HESI Comprehensive Exit Exam Answered A+ Solution Guide; Spring 2022

Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? Checking the client's blood pressure Correct Checking the ...

Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? Checking the client's blood pressure Correct Checking the client's peripheral pulses Checking the most recent potassium level Checking the client's intake-and-output record for the last 24 hours A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? "The test will take about 30 minutes." "I need to fast for 8 hours before the test." "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." Correct "I need to take a laxative after the test is completed, because the liquid that I’ll have to drink for the test can be constipating." A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: Call the nursing supervisor Ask the answering service to contact the on-call physician Correct Withhold the medication until the physician can be reached in the morning Administer the medication but consult the physician when he becomes available An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: Documenting the findings Asking the ED physician to check the client Correct Continuing to monitor the client's cardiac status Informing the client that PVCs are expected after an MI NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should: Administer the antihypertensive with a small sip of water Correct Withhold the antihypertensive and administer it at bedtime Administer the medication by way of the intravenous (IV) route Hold the antihypertensive and resume its administration on the day after the ECT A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? "Tell me more about what you’re feeling." Correct "That’s a normal response after this type of surgery." "It will take time, but, I promise you, you will get over this depression." "Every client who has this surgery feels the same way for about a month." A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse’s priority? Contacting the physician Correct Documenting the findings Checking the fluid for protein Continuing to monitor the client and the FHR A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to: Call the radiography department to obtain a chest x-ray Correct Check the client's blood glucose level to serve as a baseline measurement Hang the prescribed bag of PN and start the infusion at the prescribed rate Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency A rape victim being treated in the emergency department says to the nurse, "I’m really worried that I’ve got HIV now." What is the appropriate response by the nurse? "HIV is rarely an issue in rape victims." "Every rape victim is concerned about HIV." "You’re more likely to get pregnant than to contract HIV." "Let's talk about the information that you need to determine your risk of contracting HIV." Correct A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to: Contact the physician Stop taking the medication Take the medication with food Correct Take the medication twice a day instead of four times A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period? Type your answer in the space provided. Answer: ________mL Incorrect Correct Responses: "1670" Awarded 0.0 out of 1.0 possible points. 12.ID: 383704537 Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of: 3 minutes Correct 10 seconds 15 seconds 30 minutes A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of: Depression Correct Diabetes mellitus Hyperthyroidism Coronary artery disease Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences: Dry mouth Restlessness Feelings of depression Neck stiffness or soreness Correct Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client’s medical record would prompt the nurse to contact the prescribing physician before administering the medication? The client has a history of cataracts. The client has a history of hypothyroidism. The client takes a prescribed antihypertensive. Correct The client is allergic to acetylsalicylic acid (aspirin). A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client? Fever Diarrhea Hypertension Tongue protrusion Correct A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT? Recent stroke Correct Hypothyroidism History of glaucoma Peripheral vascular disease A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through: A lower abdominal incision Correct An upper abdominal incision An incision made in the perineal area The urethra, with the use of a cutting wire A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply. Seek medical advice if you find a skin lesion. Correct Use sunscreen with a low sun protection factor (SPF). Avoid sun exposure before 10 a.m. and after 4 p.m. Wear a hat, opaque clothing, and sunglasses when out in the sun. Correct Examine the body every 6 months for possibly cancerous or precancerous lesions. A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client’s breast? Correct The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother: To always administer less insulin on the days of soccer games That it is best not to encourage the child to participate in sports activities That the child should eat a carbohydrate snack about a half-hour before each soccer game Correct To administer additional insulin before a soccer game if the blood glucose level is 240 mg/dL or higher and ketones are present A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I’m never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? Anxiety Powerlessness Correct Ineffective coping Disturbed body image A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic? "What are your feelings right now?" Correct "Why don't you feel like washing up?" "You aren’t talking today. Cat got your tongue?" "You need to get yourself cleaned up. You have company coming today." Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note? Clear and yellow Thick and opaque Correct White and odorless Clear, with a foul odor An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client? Administering 100% oxygen Correct Having a crisis counselor available Instituting suicide precautions for the client Obtaining blood for determination of the client’s carboxyhemoglobin level A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify? Anxiety Correct Powerlessness Disruption of thought processes Inability to maintain health A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder? "Do you chew tobacco?" "Do you smoke cigarettes?" "Have you ever worked in a mine?" Correct "Are you frequently exposed to paint products?" A physician prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of morphine sulfate solution for injection reads “4 mg/mL.” How many milliliters (mL) must the nurse draw into a syringe for administration to the client? Type the answer in the space provided. Answer: _____mL Incorrect Correct Responses: "0.625, .625, 1" Awarded 0.0 out of 1.0 possible points. 29.ID: 383708582 A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client: To call his physician That he needs to drink more fluids That this is an occasional side effect of the medication Correct That this may be a sign of developing toxicity of the medication A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting: Bradycardia Increased heart rate Decreased blood pressure Improved swallowing function Correct A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication? Insomnia Rigidity and akinesia Bilateral lung wheezes Correct Orthostatic hypotension A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet? Select all that apply. Smoking Correct A high-calcium diet High alcohol intake Correct White or Asian ethnicity Correct Participation in physical activities that promote flexibility and muscle strength A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is: Corn Cocoa Peaches Sardines Correct A nurse is providing information to a client with acute gout about home care. Which of the following measures does the nurse tell the client to take? Select all that apply. Drinking 2 to 3 L of fluid each day Correct Applying heat packs to the affected joint Resting and immobilizing the affected area Correct Consuming foods high in purines Performing range-of-motion exercise to the affected joint three times a day A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. Fatigue Correct Anemia Weight loss Low-grade fever Correct Joint deformities A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client’s medical record? Select all that apply. Fever Correct Vasculitis Correct Weight gain Increased energy Abdominal pain Correct A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply. Beer Correct Apples Yogurt Correct Baked haddock Pickled herring Correct Roasted fresh potatoes The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should: Contact the physician Hold the next dose of imipramine Document the laboratory result in the client's record Correct Have another blood sample drawn and ask the laboratory