Nursing Care Questions PDF

READ ALL WORDS FROM START TO FINISH INCLUDE EVERYTHING EVERYTHING EVERYTHING ALL FROM BEGINNING OF PAGE TO THE END OF ALL PAGES Read all INCLUDE EVERYTHING SORT THEM ALL CORRECTLY With the right informations \*Sort all informations that correlates with each other all together, explain answers give details, give examples! INCLUDE EVERYTHING STEP BY STEP STUDY GUIDE A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take Ensure the client\'s weights are hanging freely from the bed. A nurse in a provider\'s office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? Take this medication between meals A nurse in a provider\'s office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? Take this medication between meals. A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? Wash daily with an antibacterial soap. A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? Avoid medications in capsule or enteric form. A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? \"Large incisions will be made in the burned tissue to improve circulation.\" A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? Decreased color perception A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? Maintain the client in Fowler\'s position. A nurse is caring for a client who has Cushing\'s syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) 1\) Buffalo hump 2) Purple striations 3) Moon face A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? Monitor intake and output hourly A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? \"You will remain NPO for 8 hours before the procedure.\" A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? Postictal phase A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make? \"The pain will dissipate if you ambulate frequently.\" A nurse is checking the suction control chamber of a client\'s chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? Verify that the suction regulator is on. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) Encourage fluid intake. 2) Monitor the puncture site for hematoma. A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client\'s jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? Prevent aspiration. A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? Hardened skin A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take? Add thickener to fluids. A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? Airway obstruction A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? 1\) Take the medication 45 minutes before eating. A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? Notify the provider.. Determine the patency of the tubing. We have an expert-written solution to this problem! A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? \"The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible.\" A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan? Re-establish communication. A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? Hypotension A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? Take temperature once a day We have an expert-written solution to this problem! A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client\'s secretions? Provide humidified oxygen. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client\'s comfort? Obtain a pair of slipper socks for the client. We have an expert-written solution to this problem! A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? Thick, red-colored urine A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? Shivering A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? \"I will not exercise if my urine is positive for ketones.\" A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? Cover the client\'s wound with a moist, sterile dressing. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? Hyperventilation A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? Avoid bending at the waist A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? Check the client\'s vital signs. A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client\'s wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? Purulent A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1\) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client\'s right nostril. Which of the following actions should the nurse take first? Test the drainage for glucose. A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? Prevent bladder distention. A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? Abnormal vaginal bleeding A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse\'s priority? Altered level of consciousness A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? Abdomen is distended A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? Change the ostomy pouch daily A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? Change the nasal drip pad as needed. A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? To prevent blood clotting A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? Loss of peripheral vision A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? Potassium 2.5 mEq/L A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching? \"I will take a tub bath instead of a shower.\" A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? Ensure the client\'s weights are hanging freely from the bed. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) 1\) Encourage fluid intake. 2) Monitor the puncture site for hematoma. A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? Abdomen is distended A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make Respiratory acidosis A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching? \"I will wear stockings with elastic tops.\" A nurse is preparing to provide morning hygiene care for a client who has Alzheimer\'s disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? Calmly ask the client if he would like to listen to some music. A nurse is collecting data on a client\'s wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? Granulation tissue A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client? Fresh fruit basket A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan? Maintain abduction of the right hip. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? Feel for a carotid pulse. A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? \"Bypass surgery must be very frightening for you.\" A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take? Tell the client to remain in the bathroom after toileting and obtain a wheelchair A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take? Fully recollapse the reservoir after emptying it A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? \"I will abstain from sexual intercourse.\" A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? Breathe in through her nose and out through pursed lips. A nurse is caring for a client who is postoperative and has a history Addison\'s disease. For which of the following manifestations should the nurse monitor? Hypotension A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) 1\) Decreasing anxiety 2) Controlling emesis 5) Reducing the amount of narcotics needed for pain relief A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? Iron A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? Ineffective airway clearance related to thick, copious secretions A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client\'s mobility? Propel a wheelchair equipped with knobs on the wheels. A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer? Sun exposure. Based on a client\'s recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? \"Do you sleep well at night?\" A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching? Fresh berries A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? Lethargy A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? \"This test will measure the intraocular pressure of the eye.\" A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider? Increase in serum creatinine A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? Drop in systolic BP more than 10 mm Hg on inspiration We have an expert-written solution to this problem! A nurse is caring for a client who has Alzheimer\'s disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take? Attempt to determine what the client was looking for A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take? Check pedal pulses every 15 min. A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza? The composition of the influenza vaccine changes yearly. A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take? Help the client write down questions to ask his provider A nurse is caring for a client who has hemiplegia following a stroke. The client\'s adult son is distressed over his mother\'s crying and condition. Which of the following responses should the nurse make? \"It must be hard to see your mother so ill and upset.\" A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching? Forgetfulness gradually progressing to disorientation A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan? Monitor client\'s cardinal fields of vision We have an expert-written solution to this problem! A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan? Monitor platelet levels A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client? Chest x-ray A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus? Urine output 650 mL/hr A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client? \"I took my metformin before breakfast.