A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being
... [Show More] irritated by the edges of the cast. What is the appropriate action on the part of the nurse - correct answer Place small pieces of tape over the rough edges of the cast
A nurse developing a plan of care for a client with HIV infection identifies several concerns. List them in order of priority, from highest to lowest. - correct answer 1 Possible infection
2 Decreased nutrition
3 Fatigue
4 Despair
An emergency department nurse has a physician's prescription to irrigate a client's ears. List in order of priority the steps that the nurse should take in performing this procedure. - correct answer 1 Use an otoscope to ensure that the tympanic membrane is intact.
2 Warm tap water to body temperature.
3 Fill an irrigating syringe with warm water.
4 Insert the irrigating solution by directing the solution toward the wall of the ear canal.
5 Document the completion of the procedure and how the client tolerated it.
The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution? - correct answer Checking for gastric residual volume and assessing tube placement
A client with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation? - correct answer "Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?"
A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat the client. Which type of insulin does the nurse take from the medication supply room for intravenous (IV) administration? - correct answer Regular (Humulin R)
A nurse is assessing a client who is experiencing chest pain. Which of the following observations indicates to the nurse that the pain is most likely a result of angina? - correct answer The pain is relieved by rest and nitroglycerin.
While being seen by a physician, a client complains of persistent fever, malaise, and night sweats. On physical examination, the physician palpates enlarged lymph nodes, and the client states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic studies are performed. Which characteristic of this type of lymphoma does the nurse expect to note while reviewing the results of the diagnostic studies? - correct answer Reed-Sternberg cells on biopsy of a lymph node
A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? - correct answer Powerlessness
Tolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitus has not been controlled with diet and exercise alone. The nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction? - correct answer "I can have a beer or glass of wine as long as I stay within my daily dietary restrictions."
A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. - correct answer -Drink copious amounts of fluid and void frequently
-Avoid contact with any individual who has signs or symptoms of a cold
A nurse reviews arterial blood gas values and notes a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse interprets these values as indicative of: - correct answer Respiratory alkalosis
A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation? - correct answer Contacting the child's physician to report the findings
A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction? - correct answer "I need to keep any unopened bottles of insulin in the freezer."
A nurse preparing to administer digoxin (Lanoxin) to a client calls the laboratory for the result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports that the result was 2.4 ng/mL. On the basis of this result, the nurse would: - correct answer Contact the physician
A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority? - correct answer Decreased fluid volume
A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally: - correct answer Decrease
A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? - correct answer "The placenta maintains the body temperature of my baby."
A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client? - correct answer 28 mm Hg
Iodine solution (Lugol solution) is prescribed to a client who is scheduled for subtotal thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the mouth and soreness of the gums and teeth. The nurse most appropriately tells the client: - correct answer To contact the physician
A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. The nurse would initially: - correct answer Identify the client's treatment goals
A child with growth hormone deficiency will be receiving somatropin (Humatrope). The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring? - correct answer Thyroid-stimulating hormone (TSH)
A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? - correct answer Epistaxis
A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is: - correct answer July 2, 2013
A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. - correct answer "I need to avoid salt in my diet."
"It's fine to take any over-the-counter medication with the lithium."
"Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."
An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. - correct answer Skin tenting
Flat neck veins
Weak peripheral pulses
Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the physician's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician to confirm the prescription for warfarin sodium because: - correct answer Levothyroxine amplifies the effect of warfarin sodium
A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside? - correct answer Calcium gluconate
A client with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. The nurse tells the client to: - correct answer Increase intake of high-fiber foods
The wife of a client with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL and that her husband is awake but groggy. The nurse tells the client's wife to immediately: - correct answer Place some honey in her husband's mouth, between his gums and cheek
A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. - correct answer Fever
Vasculitis
Abdominal pain
A nurse is providing information to a client who will be self-administering regular insulin about storage of the insulin. The nurse tells the client: - correct answer That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity
A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast? - correct answer Pick the photo that has the nipple that resembles a sunburned orange peel. Peau d'orange means orange peel in French.
Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse? - correct answer Multiple sexual partners
A client with tuberculosis will be taking pyrazinamide (Pyrazinamide), and the nurse provides instructions about the adverse effects of the medication. For which of the following occurrences does the nurse tell the client to contact the physician? - correct answer Yellow skin
A nurse is preparing the room of a client in skeletal traction who will be admitted to the nursing unit. Which item for use by the client does the nurse identify as the most important? - correct answer Trapeze bar
A client has been scheduled for an electronystagmography (ENG), and the nurse provides instructions to the client about the test. Which statement by the client tells the nurse that the client understands the instructions? - correct answer "I need to not drink coffee before the test."
A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. The nurse tells the client to immediately: - correct answer Get into the shower and rinse the skin for at least 15 minutes
A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be: - correct answer Helping the woman empty her bladder
A client is receiving an intravenous infusion of alteplase (tissue plasminogen activator, recombinant; tPA). For which adverse effect of the medication does the nurse monitor the client most closely? - correct answer Bleeding
A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs of postoperative complications. Which of the following findings would be a matter of concern for the nurse as an indication of hypocalcemia? - correct answer The client complains of a tingling sensation around the mouth.
A nurse has provided information about exercise to a client with a diagnosis of degenerative joint disease (osteoarthritis). Which of the following types of exercise does the nurse tell the client to avoid? - correct answer High-impact exercise
A nurse is performing an assessment of a client with Ménière disease. Which question does the nurse ask to elicit data about the manifestations of this disease? - correct answer "Do you have episodes of dizziness?"
A client who has undergone knee-replacement surgery will be self-administering enoxaparin sodium (Lovenox) at home. The nurse teaches the client about the medication and tells the client to: - correct answer Lie down to administer the subcutaneous injection
A nurse assessing the wound of a client with a stage 3 pressure ulcer and notes that the wound bed is pale. The nurse interprets this finding as a possible indication that: - correct answer The client's hemoglobin level is low
A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder? - correct answer "Have you ever worked in a mine?"
A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? - correct answer Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain
A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R) insulin for a client with diabetes mellitus who will be administering his own insulin but has difficulty seeing and accurately preparing doses. The nurse places the medication in the client's refrigerator with the syringes: - correct answer In a vertical position with the needles pointing up
Ciprofloxacin hydrochloride (Cipro) is prescribed to a client with a urinary tract infection. The nurse, providing instruction about the medication, tells the client that it is best to take the medication: - correct answer 2 hours after meals
A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply. - correct answer Hunger
Weakness
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