to recheck the imipramine level A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. "I need to avoid salt in my diet." Correct "It’s fine to take any over-the-counter medication with the lithium." Correct "I need to come back the clinic to have my lithium blood level checked." " I should drink 2 to 3 quarts of liquid every day." “Diarrhea and muscle weakness are to be expected, and if these occur I don’t need to be concerned.” Correct A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should: Contact the physician Document the findings Correct Institute seizure precautions Have a blood specimen drawn immediately for serum lithium testing A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves: Having the client perform a healthy coping behavior Having the client perform a ritualistic or compulsive behavior Providing a high degree of exposure of the client to the stimulus that the client finds undesirable Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening Correct A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I’m really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should: Check the client's vital signs Check for the presence of a gag reflex Correct Assess the client for the presence of bowel sounds Ask the client to gargle with a warm saline solution A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority? Inability to cope Decreased nutrition Decreased fluid volume Correct Inability to tolerate activity A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine: The sex of the fetus Genetic characteristics An accurate age for the fetus The degree of fetal lung maturity Correct A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. Bananas Potatoes Spinach Correct Legumes Correct Whole grains Correct Milk products A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside? Vitamin K Protamine sulfate Potassium chloride Calcium gluconate Correct A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is: Contacting the physician Correct Documenting the findings Continuing to monitor the client Increasing the rate of the infusion A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that: Sodium intake is restricted Fluid intake must be limited to 1 quart each day Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24-hour period Correct Urinary protein must be measured and that the physician should be notified if the results indicate a trace amount of protein A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of the following information elicited during the assessment indicate that the condition has not yet resolved? Type the option number that is the correct answer. Answer: ______ Nursing Progress Notes Hyperreflexia is present. Urinary protein is not detectable. Urine output is 45 mL/hr. Blood pressure is 128/78 mm Hg. Incorrect Correct Responses: "1" A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? Spontaneous bruising Correct Decrease in uterine size Urine output of 30 mL/hr Brownish vaginal discharge A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately: Stops the oxytocin infusion Correct Checks the vagina for crowning Encourages the client to take short, deep breaths Increases the rate of the oxytocin infusion and calls the physician A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which of the following actions should the nurse take as a result of this observation? Repositioning the mother Documenting the finding Correct Notifying the nurse-midwife Taking the mother's vital signs A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? Nausea Bloody urine Hearing loss Correct Electrocardiographic changes A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client? Painful vaginal bleeding Sustained tetanic contractions Complaints of abdominal pain Soft, relaxed, nontender uterus Correct A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that placental separation has occurred? A discoid uterus Sudden sharp vaginal pain Shortening of the umbilical cord A sudden gush of dark blood from the introitus Correct A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which of the following findings would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy? The client reports a history of sexual abuse by her father. Correct The client reports that her relationship with her spouse is stable. The client reports a satisfying intimate relationship with her spouse. The client reports that her and her spouse have never been able to conceive children A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction? "I can resume sexual activity in 4 to 6 weeks." "I need to avoid straining when I have a bowel movement." "I should wear support hose for 6 months and elevate my legs frequently." "I need to contact my surgeon immediately if I feel any numbness in my genital area." Correct An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. Skin tenting Correct Flat neck veins Correct Weak peripheral pulses Correct Moist oral mucous membranes A heart rate of 88 beats/min A respiratory rate of 18 breaths/min An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.? Type your answer in the space provided. Answer ____mL Incorrect Correct Responses: "350" Awarded 0.0 out of 1.0 possible points. 60.ID: 383712466 A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use: Salt substitutes Herbs and spices Correct Salt with cooking only Processed foods as desired Check the client's vital signs Check for the presence of a gag reflex Correct Assess the client for the presence of bowel sounds Ask the client to gargle with a warm saline solution Awarded 0.0 points out of 1.0 possible points. 61.ID: 383702999 A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions? Coffee Broccoli Cheeseburger Correct Chocolate milk Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client? Headache Drowsiness Correct Photophobia Urinary frequency A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? Diarrhea Vomiting Epistaxis Correct Epigastric pain A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk? Count the number of times that the infant swallows during a feeding Weigh the infant every day and check for a daily weight gain of 2 oz Count wet diapers to be sure that the infant is having at least six to 10 each day Correct Pump the breasts, place the milk in a bottle, measure the amount, and then bottle-feed the infant A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? "My child will need to do exercises." "My child needs to wear the brace 18 to 23 hours per day." "Wearing the brace is really important in curing the scoliosis." Correct "I need to check my child's skin under the brace to be sure it doesn't break down." Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with: Milk Water Any meal Tomato juice Correct A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally: Increase Decrease Correct Remain unchanged Double from what they normally are A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that: No edema is present The client is dehydrated Pitting edema is present Correct Blood is not pooling in the extremities A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would: Contact the physician Document the findings Correct Ask the client to walk for 5 minutes, then recheck the reflexes Perform active and passive range-of-motion exercises of the client's lower extremities, then recheck the reflexes After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? Hysterectomy Insertion of an indwelling catheter Administration of oxytocin (Pitocin) Replacement of the uterus through the vagina into a normal position Correct A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would: Notify the physician Recheck the temperature in 4 hours Correct Encourage the client to breastfeed the newborn Institute strict bedrest for the client and notify the physician A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse’s initial action should be: Documenting the findings Encouraging the woman to walk Helping the woman empty her bladder Correct Massaging the fundus gently until it becomes firm A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time? Anxiety Correct Premature grief Fluid volume loss Fluid volume overload A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? Increased platelet count Shortened prothrombin time Positive result on d-dimer study Correct Decreased fibrin-degradation products A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply. Tachycardia Correct Cool, clammy skin Decreased respiratory rate Diminished peripheral pulses Correct Urine output of less than 30 mL/hr A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock? Checking the client’s urine output Inserting an intravenous (IV) line Obtaining informed consent for a cesarean delivery Placing the client in a lateral position with the bed flat Correct A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician? Pink lochia on postpartum day 4 White lochia on postpartum day 11 Bloody lochia on postpartum day 2 Reddish lochia on