\" A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client\'s chest, the nurse should expect to hear which of the following sounds? Expiratory wheeze A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take? Don clean gloves to remove the dressing. A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure? Sitting, leaning forward over the bedside table. A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect? Denial A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed-suction drains in place. Which of the following interventions should the nurse include in the plan? Body weight A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations? Hypotension A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions? A sensory warning that a seizure is imminent A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider? \"I need something for the horrible pain in my eye.\" A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make? \"You may feel some cramping during the procedure.\" A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? Checking pupillary responses to light A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects? Reducing anxiety A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report? Frequent mood changes A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? Fever A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.) Blurry vision 3) Tachycardia 5) Sweating A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.) Edema 2) Erythema 3) Tophi 4) Tight skin A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a complication of MG for which the nurse should monitor? Respiratory difficulty.A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority? Evaluate fluid and electrolyte levels. A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching? \"You should wear glasses instead of contacts while taking this medication.\" A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates an understanding of the teaching? \"I will need to take this medication for the rest of my life.\" A nurse is caring for a client who has Parkinson\'s disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication? Decreased tremors.A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first? Stop the transfusion. A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud\'s phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching? \"I will keep my house at a cool temperature.\" A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking ferrous sulfate twice a day. Which of the following statements by the client indicate an understanding of the teaching? \"I will take the medication with orange juice.\" A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia? Vitamin B12.A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a prescription for lorazepam preoperatively. Which of the following statements by the client should indicate to the nurse that the medication has been effective? \"I feel very sleepy.\" A nurse is collecting data from a client who has AIDS. When checking the client\'s mouth, the nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions? Candidiasis.A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take? Empty the suction device every 4 hr A nurse is assisting with teaching a client who has a history of smoking about recognizing early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report which of the following manifestations of laryngeal cancer? Hoarseness.A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following laboratory values should the nurse review to determine the client\'s renal function? Serum creatinine A nurse is collecting data from a client who has Cushing\'s syndrome. Which of the following manifestations should the nurse expect? Bruising A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client\'s postoperative prescriptions, which include, \"Clear liquids, advance diet as tolerated.\" Which of the following actions should the nurse take first? Auscultate the client\'s abdomen. A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse? The wound has a halo of erythema on the surrounding skin. A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax? Absence of breath sounds A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? Peripheral edema A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take? Encourage the client to drink a carbonated beverage 1 hr before meals. A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take? Irrigate the catheter as prescribed. A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective? \"I will take a stool softener until my eye is healed.\" A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? Hypertension A nurse is caring for a client who has COPD. Which of the following actions should the nurse take? Encourage the client to drink 8 glasses of water a day.. A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk to the client? Airway obstruction A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease? An expanding circular rash A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastectomy with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm? Combing her hair A nurse in a provider\'s office is collecting data for a 45-year-old client who is having manifestations associated with perimenopause. Which of the following findings should the nurse expect? Report of dryness with vaginal intercourse We have an expert-written solution to this problem! A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times? Three to seven days after menses stops A nurse is caring for a client who has second- and third-degree burns and a prescription for a high-calorie, high-protein diet. Which of the following menu choices should the nurse recommend? Turkey and cheese sandwich with scalloped potatoes A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram. Which of the following should the nurse include in the teaching? Take a laxative the evening before the procedure. A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease? \"I feel so much better after eating.\" A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the following interventions should the nurse identify as the priority? Schedule pain medication on a routine basis. A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching? \"I should call the clinic before taking any over-the-counter medications.\" A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy? a\. Urticaria b\. Lymphedema c\. Headaches d\. Mouth sores Lymphedema A nurse is preparing to administer lactated Ringer\'s via continuos IV infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/mL. How many gtt/min should the nurse set the IV ump to administer? 33 A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching? a\. \"I should lie down when I take this medication.\" b\. \"I can keep my medication for 1 year before replacing it.\" c\. \"I should discontinue this medication if I develop a headache.\" d\. \"I can take up to five tablets in 15 minutes before seeking medical attention.\" I should lie down when I take this medication A nurse is providing discharge teaching to an older adult client following total hip arthroplasty. Which of the following instructions should the nurse include in the teaching. a\. \"You should use an incentive spirometer every 8 hours.\" b\. \"You can cross your legs at the ankles when sitting down.\" c\. \"Clean the incision daily with hydrogen peroxide.\" d\. \"Install a raised toilet seat in your bathroom.\" Install a raised toilet seat in your bathroom A nurse is planning care for a client following a cardiac catheterization. which of the following actions should the nurse take. a\. Limit the client\'s fluid intake to 1 L per day. b\. Change the client\'s dressing every 8 hr. c\. Keep the client on bed rest for 24 hr. d\. Maintain he client\'s affected extremity in extension. Maintain the client\'s affected extremity in extension A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. which of the following client statements indicates that the client is adapting to their role change? a\. \"I will need to have my partner take over shopping for groceries and cooking the meals for us.\" b\. \"I feel bad that I have to ask my partner to keep the house clean.\" c\. \"These crutches will make it impossible to care for my child.\" d\. \"It\'s going to be difficult to tell my parents I can\'t take them to their appointments anymore.\" I will need to have my partner take over shopping for groceries and cooking the meals for us A nurse is providing teaching to a client who has an impaired immune system due to chemotherapy. which of the following information should the nurse include in the teaching? a\. \"Wash your perineal area two times each day with antimicrobial soap.\" b\. \"Change the water in your drinking glass every 4 hours.\" c\. \"Change your pet\'s litter box daily.\" d\. \"Wash your toothbrush in the dishwasher once each month.\" a\. \"Wash your perineal area two times each day with antimicrobial soap.