Musculoskeletal System
A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority?
(A) Temperature 38.4 (101.1 F)
(B) Increased respiratory secretions
(C) Fluid intake of 200 mL in the prior 8 hr
(D) Limited ROM
(B) Increased respiratory secretions
RATIONALE: Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. Clients who have ALD may experience respiratory muscle weakness and dysphagia, and excessive respiratory secretions can impair the ability to clear the airway, which increases the client's risk for aspiration.
A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving?
(A) Potassium 3.2 mEq/L (3.5 to 5 mEq/L)
(B) pH 7.28 (7.35 to 7.45)
(C) Glucose 272 mg/dL (74 to 106 mg/dL)
(D) HCO3- 14 mEq/L (21 to 28 mEq/L)
(C) Glucose 272 mg/dL (74 to 106 mg/dL)
RATIONALE: A glucose reading less than 300 mg/dL indicates improvement in the client's status.
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 corticosteroid
(D) Elevate the client's lower extremities
(B) Slow the infusion rate
RATIONALE: Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breath, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take?
(A) Check the client's blood glucose according to facility mealtimes
(B) Contact the provider to clarify the prescription
(C) Request for meals to be provided for the client
(D) Hold the prescription until client is no longer NPO
(B) Contact the provider to clarify the prescription
RATIONALE: Mealtimes do not pertain to this client due to the NPO status. The nurse should monitor the client's glucose levels on a set schedule, either every 6 hr or per facility protocol. Thus, the prescription requires clarification.
A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make?
(A) "Discontinuing with the treatments is your choice if it is your wish to do so."
(B) "Your child is named as your health care surrogate. I will ask them if you can stop the treatments."
(C) "I will call your spiritual advisor to come in, so you can discuss this with them."
(D) "Next time you have an oncology appointment, you should ask the oncologist."
(A) "Discontinuing with the treatments is your choice if it is your wish to do so."
RATIONALE: The nurse should recognize the client's right to refuse treatments and inform the client of this right. The nurse should advocate for the client and offer to contact the provider for the client.
A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following interventions is the priority?
(A) Obtaining vital signs
(B) Placing the client in Fowler's position
(C) Administering epinephrine
(D) Initiating an IV infusion of 0.9% sodium chloride
(C) Administering epinephrine
RATIONALE: Evidence-based practice indicates that the priority intervention is for the nurse to administer epinephrine quickly to dilate the bronchioles and prevent circulatory shock.
A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client?
(A) "Wear an eye patch over one eye."
(B) "Make sure to have a staff member walk on your stronger side."
(C) "Scan the environment by turning your head from side to side."
(D) "Make sure to look at your feet while walking."
(C) "Scan the environment by turning your head from side to side."
RATIONALE: Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head from side to side helps enlarge a client's visual field. This technique is also useful for the client during mealtimes.
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
RATIONALE: The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?
(A) PaCO2 56 mmHg (35 to 45 mmHg)
(B) pH 7.50 (7.35 to 7.45)
(C) HCO3- 18 mEq/L (21 to 28 mEq/L)
(D) PaO2 130 mmHg (80 to 100 mmHg)
(A) PaCO2 56 mmHg (35 to 45 mmHg)
RATIONALE: A client who has COPD retains PaCO2 due to the weakening and collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange and causes the PaCO2 to increase above the expected reference range.
A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings indicates a potential complication?
(A) The client's urinary output has increased
(B) The client reports severe back pain
(C) The client's urine is red tinged
(D) The client's tube requires irrigation
(B) The client reports severe back pain
RATIONALE: The nurse should notify the provider if the client reports back pain, which can indicate that the nephrostomy tube is dislodged or clogged.
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include?
(A) Flex the foot every hour when awake
(B) Place a pillow under the knee when lying in bed
(C) Lower the leg when sitting in a chair
(D) Ensure the leg is abducted when resting in bed
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include?
- Flex the foot every hour when awake
- Place a pillow under the knee when lying in bed
- Lower the leg when sitting in a chair
- Ensure the leg is abducted when resting in bed
(A) Flex the foot every hour when awake
RATIONALE: The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return.