postpartum day 8 Correct Rationale: Lochia is the postdelivery vaginal discharge from the uterus consisting of blood from the A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to: Document the findings Correct Ask the physician to see the client immediately Ask another nurse to check for the uterine fundus Place the client in the supine position for 5 minutes, then recheck the abdomen A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? "Many of my antibodies are passed through the placenta." "The placenta maintains the body temperature of my baby." Correct "Glucose, vitamins, and electrolytes pass through the placenta." "It provides an exchange of oxygen and carbon dioxide between me and my baby." A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele’s rule, the nurse determines that the estimated date of delivery (EDD) is: June 2, 2013 July 2, 2013 Correct October 2, 2013 September 18, 2013 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication? Steak Correct Spinach Chicken Oranges A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? Sodium 140 mEq/L Hemoglobin 12.5 g/dL Blood urea nitrogen (BUN) 20 mg/dL White blood cell count of 2500 cells/mm3 Correct Which finding in a client’s history indicates the greatest risk of cervical cancer to the nurse? Nulliparity Early menarche Multiple sexual partners Correct Hormone-replacement therapy A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding? Umbilical cord compression Pressure on the fetal head during a contraction Uteroplacental insufficiency during a contraction Correct Inadequate pacemaker activity of the fetal heart A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed: At any time after the surgery When menstruation resumes When pelvic sensation and response to stimuli return In about 6 weeks, when the vaginal vault is satisfactorily healed Correct A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is: Monitoring the client for signs of returning peristalsis Instructing the client in dietary changes to prevent constipation Encouraging the client to deep-breathe, cough, and use an incentive spirometer Correct Encouraging the client to talk about the effects of the surgery on her femininity and sexuality A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client? Fever Correct Dizziness Flatulence Drowsiness A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician? Nausea Dark urine Correct Urinary frequency Decreased appetite A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement? Frequent suctioning Maintaining cuff pressure Correct Maintaining mechanical ventilation settings Alternating the use of a cuffed tube with a cuffless tube on a daily basis A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube? Correct Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply. Keeping the room slightly darkened Correct Placing the client in a room with a quiet roommate Encouraging isometric exercises if bed rest is prescribed Monitoring the client for changes in alertness or mental status Correct Restricting visits to close family members and significant others and keeping visits short Correct A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply. Hunger Correct Weakness Correct Blurred vision Correct Increased thirst Increased urine output A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician's instructions, understanding that the gait was selected after assessment of the client's: Physical and functional abilities Correct Feelings about restricted mobility Uneasiness about using the crutches Understanding of the need for increased mobility A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he is discharged home. When the nurse tells the client that he will be taught how to administer the feedings, the client states, "I don't think I’ll be able to do these feedings by myself." Which response by the nurse is appropriate? "Have you told your doctor how you feel?" "Tell me more about your concerns regarding the tube feedings." Correct "Don't worry. We’ll keep you in the hospital until you’re ready to do them by yourself." "We’ll ask the doctor about having a visiting nurse come to your home to give you your feedings." A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to: Continue monitoring the client Increase the amount of humidified oxygen Continue administering humidified oxygen Assist in intubating the client and beginning mechanical ventilation Correct A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which of the following actions should the nurse take next? Providing pin care Medicating the client Notifying the physician Correct Removing some weight from the traction A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse Bivalve the cast Ask the physician to reapply the cast Use a nail file to smooth the rough edges Place small pieces of tape over the rough edges of the cast Correct A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it’s probably cancer. Does this mean I'm going to die?" The nurse interprets the client's initial reaction as: Fear Correct Denial Acceptance Preoccupation with self A nurse notes documentation in the client’s medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which of the following findings does the nurse expect to note? Correct A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. The nurse tells the client to: Always perform the exercises while lying down Expect an improvement in the control of urine in about 1 week Tighten the pelvic muscles for as long as 5 minutes, three or four times a day Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10 Correct Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following occurrences does the nurse tell the client to report to the physician if she experiences them while taking the medication? Cough Fatigue and lethargy Dizziness and fatigue Numbness and tingling of the fingers or toes Correct A client with post–traumatic stress disorder tells the nurse that he has stopped taking his prescribed medication because he didn't like how the medication was making him feel. Which of the following initial responses by the nurse is appropriate? "That's all right. I’d stop, too, if it made me feel funny." "Tell me more about how the medication was making you feel." Correct "Did you let your doctor know that you stopped taking the medication?" "It doesn't make sense to stop the medication. I don't know why you took it upon yourself to do that." A nurse provides information to a client with peripheral vascular disease about ways to limit the disease’s progression. Which of the following measures does the nurse tell the client to take? Select all that apply. Crossing the legs at the ankles only Engaging in exercise such as walking on a daily basis Correct Washing the feet daily with a mild soap and drying them well Correct Inspecting the feet at least once a week for injuries, especially abrasions Using a heating pad on the legs to help keep the blood vessels dilated A client with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs? Providing food and fluid as the client requests Offering high-calorie and high-protein foods and fluids frequently throughout the day Correct Completing the dietary menu for the client to ensure that adequate nutrition is provided Weighing the client daily so that the client may determine whether the nutritional plan is working Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication and tells the client: That driving is prohibited while the client is taking the medication To take the medication immediately if the desire to drink alcohol occurs That the effect of the medication ends as soon as the client stops taking the medication That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol Correct A client with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which of the following responses by the nurse is therapeutic? "Why don't you really want to attend?" "This is what your physician has prescribed for you as part of the treatment plan." "OK, let's have you attend music therapy. You can sing there. How does that sound?" "Perhaps you could attend and talk to the other clients and see what they’re drawing and painting." Correct A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? "Why are you saying that?" "Stop saying that. It's not true!" "You wouldn't like someone saying that to you. Would you?" "Don’t say that. If you can’t control yourself, we’ll help you." Correct A nurse working the evening shift is helping clients get ready for sleep. A female client with mania is hyperactive and pacing the hallway. The appropriate nursing action is to: Stay with the client and observe her behavior Take the client to the bathroom and provide her with a warm bath Correct Tell the client that it is time for sleep and that she needs to go to her room Tell the client that other clients are trying to sleep and that she is being disruptive 109.ID: 383712416 Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information? "I need to limit