A
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is thebestresponse by the nurse?
A. Gather information regarding how long it will take for the children to arrive
B. Explain that the client will start to lose consciousness and the body systems will slow down.
C. Reassure the spouse that the healthcare provider will notify when to call the children.
D. Offer to discuss the client's health status with each of the adult children.
B. Explain that the client will start to lose consciousness and the body systems will slow down.
An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider?
A. Urine specific gravity is 1.040
B. Systolic blood pressure decreases 10 points when standing
C. The client denies being thirsty
D. Skin tenting occurs when the clients forearm is pinched
D. Skin tenting occurs when the clients forearm is pinched
After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information and a uniform packet. Which action should the nurse take?
A. File a detailed incident report with the specific hiring facility
B. Inform the colleague that their actions are unprofessional
C. Comment anonymously about the action on a staff discussion board
D. Communicate the colleague's actions to the unit charge nurse
A. File a detailed incident report with the specific hiring facility
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider the nurse should review which of the client's laboratory values?
A. Culture for sensitive organisms
B. Serum blood glucose (BG) level
C. Creatinine level
D. Serum albumin
A. Culture for sensitive organisms
When assessing a 6-month-old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant?
A. Crying
B. Sitting upright
C. Vomiting
D. Straining on stool
B. Sitting upright
When describing patient education approaches, the nurse would explain that informal teaching is an approach that?
A. Follows formalized plans
B. Has standardized content
C. Often occurs one to one
D. Addresses group needs
C. Often occurs one to one
The nurse assumes care of a postoperative adult client with diabetes mellitus and learns that the client has a current blood glucose level of 720 mg. When assessing the client what is the priority?
A. Assess for vital signs of fluid volume deficit.
B. Observe wound drainage characteristics.
C. Measure the level of acute pain.
D. Determine when the client last ate.
A. Assess for vital signs of fluid volume deficit.
When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate invention? (Select all that apply)
A. Sloughing tissue around wound edges
B. Complaint of increased pain and pressure
C. Change in the quality of the peripheral pulses.
D. Loss of sensation to the left lower extremity
E. Weeping serosanguineous fluid from wounds
B. Complaint of increased pain and pressure
C. Change in the quality of the peripheral pulses.
D. Loss of sensation to the left lower extremity
The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcomes indicate the program is effective?
A. At risk clients received an increase number of routine health screenings
B. Clients reported having new confidence in making healthy food choices
C. Clients who incurred disease complications promptly received rehabilitation
D. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign
C. Clients who incurred disease complications promptly received rehabilitation
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first?
A. Determine if the client is experiencing any anxiety
B. Auscultate the clients bilateral lung sounds and oxygen saturation
C. Notify the healthcare provider about the clients distress
D. Assess the delivery mechanism of the oxygen tank, tubing, and cannula
D. Assess the delivery mechanism of the oxygen tank, tubing, and cannula
Which of the following physical assessment findings in a patient with pneumonia best supports the nursing diagnosis of ineffective airway clearance?
A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles
D. Basilar crackles
The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions.
What instruction should the nurse include in the discharge nursing plan of a client who had a cataract extraction today?
A. Sexual activities may be resumed upon returning home
B. Light housekeeping is permitted but avoid heavy lifting
C. Use a metal eye shield on operative eye during the day
D. Administer eye ointment before applying eye drops
B. Light housekeeping is permitted but avoid heavy lifting
A male client tells the nurse that he is concerned that he may have a stomach ulcer because he is experiencing heartburn and a dull gnawing pain. Which is the best response by the nurse?
A. Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer.
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food.
C. Instruct the client that these mild symptoms can generally be controlled with changes in his diet.
D. Advise the client that he needs to seek immediate medical evaluation and treatment for these symptoms.
A. Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer.
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath bilateral 2+ pedal edema in an oxygen saturation on a room air of 89% which action should the nurse take first?
A. Elevate the foot of the bed
B. Restrict the client's fluids
C. Begin supplemental oxygen
D. Prepare client for hemodialysis
C. Begin supplemental oxygen
A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?
A. Patch one eye
B. Evaluate swallow
C. Reorient often
D. Range of motion
B. Evaluate swallow
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift, and is planning assignments. Which client should receive the most care hours by registered nurse (RN)?
A. 48 year olds marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race
B. 34 year old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter
C. 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter
D. An 82-year-old's client with Alzheimer's disease and newly fractured femur who has a Foley catheter and soft wrist restraint supplied
D. An 82-year-old's client with Alzheimer's disease and newly fractured femur who has a Foley catheter and soft wrist restraint supplied
The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mg/2.4 mL." How many mL should the nurse administer?
0.2mL
In caring for a client with Cushing's syndrome which serum laboratory value is most important for the nurse to monitor?
A. Creatinine
B. Lactate
C. Glucose
D. Hemoglobin
C. Glucose
A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs every two hours. Which finding should the nurse report immediately to the healthcare provider?
A. Anorexia and abdominal distention
B. Abdominal pain and vomiting
C. Confusion and tremors
D. Yellowing and itching of skin
C. Confusion and tremors
A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 103/L). Which intervention is most important for the nurse to include in this client's plan of care?
A. Assess urine and stool for occult blood
B. Monitor for signs of activity intolerance
C. Require visitors to wear respiratory masks
D. Obtain clients temperature q4 hours
A. Assess urine and stool for occult blood
A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer' IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute. In addition to reporting the findings to the surgeon, which action should the nurse implement first?
A. Measure and document the client's urinary output.
B. Request the client's reserved unit of packed red blood cells.
C. Prepare for the placement of central venous catheter.
D. Increase the infusion rate of Lactated Ringer's solution.
D. Increase the infusion rate of Lactated Ringer's solution.
A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg the nurse calculates infusion rate for the heparin solution at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to how many mL/hour?
18mL/hr
An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the -10 cm H2O mark with fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?
A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into the chamber
D. Increase wall suction to eliminate fluctuation in water seal
A. Add sterile water to the suction control chamber.
The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication?
A. Difficulty locating the uterine fundus
B. Excessive lochia
C. Saturation of more than one pad per hour
D. Hypertension
D. Hypertension
A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client admission plan of care?
A. Assess for symptoms of AIDS dementia
B. Monitor for secondary infections
C. Identify local support HIV support groups
D. Observe for adverse drug reactions
B. Monitor for secondary infections