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
RATIONALE: A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism, resulting in slow motility of the GI tract. The nurse should instruct the client to increase fiber and fluid intake to reduce the risk for constipation.
A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?
(A) "Ginkgo biloba relieves nausea for people who have vertigo."
(B) "Taking ginkgo biloba will help relieve your joint pain."
(C) "Ginkgo biloba can cause an increased risk for bleeding."
(D) "Taking ginkgo biloba decreases the risk of migraine headaches."
(C) "Ginkgo biloba can cause an increased risk for bleeding."
RATIONALE: Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with peripheral artery disease. The supplement also decreases platelet aggregation, which in turn, increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba without first speaking with their provider.
A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?
(A) Heart rate 110/min
(B) Blood pressure 138/90 mmHg
(C) Urine specific gravity 1.001 (1.005 to 1.03)
(D) BUN 8 mg/dL (10-20 md/dL)
(A) Heart rate 110/min
RATIONALE: A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate.
A nurse is providing teaching to a female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching?
(A) "Taking my daily progesterone should improve my symptoms."
(B) "A risk factor for my condition is obesity."
(C) "I should limit my daily fluid intake."
(D) "I will switch my morning cup of coffee to hot tea."
(B) "A risk factor for my condition is obesity."
RATIONALE: Excess weight creates increased abdominal pressure that can result in stress incontinence.
A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first?
(A) Obtain a sputum sample
(B) Administer antipyretics
(C) Provide hand hygiene education
(D) Initiate airborne precautions
(D) Initiate airborne precautions
RATIONALE: The client is exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions.
A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority?
(A) Check the client's neurologic status
(B) Document the client's statements
(C) Prepare the client for a CT scan
(D) Teach the client about using safety precautions for falls
(A) Check the client's neurologic status
RATIONALE: The first action the nurse should take using the nursing process is to assess the client. Therefore, the nurse should first check the neurologic status of the client.
A nurse is reviewing the laboratory results of a client who has a history of aplastic anemia. Which of the following findings indicates that the client is experiencing pancytopenia?
(A) RBC count 6.3 million/mm3 (4.7 to 6.1 million/mm3 male)
(B) WBC count 2,000/mm3 (5000 to 10,000/mm3)
(C) Platelets 450,000/mm3 (150,000 to 400,000/mm3)
(D) Potassium 3.3 mEq/L (43.5 to 5 mEq/L)
(B) WBC count 2,000/mm3 (5000 to 10,000/mm3)
RATIONALE: A decreased WBC, or leukopenia, is a manifestation of pancytopenia. Pancytopenia occurs when there is a decreased RBC count, decreased WBC count, and decreased platelets.
A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia?
(A) The client starts to cough
(B) The client's heart rate increases
(C) The client is diaphoretic
(D) The client's blood pressure decreases
(B) The client's heart rate increases
RATIONALE: Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take 3 or 4 deep breaths prior to suctioning to reduce the risk for hypoxia.
A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take?
(A) Teach the important of a clear liquid diet after discharge
(B) Tell the client to remove the incisional adhesive strips 3 days after discharge
(C) Demonstrate ways to deep breathe and cough
(D) Instruct the client to maintain bed rest for 48 hr
(C) Demonstrate ways to deep breathe and cough
RATIONALE: The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications.
A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain?
(A) Increase intake of foods containing calcium
(B) Alternate application of heat and cold to the affected joints
(C) Keep the affected extremities elevated
(D) Limit movement of the affected joints
(B) Alternate application of heat and cold to the affected joints
RATIONALE: The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and pain. The application of cold can relieve joint swelling and the application of heat can decrease joint stiffness and pain.
A nurse is teaching a client who has hyperthyroidism about managing this disorder. Which of the following recommendations should the nurse include?
A. Reduce total hours of sleep
B. Keep the immediate environment warm
C. Increase caloric intake with meals
D. Gradually increase activity
Correct Answer: C.