\" a nurse is caring for a client who has a contusion and reports thirst. The client\'s urinary output was 4,000 ml over past 24 hr. the nurse should anticipate a prescription for which of the following IV medications? Desmopressin A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports nagging dry cough. Which of the following responses by the nurse is appropriate? Sucking on a lozenge may reduce the frequency of your cough A nurse is taking an admission history from a client who reports Raynaud\'s disease. Which of the following assessment findings should the nurse identify as a parenteral trigger for exacerbation of Raynaud\'s? Using nicotine transdermal patch A nurse is caring for a client who has a central venous device and notes the tubing has become disconnected. the client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? A nurse is completing an assessment of an older client and notes reddened areas over the bony prominences, but the client\'s skin is intact. which of the following interventions should the nurse include in the plan of care? Support bony prominences with pillows A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take? A nurse in the emergency department is assessing a client. which of the following actions should the nurse take first? (click on rhe \"exhibit\" button for additional information about the client Initiate airborne precautions A nurse is reviewing the medical record of a client to identify factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client\'s risk? Historyof Crohn\'s disease A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, \"I\'m not sure I want to have a mastectomy.\" Which of the following statements should the nurse make? I can give you additional information about the procedure A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow. 1\. obtain venous access using a 19-gauge needle 2\. Obtain the unit of a packed RBCs from blood bank 3\. verify blood compatibility with another nurse 4\. Initiate traensfuntion of the unit of packed RBCs 5\. Remain with the client for the first 15 to 30 minutes A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching. I should expect less than 25 ml of secretions per day in the drainage devices A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing and makes incomprehensible sounds. which of the following glasgow Coma scale scores should the nurse assign the client? 5 A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching? I can have a frozen fruit juice bar for dessert A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first? instill 0.9% sodium chloride solution into the affected eye A nurse is assessing a client following extubation from a ventilator.for which of the following findings should the nurse intervene immediately? Stridor A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect? Elevated blood glucose A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect? Urine specific gravity 1.001 A nurse is planning care for a client who has a pulmonary embolism. which of the following interventions should the nurse include? Initiate a continuos IV heparin infusion We have an expert-written solution to this problem! a nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. which of the following instructions should the nurse include? Avoid extremely hot or cold temperatures A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following ac ons should the nurse take first? Insert a large-bore IV catheter A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation on of the graft? Palpable thrill A nurse is assessing a client who has heart failure and is receiving a loop diure c. Which of the following nding indicates hypokalemia? Muscle weakness A nurse is caring for a client in diabetic ketoacidosis (DKA) Which of the following is the priority intervention by the nurse? Infuse 0.9% normal saline A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching? I will expect my stools to be loss A nurse is caring for a client who is receiving total parenteral nutri on through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take? Switch the infusion to a 10% dextrose solution A nurse is caring for a client who is 6hr postopera ve following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of the following electrolyte imbalance? Hypocalcemia A nurse in a provider office is caring for a client who has total vision loss and is the handler of a service dog. which of the following actions should the nurse take to show consideration for the client and the service animal? Consult the client before approaching the dog. A nurse is reviewing medications taken at home with a client who has angina. which of the following statements by the client indicates an underestanding of the teaching? I should lie down before taking a dose of isosorbide dinitrate A nurse in the post anesthesia care unit is assessing a client following an appendectomy and finds a 2 cm (3/4 in) area of blood on the postoperative dressing. which of the following actions should the nurse take? Apply pressure A nurse is caring for a client who is receiving mechanical ventilation. which of the following interventions should the nurse implement? A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include? Apply new gloves when alternating between wound care sites. A nurse is providing teaching for a client who has tuberculosis and a new prescription for pyrazinamide. The nurse should instruct the client to notify the provider if which of the following adverse effects occurs? Jaundice A nurse is planning care for a client who has left-side hemiplegia following a stroke. which of the following actions should the nurse include in the plan of care? Position the client\'s table on the left side A nurse is performing an ear irriga on for a client. Which of the following ac ons should the nurse take? Point the type of the syringe toward the top of the ear canal A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomi ng. Which of the following medica ons should the nurse administer prior to chemotherapy? Ondasteron A nurse is preparing to discharge a client who has a halo device and is reviewing new prescription ons from the provider. The nurse should clarify which of the following prescriptions ons with the provider? May operate a motor vehicle when no longer taking analgesics A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following information should the nurse include in the teaching? You will to return in 2 weeks to provide a sputum specimen. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? Frothy sputum A nurse is planning care for a client who has osteoarthritis of the knees. Which of the following interventions should the nurse include in the plan? Place a large pillow under the client\'s knees when resting. We have an expert-written solution to this problem! A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first? Check the client\'s urine output A nurse is providing instructions about foot care for a client who has a peripheral arterial disease. The nurse should identify that which of the following statements by the client indications understanding of the teaching \"I rest in my recliner with my feet elevated for about an hour every afternoon\" A nurse in a provider\'s office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include? Sleep with the head of the bed elevated 6 inches A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider? High-pitched sound on inspiration A nurse is caring for a client who is 2 days postoperative following a below the knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse. Why do you think your life is over? A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. which of the following assessments should the nurse plan to perform first? Measure the client\'s core body temperature A nurse is providing instructions ons to a client who has primary syphilis. Which of the following instructions ons should the nurse include in the discharge plan? You will need to be monitor for 15 minutes after receiving each medication close A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client? Feet elevated A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing? Dark red granulation tissue A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? I\'ll cut a slit in a clean gauze pad to use as a stoma dressing A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contraindica on for receiving the medica on? Potassium 3.2 mEq/L A nurse is caring for a client admitted with a skull fracture. which of the following assessment findings should be greatest concern to the nurse? Glasgow coma scale score changes from 14 to 9 A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy? I have a hard time with brushing my hair A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following informa on should the nurse include regarding needle disposal? You can discard needles in an empty bleach bottle with a lid A nurse is assessing a client who has an arteriovenous (AV) gra in the le forearm. Which of the following ndings should indicate to the nurse a complica on of vascular access? a\. Presence of a palpable thrill b\. Dilated appearance of the AV site c\. 