing and makes incomprehensible sounds. Which of the following Glasgow Coma scale scores should the nurse assign the client?
5
20. A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?
I can have a frozen fruit juice bar for dessert
21. A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?
instill 0.9% sodium chloride solution into the affected eye
22. A nurse is assessing a client following extubation from a ventilator for which of the following findings should the nurse intervene immediately?
Stridor
23. A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
Elevated blood glucose
24. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?
Urine specific gravity 1.001
25. A nurse is planning care for a client who has a pulmonary embolism. Which of the following interventions should the nurse include?
Initiate a continuous IV heparin infusion
26. A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include?
Avoid extremely hot or cold temperatures
27. A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first?
Insert a large-bore IV catheter
28. A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation on of the graft?
Palpable thrill
29. A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following finding indicates hypokalemia?
Muscle weakness
30. A nurse is caring for a client in diabetic ketoacidosis (DKA) Which of the following is the priority intervention by the nurse?
Infuse 0.9% normal saline
31. A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?
I will expect my stools to be loose
32. A nurse is caring for a client who is receiving total parenteral nutrition through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take?
Switch the infusion to a 10% dextrose solution
33. A nurse is caring for a client who is 6hr postoperative following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of the following electrolyte imbalance?
Hypocalcemia
34. A nurse in a provider office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and the service animal?
Consult the client before approaching the dog.
35. A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?
I should lie down before taking a dose of isosorbide dinitrate
36. A nurse in the post anesthesia care unit is assessing a client following an appendectomy and finds a 2 cm (3/4 in) area of blood on the postoperative dressing. Which of the following actions should the nurse take?
Apply pressure
37. A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement?
Suction the client’s airway q 4 hrs.
38. A nurse is planning care for a client who has full thickness burns on the lower extremities. Which of the following interventions should the nurse include? Apply new gloves when alternating between wound care sites
39. A nurse is providing teaching for a client who has tuberculosis and a new prescription for pyrazinamide. The nurse should instruct the client to notify the provider if which of the following adverse effects occurs?
Jaundice
40. A nurse is planning care for a client who has left-side hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care? Position the client's table on the left side
41. A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take?
Point the type of the syringe toward the top of the ear canal
42. A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
Ondansetron
43. A nurse is preparing to discharge a client who has a halo device and is reviewing new prescription from the provider. The nurse should clarify which of the following prescriptions with the provider?
May operate a motor vehicle when no longer taking analgesics
44. A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following information should the nurse include in the teaching?
You will to return in 2 weeks to provide a sputum specimen
45. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
Frothy sputum
46. A nurse is planning care for a client who has osteoarthritis of the knees. Which of the following interventions should the nurse include in the plan?
Place a large pillow under the client's knees when resting.
47. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal
pain. Which of the following actions should the nurse take first?
Check the client's urine output
48. A nurse is providing instructions about foot care for a client who has a peripheral arterial disease. The nurse should identify that which of the following statements by the client indications understanding of the teaching
"I rest in my recliner with my feet elevated for about an hour every afternoon"
49. A nurse in a provider's office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include?
Sleep with the head of the bed elevated 6 inches
50. A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider? High-pitched sound on inspiration
51. A nurse is caring for a client who is 2 days postoperative following a below the knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?
*The elastic bandage will prevent a postoperative wound infection
52. A nurse is planning care for a client who is 8 hr. postoperative following a coronary artery bypass grafting. which of the following assessments should the nurse plan to perform first?
Measure the client's core body temperature
53. A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?
You will need to be monitor for 15 minutes after receiving each medication close
54. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client? Feet elevated
55. A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?
Dark red granulation tissue
56. A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?
I'll cut a slit in a clean gauze pad to use as a stoma dressing
57. A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contraindication for receiving the medication?
Potassium 3.2 mEq/L
58. A nurse is caring for a client admitted with a skull fracture. which of the following assessment findings should be greatest concern to the nurse?
Glasgow coma scale score changes from 14 to 9
59. A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?
I have a hard time with brushing my hair [Show Less]