my intake of fluids while I’m taking this medication." "I need to stop the medication and call my doctor if I have severe diarrhea." Correct "I can expect skin redness and a rash when I take this medication." "I may get a burning feeling in my throat, but it’s normal and will go away." A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which of the following behaviors is a characteristic of the disorder? Neediness Perfectionism Preoccupation with details Hypersensitivity to negative evaluation Correct A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. With which of the following anxiety disorders does the nurse associate this client's symptoms? Agoraphobia Avoidant personality disorder Obsessive-compulsive disorder Correct Dependent personality disorder A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care? Inflexible and rigid Self-sacrificing and submissive Highly critical of self and others Projecting blame, possibly becoming hostile Correct A client on the mental health unit says to the nurse, "Everything is contaminated." The client scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that compulsive behavior: Temporarily eases anxiety in the client Correct Is an attempt on the client's part to punish herself Is an attempt on the client's part to seek the attention of others Is a response by the client to voices telling her that everything is contaminated and that she must engage in this behavior A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse? Assessing the client for organic causes of loss of arm movement Correct Calling the crisis intervention team and asking them to assess the client Performing active and passive range-of-motion (ROM) exercises of the client's arms Asking the client to move his arms and documenting the loss of movement he has experienced A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first? Perform the physical assessment Tell the client about the nursing unit rules Establish a trusting nurse-client relationship Correct Tell the client that he or she will have to participate in self-care A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with: Severe anxiety Conversion disorder Correct Posttraumatic stress disorder (PTSD) Obsessive-compulsive disorder A client experiencing delusions says to the nurse, "I am the only one who can save the world from all of the terrorists." What is the appropriate response by the nurse? "Tell me your plan for saving the world." "Why do you think that you can accomplish this by yourself?" "I don't think anyone can save the world from the terrorists by himself." Correct "You must be powerful. Do you really believe that you can do this by yourself?" A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. Eat foods that are low in fat and protein Obtain pneumococcal and influenza vaccines Drink copious amounts of fluid and void frequently Correct Avoid contact with any individual who has signs or symptoms of a cold Correct Avoid contact with all individuals other than immediate family members A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" The nurse responds by telling the client that: Her hair will definitely fall out She should not be worrying about her hair at this point Her hair may fall out but will regrow after the chemotherapy is discontinued Correct Vigorous hair-brushing is important while the client is undergoing chemotherapy to prevent hair loss A nurse has given a client with viral hepatitis instructions about home care. Which of the following statements by the client indicates to the nurse that the client needs further teaching? “I can’t drink alcohol.” “I have to avoid having sex until the test for antibodies comes back negative.” “I need to rest a lot during the day and get enough sleep at night.” “I need to eat three meals a day with foods high in protein, fat, and carbs.” Correct A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must: Drink fluids to eliminate the dye Contact the physician if the skin appears yellow Correct Expect that the urine will be bright green until the dye has been excreted Wear sunglasses and avoid direct sunlight until pupil dilation returns to normal An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the following characteristics of the disorder does the nurse expect the client to exhibit? Select all that apply. Nausea Correct Eye pain Correct Vomiting Correct Headache Correct Diminished central vision Increased light perception A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client? 8 mm Hg 14 mm Hg 20 mm Hg 28 mm Hg Correct An emergency department nurse assessing a client with Bell's palsy collects subjective and objective data. Which of the following findings does the nurse expect to note? A symmetrical smile Tightening of all facial muscles Ability to wrinkle the forehead on request Complaints of inability to close the eye on the affected side Correct A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? Asking the child to describe the intensity of the pain Asking the child to use a numeric rating scale of 0 to 100 Asking the child whether the patient-controlled analgesia (PCA) pump is relieving the pain Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain Correct A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation? Contacting the child's physician to report the findings Correct Administering acetaminophen (Tylenol) to the child to relieve the pain Asking that the child not attend the physical education class until the neck pain has subsided Teaching the child how to use peripads to prevent embarrassment resulting from loss of bladder control A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication? "When was your last menstrual period?" "When was your last bowel movement?" "Are you having any difficulty hearing?" Correct "Are you having any difficulty breathing?" A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction? "It’s important to rotate injection sites." "I need to store the insulin in a cool, dry place." "I need to keep any unopened bottles of insulin in the freezer." Correct "I need to check the expiration date on the insulin before I use it." A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test: Is a measure of the client's hematocrit level Is a measure of the client's hemoglobin level Helps predict the risk for the development of chronic complications of diabetes mellitus Correct Provides a determination of short-term glycemic control in the client with diabetes mellitus A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need your help!" What is the appropriate way for the nurse to document this occurrence in the client's record? Writing that the client is very agitated Writing that the client yelled at the nurse Writing that the client is able to perform her own care Writing down the client's words and placing them in quotation marks Correct A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will be admitted from the emergency department. Which item does the nurse give priority to placing at the client's bedside? Bedside commode Suctioning equipment Electrocardiography machine Oxygen cannula and flowmeter Correct Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to: Increase fluid intake Correct Consume low-fiber foods Consume foods that are low in potassium Contact the physician if the urine turns yellow-brown Cyclobenzaprine (Flexeril) is prescribed to a client with multiple sclerosis for the treatment of muscle spasms. For which common side effect of this medication does the nurse monitor the client? Diarrhea Drowsiness Correct Abdominal pain Increased salivation A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains of chest pain. The medication is ineffective, so the nurse prepares to administer a second dose. Before administering the nitroglycerin, which action does the nurse make a priority? Checking the client's blood pressure Correct Obtaining blood levels of cardiac enzymes Asking the client whether he has a headache Obtaining a 12-lead electrocardiogram (ECG) Ciprofloxacin hydrochloride (Cipro) is prescribed to a client with a urinary tract infection. The nurse, providing instruction about the medication, tells the client that it is best to take the medication: With milk With an antacid 2 hours after meals Correct With aluminum hydroxide A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being discharged from the hospital. Which statement by the client indicates a need for further instruction? "I need to carry my nitroglycerin with me at all times." "I need to check my pulse before, during, and after exercise." "I need to avoid foods with saturated fats and foods high in cholesterol." "I need to participate in aerobic and weightlifting exercise three times a week." Correct A nurse provides information to a client who will be undergoing endoscopic retrograde cholangiopancreatography (ERCP). The nurse tells the client that: There is no need to fast (NPO status) before the procedure The gallbladder is easily removed during this