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The nurse evaluates the laboratory results of several clients. For which client would the nurse expect a decreased serum albumin?
1. The client who is underweight with a BMI of 19 kg/m?.
2. The client with a superficial thickness burn.
3. The client with severe liver disease.
4. The client who is dehydrated.
The client with severe liver disease
The nurse identifies a staff member is using standard precautions appropriately if which action is observed?
1. The staff member wears gloves when taking the blood pressure of a client diagnosed with AIDS
2. The staff member places contaminated linens in a leak-proof bag.
3. The staff member irrigates an abdominal wound wearing a gown and gloves.
4. The staff member removes gloves after bathing a client and puts on a clean pair of gloves to bathe another client.
The staff member places contaminated linens in a leak proof bag
A nurse provides teaching on modifiable risk factors related to the cardiovascular system. Which factor does the nurse include in the teaching? (Select all that apply.)
1. High cholesterol levels.
2. Elevated blood pressure.
3. Cigarette smoking.
4. Diet higher in sugar and fats.
5. Decreased heart rate.
1, 2, 3, 4
A middle-age adult client is admitted to the hospital for hematuria. The client has no previous history of illness, is married, and has three children in high school. Which task of middle adulthood is most likely to be disturbed by a physical disability?
1. Assisting the children to grow to adulthood.
2. Coping with a role transition.
3. Renewing earlier relationships
4. Developing adult leisure time activities.
Assisting the children to grow to adulthood.
Following a total hip arthroplasty, the older adult client is prescribed to start ambulation using a walker. Which statement by the nurse regarding ambulation is best?
1. "Sit in a low chair for ease in getting up to use the walker."
2. "Advance the walker first, then carefully walk forward."
3. "You will begin weight bearing on the affected hip soon."
4. "Practice tying your own shoes before you begin ambulating."
"Advance the walker first, then carefully walk forward."
The nurse teaches a client with a new diagnosis of eczema. Which common foods are likely contributing factors of eczema the client should eliminate in the diet?
1. Fish, nuts, chocolate.
2. Strawberries, tomato, apples
3. Milk, wheat, egg whites.
4. Soybeans, orange juice, egg yolks.
Milk, wheat, egg whites
The nurse explains to the nursing student that a client has a new diagnosis of psoriasis. Which best describes psoriasis?
1. Chronic autoimmune reaction.
2. Acute infectious disease.
3. Viral disease.
4. Cystic, self-limiting disease.
Chronic autoimmune reaction
The nurse provides care for a client with an abdominal wound. The nurse notes there is purulent drainage from the wound. Which action does the nurse take first?
1. Contacts the health care provider.
2. Places the client on contact precautions.
3. Irrigates the wound.
4. Asks the client to identify the level of pain on a numeric scale
Places the client on contact precautions.
At discharge, the nurse advises a client about a calorie-restricted diet for weight reduction. Which information does the nurse include?
1. Losing 1-2 pounds per week is safe and effective.
2. A highly restrictive diet will be most effective for the client.
3. Increase the amount of processed foods in the diet.
4. Decrease whole grain intake.
Losing 1-2 pounds per week is safe and effective.
The clinic nurse interviews a middle-age adult client who comes to the clinic reporting difficulty sleeping and ongoing fatigue. The nurse learns the client works as a security guard and frequently works the night shift. Which is the best initial statement for the nurse to make while discussing this client's problem?
1. "Tell me about your usual sleeping habits."
2. "You probably sleep when you can during your night tour."
3. "This is normal for your age group."
4. "Working the night shift is known to disrupt sleep patterns."
"Tell me about your usual sleeping habits."
The nurse provides care for an older adult client with a diagnosis of constipation. The nurse understands which factor contributes the the development of constipation in the older adult? (Select all that apply)
1. Older adult clients may eat a diet with inadequate fluids and bulk.
2. Older adults experience slowed peristalsis and decreased muscle tone.
3. Older adult clients have neurological changes in the gastrointestinal tract
4. Older adult clients may ignore the sensation to defecate.
5. Older adults are typically more sedentary and less likely to exercise.
1, 2, 4, 5
A client is experiencing an episode of acute pain. Which physiological change should the nurse expect to occur when the client experiences acute pain?
1. Decreased blood pressure.
2. Decreased skin temperature.
3. Decreased heart rate
4. Decreased respiration.
Decreased skin temperature
The nurse identifies which change in the genitourinary system is usually associated with client aging?