2+ le radial pulse d\. Absence of a bruit d\. Absence of a bruit A client who is ideal and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take? Request an interpreter during the initial assessment A nurse is teaching a client. about the nurse of the incentive spirometer. which of the following instructions should the nurse include in the teaching? Hold breaths 3 to 5 seconds before exhaling A nurse is caring for a client who sustained a spinal cord injury in a diving accident. which of the following actions should the nurse take? Monitor urine output hourly A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care? a\. Flush the catheter using a 10-ml syringe b\. Use clean technique when changing the dressing C. Cleanse the site with povidone-iodine D. Change the dressing every 24hr Flush the catheter using a 10 ml syringe A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following action should the nurse take first? a\. Prepare the client for peritoneal lavage b\. Check the color of the client\'s skin c\. Administer an opioid analgesic d\. Remove all of the client\'s clothing d\. Remove all of the client\'s clothing A nurse is caring for a client following a bronchoscopy. Which of the following action should the nurse take first? a\. Provide the client with sips of water. b\. Instruct the client to report bleeding. c\. Inform the client they might experience a low-grade fever. d\. Check the client\'s gag reflex d\. Check the client\'s gag reflex A nurse is teaching a client about using a metered-dose rescue inhaler. which of the following statements should the nurse include in the teaching? Exhale fully before bringing the inhaler to your lips A nurse is instruc ng a client who has a new diagnosis of type 1 diabetes mellitus about the sick- day rules. Which of the following statements by the client indicates an understanding of the teaching? a\. \"I will consume 250grams of carbohydrates daily while I\'m sick.\" b\. \"I will monitor my blood glucose every 8hours.\" c\. \"I will not take my diabetes medica ons while I am sick.\" d\. I will check my urine for ketones if my blood glucose is greater than 240 mg/dL d\. I will check my urine for ketones if my blood glucose is greater than 240 mg/dL A nurse is reviewing ABG results for a client who has COPD. Which of the following ndings should the nurse expect? a\. HCO3-25 mEq/L b\. PaO2 85mmHg c\. pH 7.38 d.PaCO2 48 mm Hg d.PaCO2 48 mm Hg A nurse is admi ng a client to a medical unit following placement of a permanent pacemaker. Which of the following ndings requires further assessment by the nurse? a.Hiccups b\. Sneezing c\. Presence of a sharp spike prior to the QRS complex on the ECG d\. Presence of intrinsic P waves following a QRS complex on the ECG a.Hiccups A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. which of the following routine medications to give at 0800 should the nurse withhold? a\. Metformin b\. Metoprolol c\. Valporic acid d\. Fluticasone Metformin A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care? a\. Place pillows under the client\'s knees b\. Apply compression stocking socks c\. Avoid use of anticoagulants b\. Discourage leg exercises while in bed b\. Apply compression stocking socks A nurse is caring for a client who has duodenal ulcer. which of the following actions should the nurse take? (click on the Exhibit button for additional information. Infuse packed RBCs A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse\'s priority? In the last day, I have had a severe headache and pain around my right eye. A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse an cipate? a\. BUN 8mg/dL b\. Creatinine 0.4mg/dL c\. Hgb 20g/dL d\. Potassium 6.8 d\. Potassium 6.8 mEq/L A nurse is planing care for an older adult client who has Menier\'s disease. Which of the following interventions should the nurse include in the plan? Encourage the client to change positions slowly We have an expert-written solution to this problem! A nurse is preparing to receive a client from surgery following a transverse colon resec on with colostomy placement. The nurse should expect assess the stoma at which of the following locations? B. on top A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? a\. Insert a urinary catheter b\. Administer IV fluids to the client c\. Prepare the client for an intravenous pyelogram d\. Initate beta-blocker therapy Administer IV fluids to the client A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following ac ons should the nurse plan to take?a. Slow the transfusion rate if the client reports itching b\. Prime the IV tubing with 0.45% sodium chloride c\. Complete the transfusion within 2hr d. d\. Administer through a 22-gauge Complete the infusion within 2 hr A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include? a\. Decrease carbohydrate intake b.increase phosphorus intake c\. Increase potassium intake d\. Decrease protein intake d\. Decrease protein intake A nurse is caring for an older adult client who has demen a. Which of the following ques ons should the nurse ask to assess the client\'s abstract thinking? a.\"Can you count backwards from 10 in intervals of 7?\" b\. \"Can you tell me the state where you were born?\" c.\"What do you understand about your condition?\" d\. What is mean by the saying \"Don\'t beat around the bush?\" d\. What is mean by the saying \"Don\'t beat around the bush?\" A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take? Keep soiled bed linens in the client\'s room A nurse is preparing a client for a lumbar puncture which of the following images indicates the position the nurse should assist the client into for this procedure? B. A nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of the following actions should the nurse take? Attach a dosimeter badge to the client\'s gown A nurse is teaching a client who has Grave\'s disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching? Increased temperature A nurse is caring for a client who is postoperative following a complete thyroidectomy, which of the following findings is the priority for the nurse to report to the provider? Muscle twitching A nurse is reviewing ECG rhythm strips for a group of clients. the nurse should identify that which of the following rhythms indicates bradycardia? C a nurse is caring for a client who is receiving epidural analgesia. Which of the following assessment finding is the nurse\'s priority? Hypotension A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse\'s priority to include? Turn the client lateral position during the seizure activity. A nurse is caring for a client following a below the knee amputation. The client states, \"my life is over\". Which of the following responses should the nurse take? Why do you think your life is over? A nurse in a clinic is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adult after age 60? Pneumococcal polysaccharide Herpes zoster Influenza a nurse is planning care a client who has dementia. Which of the following interventions should the nurse plan to include? \- Turn off the lights in the client\'s rom at night \- Assist the client with toiling at least once every 4 hr We have an expert-written solution to this problem! A nurse is assessing a client who has new diagnosis of DM1. Which of the following findings indicate that the client is experiencing hypoglycemia? Increased perspiration A nurse in the PACU is assessing a client who is post-operative following general anesthesia. Which of the following findings is the priority to address? vomiting upon arousal A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding? Weight gain A nurse is teaching about measure to prevent recuring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? \- Wipe the perineal area from front to back after urinating. \- Drink 3L of fluids daily \- Drink low-fructose cranberry juice A nurse is caring for a client following a cardiac-catherization who has hives and urticaria following administration of IV contrast dye. Which of the following Medication should the nurse plan to administrer? Diphenidramine A home care nurse to use non-pharmacological pain relief measures for an adult client who has severe chronic back pain. which of the following guideline should the nurse use? Discontinue opioids before trying non pharmacological methods of pain relief A nurse is caring for a female client who is receiving total parenteral nutrition without fat emulsion. Which of the following findings should the nurse report.? Crackles in the bilateral lung bases A nurse is planning care for a client who has renal calculi. Which of the following interventions should the nurse include to promote elimination of the calculi? Maintain bedrest until calculi are expelled. Withhold thiazide diuretics. Encourage intake of at least 3 L of fluid each day. Collect all urine for 24 hr in a collection container. Encourage intake of at least 3 L of fluid each day. The nurse should encourage the client to consume at least 3 L of fluid each day. Increased fluid intake increases urine production, promotes eliminiation of calculi, and helps prevent recurrence. A nurse is providing postoperative education for a client following a laparoscopic cholecystectomy for cholelithiasis. Which of the following client statements indicates an understanding of the teaching? \"The adhesive bandages on my incision will fall off as the incision heals.\" \"I will be able to take a shower in 1 week.\" \"I will need to follow a liquid diet for the first 3 days after surgery.\" \"I can begin to resume my normal activity level in 2 weeks.\" \"The adhesive bandages on my incision will fall off as the incision heals.