procedure if gallstones are found The procedure is performed specifically to visualize the esophagus, stomach, and duodenum Dye may be injected during the procedure to permit visualization of the pancreatic and biliary ducts Correct A client who has undergone knee-replacement surgery will be self-administering enoxaparin sodium (Lovenox) at home. The nurse teaches the client about the medication and tells the client to: Store the medication in the refrigerator Lie down to administer the subcutaneous injection Correct Inject the medication in the upper outer aspect of the arm Discard the medication if the solution appears pale yellow An intravenous dose of adenosine (Adenocard) is prescribed for a client to treat Wolff-Parkinson-White syndrome. Which piece of equipment does the nurse make a priority of obtaining before administering the medication? Pulse oximeter Cardiac monitor Correct Blood-pressure cuff Suction catheter and suction machine A nurse provides information to a client with coronary artery disease (CAD) about smoking-cessation measures. Which statement by the client indicates a need for further information? "A community support group will help me quit." "I should drink a cup of coffee if I feel the urge to smoke." Correct "Relaxation exercises will help control my urge to smoke." "I can try chewing gum or sucking on hard candy if I feel the urge to smoke." Captopril (Capoten) is prescribed for a hospitalized client with heart failure. Which action is a priority once the nurse has administered the first dose? Checking the client's apical heart rate Maintaining the client on bed rest for 3 hours Correct Monitoring the client for increased urine output Checking the client's breath sounds for decreased wheezing A client with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and cyanosis, and the nurse suspects pulmonary edema. The nurse would first: Obtain a pulse oximetry reading Raise the head of the client's bed Correct Administer a dose of morphine sulfate Obtain a specimen for an arterial blood gas determination The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which intended effect of the medication does the nurse monitor the client? Relief of pain Relief of anxiety Correct Decreased urine output Increased blood pressure A nurse is providing home care instructions to a client with coronary artery disease (CAD) who will be discharged home and will be taking 1 aspirin daily. The nurse tells the client: To stop the aspirin if nausea occurs To take the aspirin on an empty stomach That ringing in the ears is a sign of toxicity Correct That the aspirin is a short-term treatment and will probably be discontinued in 2 weeks A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg position, on the left side. What action does the nurse take next? Auscultating heart sounds Clamping the intravenous catheter Correct Checking the client's blood pressure Obtaining an arterial blood gas specimen A nurse is teaching a client with left-side weakness how to walk with the use of a quad-cane. The nurse ensures that: The client places the cane on the left side The top of the cane is level with the client's waist 30-degree flexion of the client's elbow is maintained when the client is holding the cane Correct The client leans on the cane and places as much weight as possible on the cane when moving it forward A nurse is preparing the room of a client in skeletal traction who will be admitted to the nursing unit. Which item for use by the client does the nurse identify as the most important? Telephone Television Trapeze bar Correct Bedside commode A nurse taking the vital signs of a client immediately after she has delivered a newborn notes that the client's heart rate is 110 beats/min. The nurse would first: Document the findings Offer the client oral fluids Recheck the heart rate in 1 hour Check the uterus and amount of lochia discharge Correct A client is receiving an intravenous infusion of alteplase (tissue plasminogen activator, recombinant; tPA). For which adverse effect of the medication does the nurse monitor the client most closely? Bleeding Correct Hearing loss Decreased urine output Increased blood pressure View video. The nurse is performing a sterile change of an abdominal dressing. Once the dressing has been removed and discarded in a waterproof bag, which action should the nurse take next? Assessing the wound Correct Donning sterile gloves Cleansing the wound Setting up the sterile field A nurse is providing morning care to a client who has undergone surgery to repair a fractured left hip. Which item is most important for the nurse to use in turning the client from side to side to change the bed linens? Trapeze bar Sliding board Adduction device Abduction device Correct A nurse provides dietary instructions to a client with osteoporosis who has sustained a fracture about foods that will promote healing. The nurse tells the client that it is best to consume foods that are high in: Fats Vitamin C Correct Carbohydrates Concentrated sugar A nurse in a physician's office is talking to a client who underwent mastectomy of the right breast 2 weeks ago. The client says to the nurse, "I hate looking at this incision. I feel that I'm not even myself anymore." The nurse interprets this statement to mean that the client is experiencing which problem? Inability to cope Distorted body image Correct Inability to care for self Inability to maintain health A nurse discovers that a client receiving heparin sodium by way of continuous intravenous (IV) infusion has removed the IV tubing from the infusion pump to change his hospital gown. After assessing the client and placing the tubing back in the infusion pump, which medication does the nurse check for in the medication room in case a heparin overdose has occurred? Protamine sulfate Correct Enoxaparin (Lovenox) Phytonadione (vitamin K) Aminocaproic acid (Amicar) The mother of a newborn found to have a congenital diaphragmatic hernia asks the nurse to explain the diagnosis. The nurse tells the mother that in this condition: The esophagus terminates before it reaches the stomach Gastric contents are regurgitated back into the esophagus Abdominal contents herniate through an opening of the diaphragm Correct A portion of the stomach protrudes through the esophageal hiatus of the diaphragm A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant? Select all that apply. Drooling Correct Wheezing Hiccuping Short periods of apnea Excessive oral secretions Correct Bowel sounds over the chest A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis (HPS) is suspected. Which characteristics associated with the disorder does the nurse expects see documented in the infant’s medical record? Select all that apply. Weight loss Correct Facial edema Metabolic acidosis Projectile vomiting Correct Distended upper abdomen Correct A client with a history of angina pectoris tells the nurse that the chest pain usually occurs with moderate to prolonged exertion and is generally relieved by nitroglycerin or rest. Which type of angina does the nurse recognize in the client’s description? Stable Correct Variant Unstable Crescendo Methylergonovine (Methergine) is prescribed for a client to control postpartum bleeding. Which action does the nurse take before administering the medication? Checking the episiotomy site Palpating the client's bladder Checking the client's blood pressure Correct Ensuring that the uterus is contracted A nurse is teaching a client with angina pectoris who is being discharged from the hospital about managing chest pain at home. Which statement by the client indicates a need for further teaching? "I need to keep fresh nitroglycerin available in case I need it." "I need to check the expiration date on the nitroglycerin bottle." "If I have any chest pain, I need to stop what I am doing and sit or lie down." "If I get chest pain, I should put 3 nitroglycerin tablets under my tongue and then go to the emergency department if that doesn’t work." Correct A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after sustaining a cervical fracture. Which instructions should the nurse include? Select all that apply. Use a straw to drink. Correct Avoid sexual activity while the vest is in place. Apply powder under the vest to prevent irritation. Use caution when leaning forward or backward. Correct Wear snug clothing to prevent the device from shifting. Do not drive, because full range of vision is impaired with the device. Correct A nurse is assessing a client who is experiencing chest pain. Which of the following observations indicates to the nurse that the pain is most likely a result of angina? The pain is relieved by rest and nitroglycerin. Correct The pain is relieved by the administration of an antacid. The pain is relieved by the administration of an antiinflammatory medication. The pain is relieved with an upright sitting position and the administration of an analgesic. A nurse has provided nutrition instructions