1. Increased sphincter tone
2. Decreased incontinence.
3. Increased frequency
4. Increased filtration.
Increased frequency
A liver scan is prescribed for a client prior to surgery. Which description best describes this procedure?
1. The client will ingest a small amount of radioactive material and venipuncture will be performed to monitor blood levels.
2. The client will stand in front of a large machine that takes x-ray pictures of the liver.
3. The client will be asked to lie still while a scanning probe is passed back and forth over the body.
4. The client's skin will be lubricated with oil and ultrasound pictures will be taken.
The client will be asked to lie still while a scanning probe is passed back and forth over the body.
The nurse provides care for a client who has taken aspirin in high, prolonged dosages. Which physiological change should the nurse anticipate?
1. Urinary frequency.
2. Hypoventilation.
3. Gastrointestinal bleeding
4. Hemoconcentration.
Gastrointestinal bleeding
While a client is being treated for a wound infection, it is most important for the nurse to routinely perform which action?
1. Check and record the client's temperature.
2. Send samples of wound drainage for culture.
3. Assess for redness of the wound.
4. Evaluate the results of the blood culture.
Check and record the clients temperature
Which nursing action is best to identify and manage a client's valuable items during hospitalization?
1. Tell the client to place valuable items in the bedside table.
2. Inform the client the nurse will hold on to any valuable items while the client is in surgery.
3. Document the disposition of the client's valuable items in the medical record.
4. Leave any valuable items at the nurses station while the client is off the unit for testing.
Document the disposition of the client's valuable items in the medical record.
On the morning before surgery, a client signs an operative consent form. Soon afterward, the client calls the nurse and states, "I do not want the surgery." Which action does the nurse take first?
1. Notifies the health care provider of the client's decision.
2. Informs the client the decision has delayed the operating room schedule.
3. Encourages the client to discuss reasons for canceling the surgery.
4. Asks the client's family to encourage the client to have the surgery.
Encourages the client to discuss reasons for canceling the surgery.
The nurse prepares a client for discharge. The client tells another staff member "That nurse really doesn't care about me and I don't want to talk anymore." Which interpretation of the client's statement by the nurse is best?
1. The client has expressed readiness to think and act independently.
2. The nurse has done something to offend the client and needs to apologize.
3. The client is not ready to go home and discharge should be delayed
4. The client has a common response to the end of the nurse-client relationship.
The client has a common response to the end of the nurse-client relationship.
A client with acute pain has a prescription for morphine sulfate 8 mg IV every 3-4 hours as needed for pain. The client asks the nurse for the medication at bedtime. Prior to administering the pain medication, the nurse takes which initial action?
1. Assumes the pain is psychological.
2. Checks to see if the client has a history of addiction.
3. Tries several other pain relief measures.
4. Assesses location, character, and intensity of pain.
Assesses location, character, and intensity of pain.
The nurse provides care for a client at risk for developing a pressure injury. The nurse knows which factor puts the client at risk? (Select all that apply.)
1. Decreased skin moisture.
2. Ambulation with an assistive device
3. Bony prominences.
4. Early stage Alzheimer disease.
5. Immobility.
6. Low serum albumin.
3, 5, 6
The nurse provides care for a client beginning intermittent heparin therapy. The nurse knows which laboratory test is used to monitor the effectiveness of heparin?
1. Activated partial thromboplastin time.
2. Prothrombin time.
3. Bleeding time.
4. Protein electrophoresis.
Activated partial thromboplastin time
The nurse provides care for a client with a body mass index (BMI) of 37.0 kg/m?. Which is the best description of the client's body weight?
1. Obese.
2. Normal weight.
3. Overweight.
4. Underweight.
Obese
Normal BMI is 18.5 to 24.9
Overweight is 25 to 29.9
Which nursing action does the nurse have to establish first when caring for a client in pain?
1. Teach the client about the pain.
2. Establish a trusting relationship with the client.
3. Determine how various relaxation techniques affect the pain.
4. Administer pharmacological agents.
Establish a trusting relationship with the client.
One morning, a client demonstrates helpless behavior and tells the nurse You all hate me!" Which response by the nurse is best?
"I do not have enough strength to make my bed." When the nurse offers to assist, the client states, "No one here likes me.
1. "That is not true. We all care about you."
2. "I think you are the one who does not like us."
3. "Everyone cares about you. Why do you think we hate you?"
4. "You seem upset. Let's sit down in your room to talk about it."
"You seem upset. Let's sit down in your room to talk about it."