\" The nurse should instruct the client that the small adhesive bandages will lose their adhesiveness in 7 to 10 days. The client can then remove the bandages or allow the bandages to fall off over time as the incision heals. A nurse is planning care to prevent hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infection for a client who is immunocompromised. Which of the following interventions should the nurse include to prevent this antibiotic-resistant infection? Initiate contact precautions for this client. Bathe the client with chlorhexidine wipes. Administer ceftaroline to the client as a prophylactic measure. Avoid using alcohol-based hand sanitizers after caring for the client Bathe the client with chlorhexidine wipes. The nurse should bathe a client who is immunocompromised with chlorhexidine wipes to decrease the risk of contracting hospital-acquired MRSA. A nurse is assessing a client who has developed type 1 herpes simplex virus. Which of the following images should the nurse identify as this type of viral infection? Picture of lips. Herpes simplex virus infection is a common viral infection in adults. The nurse should identify that this image indicates the type 1 herpes simplex viral infection because the infection causes a recurring cold sore. A nurse is assessing a client who has Graves\' disease. Which of the following findings should the nurse expect? Somnolence Cold intolerance Exophthalmos Dry, scaly skin Exophthalmos The nurse should expect a client who has Graves\' disease, an autoimmune form of hyperthyroidism, to experience exophthalmos, which is protrusion of the eyeballs. A nurse is teaching an older adult client who has peripheral neuropathy about a new prescription for duloxetine. Which of the following client statements indicates an understanding of the teaching? \"It might take several weeks to notice an improvement in my symptoms.\" \"I will need to take this medication on an empty stomach.\" \"I should take a daily ibuprofen for generalized aches.\" \"I will need to decrease my dietary sodium intake while taking this medication.\" It might take several weeks to notice an improvement in my symptoms.\" The nurse should instruct the client that duloxetine can take several weeks to be effective. This medication is an antidepressant that reduces the discomfort of peripheral neuropathy. A nurse is teaching a client who has scabies about a new prescription for lindane lotion. Which of the following client statements indicates an understanding of the treatment for this parasitic infection? \"I will apply the lotion once a day for 1 week.\" \"I will rub in the lotion thoroughly from my face to my toes.\" \"I will wash the lotion off 12 hours after I apply it.\" \"I should avoid bathing for 6 hours prior to applying the lotion.\" \"I will wash the lotion off 12 hours after I apply it.\" The nurse should instruct the client to apply the lotion and leave it in place for 8 to 12 hr and then remove it by washing it off. A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse report to the provider immediately? WBC 16,000/mm³ Board-like abdomen Nausea and vomiting Temperature of 38° C (100.4° F) Board-like abdomen When using the urgent vs. nonurgent approach to client care, the nurse should identify that a board-like abdomen is the priority finding indicating peritonitis. The nurse should notify the provider immediately. A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent reflux. Which of the following information should the nurse include in the teaching? Drink tomato juice with the breakfast meal. Suck on peppermint when having indigestion. Elevate the head of the bed 10 cm (4 in) using wooden blocks. Plan to finish eating at least 3 hr before bedtime. Plan to finish eating at least 3 hr before bedtime. The nurse should encourage the client not to eat anything at least 3 hr before bedtime to prevent reflux. A nurse is teaching a client who has a deep-vein thrombosis about a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching? \"I will stop taking the medication immediately if I experience nausea.\" \"I should contact my provider if I notice a pink-tinged color to my urine.\" \"I will increase my dietary intake of spinach.\" \"I will not be able to use an electric razor while I am taking this medication.\" \"I should contact my provider if I notice a pink-tinged color to my urine.\" The nurse should instruct the client to monitor for blood in the urine. The client should report a pink-tinged urine color to the provider. A nurse is reviewing the urinalysis results of a client who has completed a 14-day course of ciprofloxacin to treat pyelonephritis. Which of the following values should indicate to the nurse that the client has a continuing infection? Negative nitrites RBCs \< 2 Positive leukocyte esterase Amber-colored urine Positive leukocyte esterase The nurse should identify that a positive leukocyte esterase test is an indication of the presence of WBCs in the urine and the presence of continued infection. A nurse is assessing a client for manifestations of grief after having a colostomy for removal of colon cancer. Which of the following findings indicates to the nurse that the client has accepted the loss? Becomes angry when it is time to perform colostomy care Touches the colostomy stoma when the bag is changed Looks away as the nurse empties the colostomy bag Tells others that it will be nice to have a normal bowel movement again Touches the colostomy stoma when the bag is changed The client touching the colostomy stoma when the bag is changed should indicate to the nurse that the client is accepting and coping with the alteration of body image and has gone through the stages of grief. A nurse is assessing a school-age child who has appendicitis with possible perforation. Which of the following findings should the nurse identify as a manifestation of peritonitis? Abdominal distention Bradycardia Hyperactive bowel sounds Slow, deep breathing Abdominal distention The nurse should identify that peritonitis is an inflammation of the lining of the abdominal wall. This inflammation, along with the ileus that develops, causes abdominal distention; therefore, the nurse should identify this as a manifestation of peritonitis. A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings is a priority to report to the provider? Melena stools Hemoglobin 7.6 mg/dL Weight gain of 1.4 kg (3 lb) in 2 weeks Dyspepsia during the day Hemoglobin 7.6 mg/dL When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is the hemoglobin below the expected reference range, which in an indication of a peptic ulcer that is chronically bleeding. A nurse in an emergency department is assessing a client who has hyperthermia. Which of the following findings should the nurse identify as an indication that the client has heat exhaustion? Hallucinations Vomiting Bradycardia Seizures Vomiting The nurse should identify that heat exhaustion is usually the result of excess sweating, leading to dehydration. Manifestations include nausea, vomiting, headache, dizziness, fainting, and a temperature typically between 38.3º C and 38.9º C (101º F and 102º F). A nurse is providing teaching to a client who is experiencing malabsorption related to lactose intolerance. Which of the following foods should the nurse recommend to the client as the best nondairy source of calcium? Ground beef Collard greens Cauliflower Walnuts Collard greens The nurse should determine that collard greens are the best food source to recommend because 1 cup contains 268 mg of calcium per serving. A nurse is planning care for a client who is postoperative and has developed left lower leg deep-vein thrombosis. Which of the following interventions should the nurse include in the plan of care? Initiate complete bed rest. Massage the left lower leg three times a day. Make sure the client\'s legs are elevated while in bed. Apply cold compresses to the left lower leg every 2 hr. Make sure the client\'s legs are elevated while in bed. The nurse should ensure the client elevates her legs in bed and wears antiembolic stockings to help prevent venous insufficiency. A nurse is assessing a client who is 1 day postoperative following open ileostomy placement to treat an inflammatory bowel disorder. Which of the following findings is the priority for the nurse to report to the provider? The stool is a dark green liquid with a small amount of blood. The ileostomy output is 1,000 mL for the past 24 hr. The stoma is purple in color. The output from the NG tube has decreased over the past 24 hr. The stoma is purple in color. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is the color of the stoma. Stomas should be pink to bright red in color and shiny. A stoma that is pale bluish, dark red-purplish, or black in color is not receiving adequate blood supply. A nurse is developing a plan of care for a preschooler who has heart failure. Which of the following interventions should the nurse include in the plan? Assess and record the child\'s blood pressure every 6 to 8 hr. Weigh the child once each week using the same scale. Place the child in a supine position for a minimum of 4 hr each day. Offer small, frequent meals based on the child\'s endurance level. Offer small, frequent meals based on the child\'s endurance level. The nurse should offer small, frequent meals based on the child\'s endurance level. The child requires an increase in caloric intake, but often has a low energy level. The nurse should choose times for meals when the child is most rested, and make sure those meals are high in calories. A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take to treat this form of hyperthermia? Apply ice packs to the client\'s axillae, neck, groin, and chest. Administer aspirin to the client Initially offer the client cool, oral fluids. Continue cooling measures until the client\'s rectal temperature is 37.2º C (99º F). Apply ice packs to the client\'s axillae, neck, groin, and chest. The nurse should recognize that treatment for heat stroke involves cooling the client\'s core body temperature quickly. The nurse should apply ice to the client\'s axillae, neck, groin, and chest while also spraying the client\'s body with tepid water. A nurse is teaching a client who has asthma about medications to treat an acute asthma attack. Which of the following medications should the nurse include in the teaching? Fluticasone Salmeterol Albuterol Montelukast Albuterol Albuterol is a short-acting beta agonist that causes bronchodilation. The client should use albuterol during asthma attacks and before engaging in activities that are likely to cause an attack. The nurse should instruct the client to keep an albuterol inhaler with him at all times. A nurse is assessing a client who is postoperative following the placement of an ileostomy due to complications of ulcerative colitis. In which of the following areas should the nurse expect the ileostomy to be located? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) The nurse should expect a client who is postoperative following the placement of an ascending colostomy to have an ostomy located on the right side of the abdomen, lateral to, and slightly above the umbilicus. A nurse is assessing a school-age child who has diabetes mellitus and a blood glucose level of 250 mg/dL. Which of the following findings should the nurse expect? Hyperreflexia Fruity breath odor Sweating Shallow respirations Fruity breath odor The nurse should expect a child who has a blood glucose level of 250 mg/dL to have a fruity or acetone breath odor. Other manifestations include lethargy, thirst, and confusion. A nurse is providing teaching to a client who has diabetes mellitus and a new prescription for extended-release metformin. Which of the following client statements indicates an understanding of the teaching? \"I will avoid drinking grapefruit juice.\" \"I will chew the medication if I can\'t swallow it whole.\" \"I will call the doctor if I have muscle pain in my back.\" \"I will take this medication on an empty stomach.\" \"I will call the doctor if I have muscle pain in my back.\" Metformin, a biguanide, can cause lactic acidosis, which is a life-threatening complication manifesting as muscle aches, sleepiness, malaise, and hyperventilation. If these manifestations develop, the client should stop taking the medication and notify the provider immediately. A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following information should the nurse include in the teaching? \"If you miss a dose, you should take two doses the next morning.\" \"You should stop taking this medication immediately if you experience depression.\" \"You might experience an increased sensitivity to heat while taking this medication.\" \"You should contact your provider if your pulse rate drops below 60 per minute.\" \"You should contact your provider if your pulse rate drops below 60 per minute.\" The nurse should teach the client how to monitor his pulse rate and further instruct the client to withhold the medication and notify his provider if his pulse rate drops below 60/min. A community health nurse is teaching a group of older adult clients about interventions to prevent pneumonia. Which of the following instructions should the nurse include in the teaching? \"Obtain a pneumococcal vaccination every 2 years.\" \"Contact your provider if you have a fever that lasts 18 hours.\" \"Wash your hands when you return home from running errands.\" \"Avoid exposure to cold air by shopping inside enclosed malls.\" \"Wash your hands when you return home from running errands.\" The nurse should instruct clients that handwashing is one way to avoid organisms that can cause pneumonia. Handwashing after using the restroom or being in public areas can minimize the risk of developing pneumonia. A nurse is discussing lactose-free foods with a client who is experiencing malabsorption due to lactose intolerance. Which of the following foods should the nurse recommend? Sour cream Soy milk Ice cream Plain yogurt Soy milk The nurse should instruct the client to consume foods that are lactose-free and are nondairy products. Acceptable foods include soy milk, almond milk, and soy cheeses. A nurse is providing dietary teaching for a client who has hyperlipidemia due to nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? Less than 30% of daily calories should come from fat. Decrease caloric intake to less than 25 cal/kg/day. Increase sodium intake. Limit daily intake of foods high in carbohydrates. Less than 30% of daily calories should come from fat. The nurse should instruct the client to choose foods low in fat and ensure that less than 30% of her daily total caloric intake is from fat. Limiting daily fat intake will improve lipid levels. A nurse is assessing a client whose ABG results are pH 7.51, PaCO2 29 mm Hg, and HCO3- 24 mEq/L. Which of the following findings should the nurse expect? Paresthesias Bradycardia Muscle flaccidity Respiratory depression Paresthesias One of the manifestations of respiratory alkalosis is numbness and tingling, or paresthesia, due to a decrease in calcium ionization. Other manifestations include lightheadedness, tachycardia, and cardiac dysrhythmias. A nurse is teaching the parent of a school-age child who has pediculosis capitis about treating this parasitic infestation. Which of the following instructions should the nurse include? Wash bedding, clothes, and towels in hot water in a washing machine. Rinse the child\'s hair with vinegar three times a day. Seal items that are not machine washable in plastic bags for 1 week. Boil the child\'s combs, brushes, and hair clips for 5 min. Wash bedding, clothes, and towels in hot water in a washing machine. The nurse should instruct the parent to wash all cloth items the child has been in contact with in hot water and dry them on a hot setting in a clothes dryer for 20 min. This helps kill any lice or nits in these items. A nurse is providing teaching to an adolescent client who has methicillin-resistant Staphylococcus aureus. Which of the following instructions should the nurse provide to prevent the spread of this infection? \"Expose the infected areas of skin to open air and sunlight as much as possible.\" \"Bathe in a tub of warm water using mild soap twice daily.\" \"Place soiled dressing bandages in a red biohazard bag for disposal.\" \"Do not return to football practice until the infection has healed.\" \"Do not return to football practice until the infection has healed.\" The nurse should instruct the client to avoid close contact with others to prevent the spread of infections. The client should not participate in contact sports until the areas of infection are healed. A nurse in an emergency department is caring for a client who reports abdominal pain, vomiting, and appears dehydrated. The client\'s ABG results are pH 7.28, PaCO2 36 mm Hg, and HCO3-14 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis Metabolic acidosis With this acid-base imbalance, the client\'s pH is below the expected reference range, the PaCO2 is within or below the expected reference range, and the HCO3- is below the expected reference range. Diabetic ketoacidosis is a common cause of metabolic acidosis. A nurse is teaching about herbal supplements with a group of newly licensed nurses. Which of the following herbal supplements should the nurse include in the teaching for treating hyperlipidemia? Feverfew Gingko Valerian Garlic Garlic The nurse should include that garlic can help improve cholesterol levels, which then helps to reduce the buildup of plaque in the arteries. For some clients, it can also help lower blood pressure. A hospice nurse is caring for a preschooler who has a terminal illness. One of the child\'s parents tells the nurse that it is too difficult to cope any longer and has decided to move out of the house. Which of the following responses should the nurse make? \"Let\'s talk about a few ways you have dealt with stress in the past.\" \"I believe that you will regret that decision. Your family needs your support.\" \"I agree that you have to do what is best for your well-being at this time.\" \"I think you should try to put your feelings aside and focus solely on your child.\" \"Let\'s talk about a few ways you have dealt with stress in the past.