to a mother of an infant. Which statement by the mother indicates to the nurse that the mother requires further instruction? "It’s best to use cow's milk, as long as it’s whole milk and not skim." Correct "When I start feeding solid foods, I might need to add water to the food." "When the baby starts to take juices, I shouldn’t warm the juice, because that will destroy the vitamin C." "The baby will get the right nutrition if I feed breast milk or store-bought formula that’s been fortified with iron.” A pediatric nurse is caring for a hospitalized toddler. Which of the following activities does the nurse deem the most appropriate for the toddler? Singing games Watching videos Simple board games Large building blocks Correct A nurse in a physician's office is reviewing the medical record of a child with a diagnosis of lactose intolerance. Which of the following findings does the nurse expect to see documented in the child's record? Fatty stools Episodes of foul-smelling ribbonlike stools Episodes of profuse watery diarrhea and vomiting Episodes of cramping abdominal pain and excessive flatus Correct A nurse is providing dietary instructions to the mother of a child with celiac disease. The nurse tells the mother that it is acceptable to give the child: Boiled rice Correct Cooked pasta Warm oatmeal Baked macaroni and cheese A nurse admitting a newborn to the nursery notes that the physician has documented that the newborn has a gastroschisis. The nurse performs an assessment, expecting to note that the viscera are: Inside the abdominal cavity and under the skin Inside the abdominal cavity and under the dermis Outside the abdominal cavity, not covered with a sac Correct Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane A nurse is monitoring a child with intussusception for signs of peritonitis. For which of the following findings, indicative of this complication, does the nurse notify the physician? Increased alertness Increased heart rate Correct A sausage-shaped abdominal mass Diarrhea and the passage of bloody mucous stool The nurse, auscultating the breath sounds of a client, hears these sounds. What are they? Rhonchi Crackles Wheezes Correct Vesicular Content Area: Adult Health/Respiratory Awarded 0.0 points out of 1.0 possible points. 170.ID: 383703631 A registered nurse is planning client assisgnments for the day. There is a licensed practical nurse and a nursing assistant on the team. Which client is the appropriate choice for the nursing assistant? A client with hemophilia who needs assistance with shaving A client with pneumonia who requires frequent oropharyngeal suctioning A client with rheumatoid arthritis who needs assistance with feeding and ambulation Correct A client with heart failure who needs daily weights and monitoring of intake and output A nurse is monitoring a client with bronchogenic carcinoma for signs of superior vena cava syndrome. For which early sign of this oncological emergency does the nurse assess the client? Dyspnea Cyanosis Hypotension Stokes sign Correct A nurse is caring for a client who has undergone transsphenoidal hypophysectomy to remove a microadenoma of the pituitary gland. Which of these findings would be of greatest concern to the nurse? Urinary specific gravity is low Correct Blood pressure is 138/80 mm Hg. The client complains of a dry mouth. The client frequently performs deep-breathing exercises. The nurse notes the presence of drainage on the mustache dressing of a client who has undergone transsphenoidal hypophysectomy. The initial nursing action is to: Contact the surgeon Change the dressing Document the findings Check the drainage for glucose Correct A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs of postoperative complications. Which of the following findings would be a matter of concern for the nurse as an indication of hypocalcemia? The client's temperature is 100.6˚ F. The client's voice is hoarse and weak. The client's heart rate is 92 beats/min. The client complains of a tingling sensation around the mouth. Correct A nurse is monitoring a client who was brought to the emergency department in an unresponsive state and is now being treated for hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which of the following findings indicates to the nurse that fluid replacement is inadequate? Increased urine output Potassium level of 3.6 mEq/L Blood pressure of 128/80 mm Hg Level of consciousness remains unchanged Correct A nurse is reviewing the laboratory results of a client in the emergency department with diabetic ketoacidosis (DKA). Which laboratory result would the nurse expect to note? Creatinine 1.0 mg/dL Serum bicarbonate of 12 mEq/L Correct Blood urea nitrogen (BUN) of 15 mg/dL Negative results on urinary ketone testing Propylthiouracil (PTU) has been prescribed for a client with Graves disease, and the nurse provides instructions to the client about the medication. For which of the following occurrences does the nurse tells the client to contact the physician? Fatigue Diaphoresis Sore throat Correct Heat intolerance A nurse is providing information to a client with diabetes insipidus who will be taking desmopressin acetate (DDAVP) by way of the nasal route. For which of the following occurrences does the nurse tell the client to contact the physician? Abdominal cramps Stuffy or runny nose Headache and nausea Correct Decreased urine output A client with diabetes mellitus calls the clinic nurse and reports that she has been vomiting during the night and now has diarrhea. Which question does the nurse make a priority of asking the client? "Do you have a fever?" "Did you eat any breakfast?" "Are you urinating frequently?" "Have you tested your blood glucose?" Correct A nurse is providing information to a client who will be self-administering regular insulin about storage of the insulin. The nurse tells the client: That placing the vial near heat or in sunlight will not affect the insulin To freeze unopened vials and remove a vial from the freezer 24 hours before opening it That insulin stored at room temperature causes more discomfort on injection than does cold insulin That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity Correct A nurse reviews the medical record of a client with histoplasmosis. Which clinical manifestation of this infection does the nurse expect to see documented? Neurological deficits Cardiac dysrhythmias Gastrointestinal disturbances Flulike pulmonary symptoms Correct A client with a medical history of diabetes mellitus is found to have sarcoidosis, and oral prednisone is prescribed. The nurse provides instructions to the client about the medication and tells the client to: Eat foods that are high in sodium Decrease the daily dose of insulin Eat foods that are low in potassium Closely monitor the blood glucose level Correct A client with tuberculosis will be taking pyrazinamide (Pyrazinamide), and the nurse provides instructions about the adverse effects of the medication. For which of the following occurrences does the nurse tell the client to contact the physician? Headache Yellow skin Correct Difficulty sleeping Nasal congestion A client who was involved in a high-speed motor vehicle crash is brought to the emergency department. Which of the following findings indicates to the nurse that the client has sustained flail chest? Asymmetrical chest movement Correct Complaints of mild chest discomfort Increased breath sounds on auscultation Deep respirations, 18 breaths/min A client is found to have hypoxemic respiratory failure. Which finding does the nurse expect to note on review of the results of the client's arterial blood gas analysis? Pao2 of 73 mm Hg, Paco2 of 62 mm Hg Pao2 of 58 mm Hg, Paco2 of 35 mm Hg Pao2 of 60 mm Hg, Paco2 of 45 mm Hg Pao2 of 49 mm Hg, Paco2 of 32 mm Hg Correct A client with acute gouty arthritis is being started on medication therapy with indomethacin (Indocin). The nurse, providing medication instructions, and tells the client to take the medication: At bedtime With food Correct 1 hour before meals On an empty stomach An emergency department nurse is monitoring a client who sustained a severe inhalation burn injury during a fire in which the client was trapped in an enclosed space. The nurse auscultates the client's trachea and notes that the previously heard wheezing sounds have disappeared. The nurse most appropriately: Continues monitoring the client Notifies the emergency department physician Correct Documents the client's improvement in the medical record Removes the oxygen mask and fits the client with a nasal cannula A nurse reviews arterial blood gas values and notes a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse interprets these values as indicative of: Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis Correct A nurse provides information to a client with chronic obstructive pulmonary disease (COPD) about methods of alleviating shortness of breath while the client is eating. Which statement by the