A
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes that the clients dialysate output is less than the input and that his abdomen is distended. Which of the following actions should the nurse take?
A. inserts an indwelling urinary catheter.
B. administer pain medication to the client.
C. Change the client's position.
D. place the drainage bag above the clients abdomen.
C. Change the client's position.
A nurse is checking laboratory values to determine if a client with diabetes mellitus is adhering to the treatment plan. Which of the following tests should the nurse use to make this determination?
a. Glycosylated hemoglobin levels.
b. Urine sugar and acetone levels.
c. Glucose tolerance test.
d. Fasting serum glucose.
A. Glycosylated hemoglobin levels.
(HbA1c). Shows 4 month lifespan.
A nurse is monitoring 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?
a. Take a photograph of the peripheral IV site.
b. Obtained and record the client's vital signs.
c. Stop the infusion.
d. Identify all medications administered through the IV site for the past 24 hours.
C. Stop the infusion.
A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?
a. High-pitched sound heard in the ear.
b. Intermittent rapid eye movement.
c. Itching of the external canal.
d. Feeling of fullness in the ear.
D. Feeling of fullness in the ear.
A nurse is reviewing the medication history of a client who has mild intermittent asthma. The nurse should anticipate a prescription for which of the following inhalers for the client?
a. Ipratropium
b. Albuterol sulfate.
c. Tiotropium.
d. Budesonide.
B. Albuterol Sulfate
A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure?
a. Wheezing.
b. Bradypnea.
c. Tachycardia.
d. Diaphoresis.
C. Tachycardia
Signs of impending RF: tachycardia, dyspnea, restlessness, H/A, HTN
A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes, a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages?
a. IV
b. I
c. III
d. II
D. II
A nurse is caring for a client who has a pelvic fracture. The client reports said shortness of breath, stabbing chest pain, and feelings of doom. This client is experiencing, which of the following complications?
a. pneumonia
b. Pulmonary embolism
c. tension pneumothorax
d. tuberculosis
b. pulmonary embolism
A nurse is providing teaching to a client who is receiving chemotherapy and has developed neutropenia. Which of the following statement statements indicates that the client needs further instructions?
a. I'll keep an antibacterial hand gel in my purse.
b. My partner will have to take care of the cats litter boxes for a while.
c. I'm planning a large gathering of friends and family for the holidays.
d. I will eat canned fruits and vegetable vegetables.
C. I'm planning a large gathering of friends and family for the holidays
A nurse is caring for a client who has peptic ulcer disease and reports a headache. Which of the following medications to the nurse plan to administer?
a. Ibuprofen.
b. Naproxen.
c. Aspirin.
d. Acetaminophen.
d. Acetaminophen
PUD = BLEEDING
A nurse is teaching a client about the manifestations of an allergic reaction. The relief of histamine causes which of the following reactions?
a. Increased mucus secretion.
b. Bronchial dilation.
c. Bradycardia.
d. Vertigo.
A. Increased mucus secretion.
A nurse is caring for a client who has been receiving medication through a transdermal patch. The client is experiencing therapeutic benefits from the medication even though the medication in the patch is no longer active. The nurse should recognize that this is an example of which of the following?
a. pharmacodynamic tolerance
b. placebo effect
c. metabolic tolerance
d. tachyphylaxis
B. placebo effect
A nurse is assessing 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?
a. First-degree frostbite
b. Second-degree frostbite.
c. Third-degree frostbite.
d. Force degree frostbite.
C. Third-degree frostbite.
A nurse is providing discharge teaching to the partner of a client who has a new diagnosis of hepatitis A. Which of the following instructions should the nurse include in the teaching?
a. During this illness, she may take acetaminophen for fevers or discomfort.
b. Encourage her to eat foods that are high in carbohydrates.
c. The provider will prescribe a medication to help her liver heal fast faster.
d. Have her perform moderate exercise to restore her strength more quickly.
B. Encourage her to eat foods that are high in carbohydrates.
A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first?
a. Instruct the client to cough.
b. Administer oxygen via face mask.
c. Evaluate the client for stridor.
d. Keep the client in a semi- to high-Fowler's position.
C. Evaluate the client for stridor.
AIRWAY FIRST ALWAYS
A nurse is assessing a 66 year-old client during a routine physical examination. This is the client's first clinic visit, and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies "I am not sure but it's been at least five years since I've had any immunizations". Which of the following responses should the nurse provide?
a. "In case you had the immunization before, we can't give you another one."
b. "You'll need a series of three injections."
c. "This immunization is unsafe for people over the age of 65 years old."
d. "Let's go ahead and give you this immunization."
D. "Let's go ahead and give you this immunization."
CDC reqs for clients over 65 years old.
A nurse is caring for a client who has a fractured right hip. Which of the following types of traction should the nurse expect the client to have prior to hip arthroplasty surgery?
a. Balanced skeletal traction.
b. Pelvic belt.
c. Pelvic sling.
d. Bucks traction.
D. Bucks traction
A nurse is teaching a client who has a new prescription for amitriptyline to treat depression. Which of the following client statements indicates an understanding of the teaching?
a. I should take this medication when I experience active symptoms.
b. I should take this medication before bedtime.
c. This medication may cause excess salvation.
d. I might experience weight loss while taking this medication.
B. I should take this medication before bedtime.
A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is O-negative. Which of the following actions should the nurse take?
a. Continue to monitor for manifestations of a transfusion reaction.
b. Remove the unit of plasma immediately and start an IV infusion of normal saline solution.
c. Continue the transfusion and repeat the type and cross match.
d. Prepare to administer a dose of diphenhydramine IV.
B. Remove the unit of plasma immediately and start an infusion of normal saline solution
O- can only receive O-
A nurse is assessing a client lab values before surgery. Which results should the nurse report to the provider?(select all the apply.)
a. Potassium 3.9 mEq/L
b. Sodium 145 mEq/L
c. Creatinine 2.8 mg/dL
d. Blood glucose 235 mg/dL
e. WBC 17,850/mm3
C, D, E
This is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care?
a. Restrict fluids to 1000 ML per day.
b. Measure the clients abdominal girth daily.
c. Check IV sites every four hours for bleeding.
d. Administer an enema as needed for constipation.
B. Measure the clients abdominal girth daily
A nurse is preparing an in-service presentation about the management of myocardial infarction parentheses MI). Death following MMI is often a result of which of the following complications?
a. Cardiogenic shock.
b. Dysrrhythmia.
c. Heart failure.
d. Pulmonary edema.
B. Dysrrhythmia
A nurse is teaching a client who has a new prescription for alendronate for the treatment of osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?
a. I will take the medication in the evening.
b. I will drink a full glass of milk with the medication.
c. I will take the medication at meal time.
d. I will sit upright after taking the medication.
D. I will sit upright after taking the medication.
Alendronate can cause esophageal irritation!!
A nurse administered medazepam IV bolus to a client before a procedure. The client's blood pressure is 86/40mmHg, and the heart rate is 134bpm. Which of the following IV medications should the nurse administer?
a. Naloxone.
b. Morphine.
c. Flumazenil.
d. Atropine.
C. Flumazenil
Midazolam is a benzo!
A nurse is caring for a client who developed malignant hyperthermia. Which of the following actions should the nurse take?(select all that apply.)
a. Infuse iced IV fluids.
b. Provide 100% oxygen.
c. Place a cooling blanket on the client.
d. Treat the complication while the surgeon finishes the surgery.
e. Administer IV dantrolene.
A, B, C, E