\" This statement by the nurse combines two therapeutic responses, active listening and focusing. Used together, these techniques facilitate communication by letting the parent know one\'s feelings are heard and taken seriously, which conveys acceptance and respect. Therefore, the parent feels the nurse validates the concerns and becomes comfortable asking the nurse sensitive questions about the child. A nurse is providing discharge teaching for a client who had lithotripsy to break up calculi in the right kidney. Which of the following findings should the nurse instruct the client to report to the provider? Bruising over the right flank area Blood-tinged urine Urine pH 6.0 Painful urination Painful urination The nurse should instruct the client to immediately report flank or bladder pain, chills and fever, or difficulty urinating to the provider. Development of difficulty urinating, including decreased urine output or pain with urination, can mean that the client is developing an infection or can signal reoccurrence of a stone. A nurse is caring for a client who has left hemiparesis following a stroke. Which of the following actions should the nurse take? Use a gait belt and stand on the client\'s right side to assist with ambulation. Encourage the client to use wide-grip utensils when eating with the right hand. Place personal items on the bedside table close to the bed on the client\'s left side. Remove rolled toilet paper from the holder for easier access for the client Encourage the client to use wide-grip utensils when eating with the right hand. The nurse should encourage the client who has hemiparesis to use wide-grip utensils when eating with the right hand, which can accommodate a weak grasp and encourage independence in eating. A nurse is developing an in-service for a group of coworkers about adolescents\' reactions to death. Which of the following information should the nurse include when discussing an adolescent\'s response to death? Adolescents cope with death better than children of other ages. Adolescents view funeral services as an opportunity for closure. Adolescents are more concerned with the past than the present or future. Adolescents often alienate themselves from their peers when grieving. Adolescents often alienate themselves from their peers when grieving. The nurse should identify that adolescents dealing with death often have difficulty communicating their feelings and alienate themselves from their peers and families. A nurse in an emergency department is assessing a client who is experiencing mild hypothermia. Which of the following manifestations should the nurse expect? Stupor Decreased pulse Slurred speech Dysrhythmias Slurred speech The nurse should expect a client who is experiencing mild hypothermia to exhibit manifestations such as slurred speech, shivering, decreased coordination, and diuresis. A nurse is providing discharge teaching to an older adult client who had surgery to treat visual impairment due to cataracts. Which of the following client statements indicates an understanding of the teaching? \"I will keep an eye patch in place for the first 3 days after surgery.\" \"It is okay for me to lift my 2-year-old granddaughter.\" \"I will be able run the vacuum cleaner in a day or two.\" \"It might take 4 to 6 weeks for my vision to fully improve.\" \"It might take 4 to 6 weeks for my vision to fully improve.\" The nurse should instruct the client that it can take up to 4 to 6 weeks for optimal recovery; however, the client can expect visual improvement immediately following surgery. A nurse on a mental health unit is developing a plan of care for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse identify as the priority? Reduce environmental stimulation. Protect the client from harm. Administer an anxiolytic. Encourage physical exercise. Protect the client from harm. The greatest risk to this client is injury from uncontrollable thoughts and activity; therefore, the priority intervention is to protect the client from harming himself or others by moving to a quiet environment with decreased stimulation and staying with the client. A nurse is assessing a client who has as an ulcer due to peripheral vascular disease. Which of the following findings should the nurse identify as an indication that the client has a venous ulcer rather than an arterial ulcer? Diminished peripheral pulsations in the right lower leg Discoloration and edema of the right ankle Atrophy of the skin and hair loss on the right leg Dependent rubor in the right leg Discoloration and edema of the right ankle The nurse should identify that manifestations of peripheral venous disease include discoloration and edema of the ankle, resulting from venous hypertension. A nurse is leading a small group discussion in an acute care mental health facility when one client suddenly begins to experience a panic attack. Which of the following actions should the nurse take? Teach the client how to use breathing techniques while continuing the discussion. Remain with the client until manifestations subside. Speak in a high-pitched louder voice to gain the client\'s attention. Instruct the client to join another group who is practicing yoga. Remain with the client until manifestations subside. The nurse should remain with the client in a quiet place throughout the panic attack to ensure the client\'s safety and assist with anxiety reduction techniques. A nurse is caring for a client who has respiratory depression following opioid administration to control cancer-related pain. The client\'s ABG results are pH 7.28, PaCO2 49 mm Hg, and HCO3- 24 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis Respiratory acidosis With this acid-base imbalance, the client\'s pH is below the expected reference range, the PaCO2 is above the expected reference range, and the HCO3- is within or possibly above the expected reference range. Common causes of respiratory acidosis are respiratory depression due to anesthesia or opioid administration, airway obstruction, and inadequate chest expansion. A nurse has arrived at the site of an accident where a client has sustained a traumatic amputation of the big toe. Identify the sequence of steps the nurse should take to treat the musculoskeletal trauma. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) The nurse should first call 911 and examine the amputation site. Next, the nurse should apply direct pressure with layers of dry cloth to slow or stop the bleeding. Then, the nurse should elevate the affected extremity above the client\'s heart to slow the bleeding. Next, the nurse should find the toe and wrap it in sterile gauze or a clean cloth to decrease contamination for possible surgical reattachment. Finally, the nurse should place the wrapped toe in a bag and place the bag in 1 part ice and 3 parts water to maintain tissue integrity for possible reattachment. A nurse is assessing a client who has been taking antacids frequently for gastrointestinal distress. The assessment findings include drowsiness, muscle weakness, bradycardia, and hypotension. Which of the following electrolyte imbalances should the nurse suspect? Hypophosphatemia Hypochloremia Hypermagnesemia Hypernatremia Hypermagnesemia The nurse should identify that frequent ingestion of antacids and laxatives that contain magnesium can cause hypermagnesemia. Manifestations include hypotension, bradycardia, absent deep tendon reflexes, weak skeletal muscle contractions, ECG changes, lethargy, and drowsiness that can progress to coma. A nurse in a provider\'s office is completing a preoperative screening for a client who is scheduled for a knee arthroplasty later that week. Which of the following findings requires the nurse\'s intervention? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) Coagulation time The nurse should report the client\'s coagulation time, or INR, to the provider immediately because it is above the expected reference range, which predisposes the client to intraoperative and/or postoperative hemorrhage. The nurse should expect the provider to postpone the joint arthroplasty until the client\'s clotting time is within the expected reference range. A nurse in an emergency department is caring for a client whose ABG results are pH 7.31, PaCO2 50 mm Hg, and HCO3- 25 mEq/L after experiencing an airway obstruction. Which of the following interventions is the nurse\'s priority for this client? Apply oxygen therapy to the client. Administer an anti-inflammatory medication. Check the client\'s nail beds. Initiate IV fluid therapy. Apply oxygen therapy to the client. The first action the nurse should take when using the airway, breathing, circulation approach to caring for a client who has respiratory acidosis is to improve the client\'s oxygenation. When the client\'s airway is patent, oxygenation and ventilation are the priorities. A nurse is caring for a client who has a fear of open spaces. Which of the following clinical names for this fear should the nurse document in the client\'s medical record? Pyrophobia Agoraphobia Monophobia Astraphobia Agoraphobia The nurse should document that the client is experiencing agoraphobia in the client\'s medical record. Agoraphobia is the fear of being outside and can be debilitating and limit a client\'s ability to function. A nurse is teaching a client ways to prevent osteoporotic fractures due to osteoporosis. Which of the following information should the nurse include in the teaching? \"Maintain bone health by eating fruits, vegetables, and protein.\" \"Tamsulosin can slow the progression of bone deterioration.\" \"Walk 20 minutes two times a week to manage osteoporosis.\" \"Start to increase vitamin C and magnesium in your diet.\" \"Maintain bone health by eating fruits, vegetables, and protein.\" The nurse should instruct the client that the best way to maintain bone health and bone remodeling is by eating fruits, vegetables, and protein. A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux about home care. Which of the following statements by the parent indicates an understanding of the teaching? \"I should feed my infant a larger amount of formula less frequently.\" \"I should feed my infant a bottle of formula within 1 hour of bedtime.\" \"I should place my infant on his side to sleep.\" \"I should add 1 teaspoon of rice cereal to my infant\'s formula.\" \"I should add 1 teaspoon of rice cereal to my infant\'s formula.