Clients whose thyroid hormone levels are high have increased protein, lipid, and carbohydrate metabolism, resulting in the loss of protein stores and a negative nitrogen balance. Even with an increased appetite, meeting energy demands is often difficult, and weight loss is common. Muscle weakness and wasting can develop without adequate caloric and protein intake.
Incorrect Answers:
A. Clients who have hyperthyroidism often report an inability to sleep. A decreased attention span and mild to severe hyperactivity are common. The nurse should suggest frequent rest periods in a quiet environment.
B. Clients who have hyperthyroidism often have a low-grade fever and diaphoresis due to their hypermetabolic state. A cool environment can decrease the discomfort of heat intolerance.
D. Clients who have hyperthyroidism are often restless and have an increased systolic blood pressure, tachycardia, and other dysrhythmias. During the acute phase, increased activity is not an appropriate recommendation.
A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?
(A) "Older adult clients might require up to 6 grams of acetaminophen over 24 hr for effective pain control."
(B) "Ibuprofen can cause GI bleeding in older adult clients."
(C) "Meperidine is the medication of choice for older adult clients experiencing severe pain."
(D) "Older adult clients taking oxycodone are at risk for diarrhea."
(B) "Ibuprofen can cause GI bleeding in older adult clients."
RATIONALE: A common adverse effect of ibuprofen is GI bleeding, and older adult clients have an increased risk GI toxicity and bleeding.
A nurse is providing discharge instructions to a client following an upper GI series with barium contrast. Which of the following information should the nurse provide?
(A) Increase fluid intake
(B) Take an over-the-counter antidiarrheal medication
(C) Expect black, tarry stools
(D) Follow a low-fiber diet
(A) Increase fluid intake
RATIONALE: Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test.
A nurse in the emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?
(A) "It's like a curtain closed over my eye."
(B) "This sharp pain in my eye started 2 hours ago."
(C) "I've been having more and more difficulty seeing over the last few weeks."
(D) "I seem to have more problems seeing different colors."
(A) "It's like a curtain closed over my eye."
RATIONALE: A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field.
A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the following information should the nurse include in the teaching?
(A) After 1 week of medication, TB is no longer communicable
(B) Dispose of contaminated tissues in a paper bag
(C) Airborne precautions are necessary in the home
(D) Family members in the household should undergo TB testing
(D) Family members in the household should undergo TB testing
RATIONALE: Family members who live in the same household with the client have been exposed to TB. Therefore, the nurse should recommend TB screening to foster early detection and treatment of TB.
A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
(A) Insert a padded tongue blade
(B) Apply oxygen
(C) Restrain the client
(D) Loosen restrictive clothing
(D) Loosen restrictive clothing
RATIONALE: The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.
A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.)
(A) Following a smoking cessation program
(B) Maintain an appropriate weight
(C) Eat a low-fat diet
(D) Increase fluid intake
(E) Decrease intake of complex carbohydrates
A, B, C
(A) Following a smoking cessation program
RATIONALE: Smoking cessation is an important lifestyle modification to prevent atherosclerosis.
(B) Maintain an appropriate weight
RATIONALE: Preventing obesity through diet and exercise can help to prevent atherosclerosis.
(C) Eat a low-fat diet
RATIONALE: Eating a low-fat diet decreases LDL cholesterol and can prevent atherosclerosis.
A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer?
(A) Dyspnea
(B) Hemoptysis
(C) Mucus production
(D) Dysphagia
(A) Dyspnea
RATIONALE: Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing and improve comfort.
A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an expected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider?
(A) Sedimentation rate
(B) Hematocrit
(C) Calcium
(D) Acid phosphatase
(A) Sedimentation rate
RATIONALE: An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following findings indicates that the client is experiencing a complication?
(A) The client reports that the sequential compression devices (SCDs) are uncomfortable
(B) The client reports pain at the surgical site as 4 on a scale of 0 to 10.
(C) The client's surgical site dressing has required changing twice in 2 hr due to drainage
(D) The client needs assistance with a walker when ambulating in the room
(C) The client's surgical site dressing has required changing twice in 2 hr due to drainage
RATIONALE: Frequent dressing changing after surgery may indicate poor clotting and increased bleeding.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority?