client indicates a need for further instruction? "I should rest before I eat." "I should use my bronchodilator 30 minutes before I eat." "Pursed-lip breathing will help relieve my shortness of breath." "I should eat three meals a day, and the biggest meal should be at suppertime." Correct A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For which characteristic sign or symptom of this complication does the nurse monitor the client? Pleuritic chest pain Correct Slowed heart rate Chills and a high fever Decreased respiratory rate A nurse caring for a client 24 hours after a radical neck dissection notes the presence of serosanguineous drainage in the portable wound suction device attached to the surgical site. On the basis of this finding, the nurse should: Contact the physician Document the findings Correct Ask the physician to remove the drains Increase the pressure on the wound suction device Although previously well controlled with glyburide (Diabeta), a client’s fasting blood glucose has been running 180 to 200 mg/dL. On reviewing the client's record, which medication, recently added to the client's regimen, does the nurse recognize as a possible contributor to the hyperglycemia? Phenelzine (Nardil) Atenolol (Tenormin) Allopurinol (Zyloprim) Lithium carbonate (Lithobid) Correct A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note? Weight gain Flushed face Client complaint of diarrhea A blood pressure higher than the normal range Correct The nurse is the first responder at the scene of a bus crash. After a quick assessment of the victims, which one does the nurse care for first? A victim with a twisted ankle and leg bruises A victim with an open fracture of the arm that is bleeding profusely Correct A victim who is anxiously moving among the victims, searching for her husband A victim who is unresponsive, with severe swelling and bruising around the eyes, and is not breathing A client with suspected HIV infection has positive results on enzyme-linked immunosorbent assay (ELISA) and Western blot tests. The plasma HIV RNA level is assessed, and the result is reported as 8000 copies/mL. The nurse interprets the results of the HIV RNA test as indicating that the client: Is at low risk for AIDS Correct Is at high risk for AIDS Is at risk for HIV infection Requires further testing to confirm the presence of HIV A nurse developing a plan of care for a client with HIV infection identifies several concerns. List them in order of priority, from highest to lowest. Incorrect Despair Possible infection Fatigue Decreased nutrition The correct order is: Possible infection Decreased nutrition Fatigue Despair A client is found to have iron-deficiency anemia, and ferrous sulfate (Feosol) is prescribed. The nurse tells the client that it is best to take the medication with: Milk Apple juice Orange juice Correct Scrambled eggs A nurse is monitoring a client with pheochromocytoma who is receiving an intravenous (IV) infusion of phentolamine. Which vital sign does the nurse monitor most closely during the infusion? Apical pulse Respirations Temperature Blood pressure Correct Oral prednisone 5 mg/day has been prescribed for a client with a chronic respiratory disorder, and the nurse provides instructions to the client about the medication. The nurse tells the client to: Take the medication on an empty stomach Take half of the daily dose if weight gain occurs Stop taking the medication if the ankles begin to swell Call the physician if a fever, sore throat, or muscle aches develop Correct As a nurse prepares to administer medications to an assigned client, the client asks, "Why don't you just leave me alone?" What is the best response by the nurse? "Don't yell at me." "These medications will help you feel much better." "Why do you want to be left alone? I’m here to help you." "I can see that you’re upset. Would you like to talk about it?" Correct A nurse is assessing a client with hepatitis for signs of jaundice. Which area does the nurse check, knowing that it will provide the best data regarding the presence of jaundice? Lips Soles Palms Mucous membranes Correct A mother calls the emergency department and tells the nurse that her 3-year-old child drank ammonia from a bottle while the mother was cleaning house. The nurse tells the mother to immediately: Induce vomiting Call the child's physician Bring the child to the emergency department Encourage the child to drink water or milk in small amounts Correct Calcium disodium edetate (EDTA) and British antilewisite (BAL, dimercaprol) is prescribed for a child with lead poisoning. What does the nurse ask the child's mother before administering the medications? "Can your child swallow pills?" "Has your child been running a fever?" "Does your child have an allergy to peanuts?" Correct "How long has your child been exposed to the lead?" A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen (Tylenol). Which medication does the nurse prepare, anticipating that it will be prescribed to treat the child? Protamine sulfate Succimer (Chemet) Phytonadione (vitamin K) Acetylcysteine (Mucomyst) Correct A female client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid (aspirin) daily in a divided dose. At the physician's office, the client tells the nurse that she has been experiencing ringing in the ears over the past few days. The nurse tells the client that: This is expected and nothing to be concerned about It is important to drink at least 10 glasses of water a day to prevent ringing in the ears This is a sign of toxicity, so the aspirin will be discontinued and replaced with a nonsteroidal antiinflammatory medication The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage Correct A nurse is caring for a client who sustained burn injuries on the anterior lower legs and anterior thorax. What percentage of the client’s body, according to the Rule of Nines, has been affected? 36% Correct 42% 45% 31.5% A client is brought to the emergency department after sustaining smoke inhalation injury during a fire in the client's home. The nurse plans to first: Check for a patent IV line Provide emotional support to the client Provide the client with 100% oxygen by mask Correct Administer intravenous (IV) fluids as prescribed A client with emphysema is receiving theophylline (Theo-24). While providing dietary instructions, the nurse tells the client that it is acceptable to consume: Cola Coffee Hot cocoa Apple juice Correct Testing of the plasma theophylline level in a client who is receiving a continuous intravenous infusion of theophylline reveals a level of 20 mcg/mL. The nurse interprets this result as: Below the therapeutic range In excess of the therapeutic range At the top of the therapeutic range Correct In the middle of the therapeutic range Fluticasone propionate (Advair) and albuterol (Ventolin HFA), administered by inhalation twice daily, are prescribed for a client with asthma. The nurse, providing information to the client about administration of the medication, tells the client to use the: Fluticasone propionate immediately after inhaling the albuterol Albuterol immediately after inhaling the fluticasone propionate Fluticasone propionate several minutes before inhaling the albuterol Albuterol several minutes before inhaling the fluticasone propionate Correct A nurse assessing the wound of a client with a stage 3 pressure ulcer and notes that the wound bed is pale. The nurse interprets this finding as a possible indication that: The wound is healthy The wound is improving Necrotic tissue is present The client's hemoglobin level is low Correct A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. The nurse tells the client to immediately: Contact the physician Report to the emergency department for treatment Get into the shower and rinse the skin for at least 15 minutes Correct Go to the drugstore, purchase an over-the-counter topical corticosteroid, and rub it into the exposed skin A nurse provides skin care instructions to a client with acne vulgaris. Which statement by the client indicates a need for further instruction? "I should use oil-based cosmetics." Correct "I shouldn't leave make-up on overnight." "I should avoid rubbing my face vigorously." "I should wash my face two or three times a day with a mild cleanser." Oral candidiasis (thrush) develops in a client infected with HIV, and the nurse provides instruction to the client about measures to relieve the discomfort. Which statement by the client indicates a need for further instruction? "I should avoid spicy foods." "I should eat foods with a soft texture." "I should use a soft-bristled toothbrush." "I should put ice in my drinks to help soothe the discomfort." Correct A client with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B (Fungizone). Which parameter does the nurse check to detect the most common adverse effect of this medication? Temperature Blood pressure Peripheral pulses Intake and output Correct A hospitalized client scheduled for