\" The parent should add 1 teaspoon to 1 tablespoon of rice cereal in order to thicken the formula. This will decrease the incidence of gastric reflux. A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition. Which of the following actions should the nurse take? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) Administer the prescribed regular insulin. The nurse should administer 3 units of regular insulin to the client for blood glucose greater than 200 mg/dL. A nurse is caring for a client who has had prolonged vomiting, has an NG tube for gastric decompression, and is receiving total parenteral nutrition. The client\'s ABG results are pH 7.48, PaCO2 50 mm Hg, and HCO3- 30 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis Metabolic alkalosis When a client is experiencing metabolic alkalosis, the pH is above the expected reference range, the PaCO2 is within or above the expected reference range, and the HCO3- is above the expected reference range. Common causes of metabolic alkalosis include overuse of antacids, prolonged vomiting, NG suctioning, total parenteral nutrition, and thiazide diuretic use. A nurse in an emergency department is assessing a preschooler who has severe dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following findings should the nurse identify as an indication that the treatment is effective? Urine output 0.5 mL/kg/hr Capillary refill 3 seconds Heart rate 148/min Brisk skin turgor Brisk skin turgor The nurse should expect the child to have brisk skin turgor if fluid replacement therapy is effective. A nurse is reviewing the laboratory report of a client who is taking exenatide to treat type 2 diabetes mellitus. The nurse should recognize that which of the following laboratory results is an indication of an adverse reaction to the medication? HbA1c 6.8% Hct 45% Creatinine 0.9 mg/dL Lipase 185 units/L Lipase 185 units/L The nurse should recognize that an elevated lipase is an indication of pancreatitis, which can indicate the client is experiencing an adverse effect to exenatide. Physical manifestations of pancreatitis include ongoing, severe abdominal pain and vomiting. A nurse is teaching disease management techniques to a client who has COPD. Which of the following instructions should the nurse include in the teaching? Avoid activities that increase the respiratory rate. Use pursed-lip breathing when feeling short of breath. Consume a diet high in carbohydrates for increased energy. Limit fluid intake to 1.5 L daily. Use pursed-lip breathing when feeling short of breath. The nurse should instruct the client how to use diaphragmatic and pursed-lip breathing to control breathing when feeling dyspneic. A nurse is assessing an older adult client who is experiencing malnutrition. Which of the following findings should the nurse expect? Periorbital edema Diaphoretic skin Clubbing of fingers Brittle hair Brittle hair The nurse should expect a client who is experiencing malnutrition to have dry, brittle hair, muscle wasting, a depressed mood, and poor wound healing. A nurse is providing teaching to a client who has a hearing impairment and has a new prescription for a hearing aid. Which of the following client statements indicates an understanding of the teaching? \"I should wipe off the hearing aid each day with an alcohol wipe.\" \"I will change the battery in the hearing aid when it makes a whistling sound.\" \"I will make sure the hearing aid is off before inserting it in my ear.\" \"I should start wearing the hearing aid for at least 1 hour at a time.\" \"I will make sure the hearing aid is off before inserting it in my ear.\" The client should turn down the volume of the hearing aid and turn it off before inserting it in the ear. This ensures that the client is not exposed to any uncomfortably loud noise when it is inserted. Once it is in place, the client should turn the hearing aid on and adjust the volume to a comfortable level. A nurse is providing discharge planning for a client who has gestational diabetes. Which of the following interventions should the nurse identify as the priority? Determine the client\'s knowledge regarding gestational diabetes. Explain the effects of gestational diabetes on the pregnancy and fetus with the client. Discuss dietary meal plans for gestational diabetes with the client. Tell the client about manifestations of hypoglycemia. Determine the client\'s knowledge regarding gestational diabetes. The first action the nurse should take when using the nursing process is to assess the client. It is important for the nurse to determine the client\'s knowledge level regarding the disease process. This provides the nurse with information regarding where to start with the client teaching process. A nurse is teaching a client who has atherosclerosis about self-care. Which of the following instructions should the nurse include in the teaching? Consume five to seven servings of red meat per week. Limit daily calorie intake from saturated fat to 18%. Increase fiber intake to at least 30 g per day. Exercise 2 days a week for at least 60 min. Increase fiber intake to at least 30 g per day. The nurse should instruct the client to increase daily fiber intake to at least 30 g. Fiber assists in the elimination of lipids and minimizes the development of atherosclerosis. A nurse is providing home care instructions to a client who had a short-arm plaster cast applied for a wrist fracture. Which of the following instructions should the nurse include? Apply heat for the first 48 hr. Wear a sling when resting in bed. Elevate the wrist above heart level. Use a soft-bristle toothbrush to relieve itching under the cast. Elevate the wrist above heart level. The nurse should instruct the client to elevate the wrist above heart level to reduce swelling and minimize pain. A nurse in a provider\'s office is assessing a preschooler who has developed contact dermatitis following exposure to poison ivy. Which of the following statements should the nurse make to the child\'s parent regarding disease management? \"Wash your child\'s exposed clothing in cold water using powder detergent.\" \"Keep your child away from other children for 10 days after lesions appear.\" \"Scrub your child\'s affected areas with an antibacterial soap every other day.\" \"Place your child in an oatmeal bath using tepid water for 15 minutes.\" \"Place your child in an oatmeal bath using tepid water for 15 minutes.\" The nurse should instruct the parent that tepid baths containing oatmeal or mineral oil can decrease itching and evenly disperse the antipruritic solution. The parent should not place the child in a hot bath as this can aggravate the child\'s condition and increase itching. A nurse is assessing a client who has COPD and is receiving nebulized acetylcysteine. Which of the following findings should the nurse expect if the medication has been effective? Cough has been suppressed. WBC count is within expected reference range. Blood glucose levels are increased. Mucus is thin and white in color. Mucus is thin and white in color. The client who has COPD can experience manifestations of thick, tenacious secretions. White or clear mucus is an expected finding, which indicates the client is free of respiratory infection. Acetylcysteine is a mucolytic used to thin secretions and enable the client to expectorate them more easily. A nurse is assessing a 3-month-old infant who has gastroenteritis with severe dehydration. Which of the following findings should the nurse expect? Flat anterior fontanel Capillary refill 2 seconds 5% weight loss Absence of tears Absence of tears The nurse should expect an infant who has severe dehydration to have an absence of tears when crying. Other manifestations include tachycardia, hypotension, intense thirst, and oliguria or anuria. A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider? Presence of a transparent cornea Presence of strabismus Pinna moderately extends outward from the skull Walls of peripheral aspect of auditory canal are pink Presence of strabismus The nurse should recognize that the presence of strabismus, or crossing of the eyes, should disappear by 4 months of age. If this is not corrected by 4 to 6 years of age, it can lead to amblyopia; therefore, the nurse should report this finding to the provider. A nurse is reviewing the medical record of a client who has a family history of gallstones. Which of the following findings should the nurse identify as a risk factor for developing cholecystitis? Client is an adult male. Client is taking atorvastatin. Client is of Asian descent. Client has a history of asthma. Client is taking atorvastatin. The nurse should identify that increased serum cholesterol and taking cholesterol-lowering medications, such as atorvastatin, increases the client\'s risk of developing cholecystitis. A nurse on a pediatric unit is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? Place the child in a room equipped with a positive-pressure airflow system. Place the child in a room equipped with a negative-pressure airflow system. Initiate droplet precautions for the child. Initiate contact precautions for the child. Initiate droplet precautions for the child. The nurse should initiate droplet precautions for a child who has pertussis, which is spread by large droplets in the air; therefore, the nurse should wear a surgical mask within 1 m (3.3 feet) of the child. A nurse is caring for a client who is receiving heparin therapy and has an aPTT of 92 seconds.

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