(A) Moderate serosanguineous drainage on the dressing
(B) Calcium 9.5 mg/dL (9 to 10.5 mg/dL)
(C) Temperature 38.9 C (102 F)
(D) Decreased bowel sounds
(C) Temperature 38.9 C (102 F)
RATIONALE: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is an elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to provider because it can lead to seizures and coma.
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
(C) Check for the type and number of units of blood to administer
RATIONALE: According to evidence-based practice, the nurse should first confirm that the type and number of units of blood matches what is indicated in the client's medication administration record.
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend?
(A) Add full-fat yogurt to the diet
(B) Add cabbage to the diet
(C) Replace butter with coconut oil
(D) Replace shellfish with red meat
(B) Add cabbage to the diet
RATIONALE: To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.
A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients?
(A) A client who is taking potassium supplements, has a potassium level of 3.2 mEq/L (3.5 to 5 mEq/L), and reports constipation.
(B) A client who has Alzheimer's Disease (AD), has a room near the nurse's station, and is agitated.
(C) A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed.
(D) A client who has conductive hearing loss, speaks softly, and is scheduled for a cerumen removal.
(C) A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed.
RATIONALE: A feeling of something popping or loosening with coughing might indicate a wound dehiscence. This client will need to have revisions to the plan of care, which can include management of the dehiscence, prevention of evisceration, or possible surgical repair of an evisceration if one occurs.
A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching?
(A) "I will wear a badge to measure how much radiation I am receiving."
(B) "I will remove the markings on my skin after each radiation treatment."
(C) "I will avoid direct exposure to the sun."
(D) "I will rinse my mouth with a commercial mouthwash."
(C) "I will avoid direct exposure to the sun."
RATIONALE: The client should avoid exposure of irradiated skin areas to the sun for at least 1 year after completing radiation therapy. Skin in the radiation path is especially sensitive to sun damage.
A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?
(A) Place a padded tongue blade at the client's bedside
(B) Keep the side rails lowered on the client's bed
(C) Maintain the client's bed at hip level or above
(D) Ensure that the patient has a patent IV
A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?
- Place a padded tongue blade at the client's bedside
- Keep the side rails lowered on the client's bed
- Maintain the client's bed at hip level or above
- Ensure that the patient has a patent IV
(D) Ensure that the patient has a patent IV
RATIONALE: The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.
A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority?
(A) Initiate oxygen at 2 L/min via nasal cannula
(B) Apply firm pressure to the insertion site
(C) Take the client's vital signs
(D) Obtain a stat order for an aPTT
(B) Apply firm pressure to the insertion site
RATIONALE: The greatest risk to the client is bleeding. Therefore, the priority intervention is for ythe nurse to apply firm pressure to the hematoma and stop the bleeding.
A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus?
A. A client who has a chest tube following a pneumothorax
B. A client who has an acute exacerbation of Crohn’s disease
C. A client who is postoperative following a laparoscopic appendectomy
D. A client who is recovering from thyroid storm
Correct Answer: A.
Crepitus, a crackling sound resulting from air trapped under the skin, can be palpated following a pneumothorax. The nurse should report this finding to the provider.
Incorrect Answers:
B. A client who has Crohn’s disease is not at risk for crepitus. Crohn’s disease is an inflammatory disorder of the small intestines.
C. A client who is postoperative following a laparoscopic appendectomy is not at risk for crepitus because the surgery is minimally invasive.
D. A client who is recovering from thyroid storm is not at risk for crepitus. Thyroid storm results in fever, tachycardia, and hypertension due to excessive release of thyroid hormone.
The 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 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."
RATIONALE: The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body changes.
A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
(A) Maintain adduction of the client's legs
(B) Encourage ROM of the hip up to a 120 degree angle
(C) Place a pillow between the client's legs
(D) Keep the client's hip internally rotated
(C) Place a pillow between the client's legs
RATIONALE: The nurse should place a pillow between the client's legs to prevent hip dislocation.
A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?
(A) "I will monitor my blood sugar carefully because the medication increases the secretion of insulin."
(B) "I should take this medication with a meal."
(C) "I can expect to gain weight while taking this medication."
(D) "While taking this medication, I will experience flushing of my skin."
(B) "I should take this medication with a meal."
RATIONALE: The client should take metformin with or immediately following meals to improve absorption and to minimize GI distress.
A nurse is providing teaching to a client who has cancer and a new prescription for opioid analgesic for pain management. Which of the following information should the nurse include in the teaching?
(A) "It is an expected effect to sleep throughout the day when taking this medication."
(B) "Your constipation will be lessened as you develop a tolerance to the medication."
(C) "You should void every 4 hours to decrease the risk of urinary retention."
(D) "If you experience ringing in your ears, your dose will need to be reduced."
(C) "You should void every 4 hours to decrease the risk of urinary retention."
RATIONALE: The nurse should instruct the client to void at least every 4 hr to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics.
A nurse is providing discharge teaching to a client who has a gastric ulcer a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions?
(A) Neutralizing gastric acid
(B) Reducing the growth of ulcer-causing bacteria
(C) Coating the stomach lining
(D) Suppressing gastric acid production
(D) Suppressing gastric acid production
RATIONALE: Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production.
A nurse is assessing a group of clients for indications of role changes. The nurses should identify that which of the following clients is at risk for experiencing a role change?
(A) A client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose
(B) A client who had a cholecystectomy and is starting on a modified-fat diet
(C) A client who has Crohn's disease and is experiencing diarrhea 3 times a day
(D) A client who has multiple sclerosis and is experiencing progressive difficulty ambulating
(D) A client who has multiple sclerosis and is experiencing progressive difficulty ambulating
RATIONALE: The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change as the client becomes less independent.
A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?
(A) "I will monitor my blood pressure while taking this medication."
(B) "I should take a vitamin D supplement to increase the effectiveness of the medication."
(C) "I should inform the provider if I experience an increased appetite while taking this medication."
(D) "I will decrease the amount of protein in my diet while taking this medication."
(A) "I will monitor my blood pressure while taking this medication."
RATIONALE: The client should monitor their blood pressure while taking this medication because HTN is a common adverse effect and can lead to hypertensive encephalopathy.
A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority?
(A) Loosen the clothing around the client's neck
(B) Check the client's pupillary response
(C) Turn the client to the side
(D) Move furniture away from the client
(C) Turn the client to the side
RATIONALE: The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration.
A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider?
(A) Temperature 37.2 C (99 F)
(B) Blood pressure 100/70 mmHg
(C) Weight loss
(D) Restlessness
(D) Restlessness
RATIONALE: Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is restlessness, which can be an indication the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue, and headache.
A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.)
A. Explain that the client will receive sedation and will not remember the procedure.
B. Verify that the client understands the purpose and nature of the procedure.
C. Offer the client sips of clear liquids until 1 hr before the test.
D. Obtain a pre-procedural sputum specimen.
E. Instruct the client to keep his neck in a neutral position.
A, B
For a bronchoscopy, clients typically receive premedication with a benzodiazepine or an opioid to ensure sedation and amnesia. The client will have signed a consent form, so the nurse should verify that the provider explained the procedure and that the client understands it.
Incorrect Answers:
C. The client should remain NPO for 4 to 8 hours prior to the procedure to minimize aspiration risk.
D. The provider can obtain any necessary sputum specimens during the procedure.
E. The client’s neck will be hyperextended to bring the pharynx into alignment with the trachea and to allow insertion of the scope without trauma.
A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include?
(A) Flex the affected arm when ambulating
(B) Numbness can occur along the inside of the affected arm
(C) Begin ROM exercises 1 day after surgery
(D) Dress in clothing that fits snugly
(B) Numbness can occur along the inside of the affected arm
RATIONALE: The nurse should instruct the client that numbness can occur near the incision and along the inside of the affected arm due to nerve injury.