surgery is told by the physician that she is extremely anemic and will need a blood transfusion. The client, a Jehovah's Witness, tells the nurse that she is refusing the transfusion. What is the most appropriate initial nursing action? Supporting the client's decision to refuse the transfusion Correct Teaching the client ways to increase dietary intake of iron Telling the client about the importance of the blood transfusion Telling the client that if she refuses the blood transfusion, the surgery will have to be canceled A nurse is performing an assessment of a client with Ménière disease. Which question does the nurse ask to elicit data about the manifestations of this disease? "Do you have headaches?" "Have you had any loss of appetite?" "Do you have episodes of dizziness?" Correct "Have you been having any diarrhea?" A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. The nurse would initially: Identify the client's treatment goals Correct Share current research outcomes with the client Offer options that may be beneficial to the client Tell the client that the physician does not believe in these therapies A client has been scheduled for an electronystagmography (ENG), and the nurse provides instructions to the client about the test. Which statement by the client tells the nurse that the client understands the instructions? "I need to not drink coffee before the test." Correct "I’ll need to receive sedation before the test." "I won’t be able to eat for 24 hours after the test." "I can eat a light breakfast on the morning of the test." An emergency department nurse has a physician's prescription to irrigate a client's ears. List in order of priority the steps that the nurse should take in performing this procedure. Incorrect Document the completion of the procedure and how the client tolerated it. Fill an irrigating syringe with warm water. Warm tap water to body temperature. Use an otoscope to ensure that the tympanic membrane is intact. Insert the irrigating solution by directing the solution toward the wall of the ear canal. The correct order is: Use an otoscope to ensure that the tympanic membrane is intact. Warm tap water to body temperature. Fill an irrigating syringe with warm water. Insert the irrigating solution by directing the solution toward the wall of the ear canal. Document the completion of the procedure and how the client tolerated it. A community health nurse is preparing a poster for a health fair that will include information about the ways to prevent ear infection or ear trauma. Which prevention measures does the nurse include on the poster? Select all that apply. Always sneeze with the mouth closed. Occlude one nostril when blowing the nose. Keep the volume of headphones at the lowest setting. Correct Avoid environmental conditions involving rapid changes in air pressure. Correct Clean the external ear and canal daily in the shower or while washing the hair. Correct Be cautious when using cotton-tipped applicators to clean the external ear canal. A nurse assigns a nursing assistant to care for a client who is hearing impaired and provides instructions to the nursing assistant about the effective methods for communicating with the client. Which statement by the nursing assistant indicates that further instruction is needed? "I should speak slowly and clearly to the client." "I should stand directly in front of the client when I’m talking." "I should make sure that the room is well lit when I’m talking to the client." "I should raise the volume of my voice and stand on the client's affected side when I’m talking to him." Correct A Tensilon test is performed on a client with suspected myasthenia gravis. Which finding constitutes a positive result? A decrease in muscle strength No change in muscle strength An increase in muscle strength Correct The presence of tremors in previously weakened muscles A client with myasthenia gravis who has been taking pyridostigmine bromide (Mestinon) for the treatment of the disorder comes to the emergency department complaining of severe muscle weakness, and cholinergic crisis is diagnosed. Which medication does the nurse prepare for immediate use in treating the crisis? Atropine sulfate Correct Carisoprodol (Soma) Cyanocobalamin (vitamin B12) Cyclobenzaprine hydrochloride (Flexeril) A nurse provides information about activity and exercise to the wife of a client with Parkinson's disease. Which statement by the spouse indicates a need for further instruction? "He needs to have a broad base of support when ambulating." "He needs to avoid staying in one position for a prolonged period." "I should encourage him to keep his hands hanging at his side when he walks." Correct "I should help him perform range-of-motion exercises of his joints three times a day." A nurse is caring for a client who has had a stroke and is experiencing hemianopsia. Which of the following measures does the nurse take in the care of the client? Approaching the client from the side of nonintact vision Teaching the client to move the head from side to side (scan) when eating Correct Placing objects needed for self-care within the client's nonintact visual field Positioning the client in the room so that his nonintact visual field faces the door A nurse has provided information about exercise to a client with a diagnosis of degenerative joint disease (osteoarthritis). Which of the following types of exercise does the nurse tell the client to avoid? High-impact exercise Correct Swimming and water exercise Daily range-of-motion exercises A client with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation? "Only you can help?" "You decided not to take your medication?" "If you can make that observation, you probably don't need your medication any longer." "Your doctor wants you to continue this medication because it’s helping you. Do you recall needing to be hospitalized because you stopped your medication?" Correct A nurse prepares to administer digoxin (Lanoxin) to a client with congestive heart failure. Which vital sign must be checked before the medication is administered? Temperature Respirations Apical pulse Correct Blood pressure A nurse preparing to administer digoxin (Lanoxin) to a client calls the laboratory for the result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports that the result was 2.4 ng/mL. On the basis of this result, the nurse would: Contact the physician Correct Administer the digoxin Wait for the physician to make rounds and report the result Check the client's apical heart rate and administer the digoxin if the rate is faster than 60 beats/min A nurse transcribing the prescriptions of a client admitted to the nursing unit notes that metformin (Glucophage) 850 mg/day has been prescribed. The nurse makes a note in the client's medication record that the medication should be administered: At noon With supper With the morning meal Correct With the midafternoon snack The wife of a client with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL and that her husband is awake but groggy. The nurse tells the client's wife to immediately: Call the physician Administer glucagon hydrochloride (Glucagon) Call an ambulance to bring her husband to the emergency department Place some honey in her husband's mouth, between his gums and cheek Correct A client with type 1 diabetes mellitus is instructed by the physician to obtain glucagon hydrochloride (Glucagon) for emergency home use. The nurse provides information to the client's wife about the medication. Which statement by the client’s wife indicates that she understands the information? "I need to store this medication in the freezer." "I know that this is used to treat episodes of high blood sugar." "I can give this medication instead of insulin if his insulin runs out." "I need to give this if he has signs of low blood sugar and goes into a coma." Correct A client with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. The nurse tells the client to: Stop the medication Contact the physician immediately Increase intake of high-fiber foods Correct Add a half-ounce of mineral oil to the daily diet A client has a physician's appointment to get a prescription for sildenafil (Viagra). The nurse obtains the health history from the client. Which finding indicates that the medication is contraindicated? The client has type 2 diabetes mellitus. The client has a history of renal calculi. The client is taking glargine (Lantus) insulin. The client takes isosorbide dinitrate (Isordil). Correct Vasopressin (Pitressin) is prescribed to a client with diabetes insipidus. For which sign, indicative of an adverse effect of the medication, does the nurse monitor the client? Chest pain Correct Constipation Loss of appetite Decreased urine output Desmopressin (DDAVP) is prescribed to a client with diabetes insipidus. Which parameter does the nurse tell the client that it is important to monitor while she is taking the medication? Appetite Pulse rate Bowel pattern Intake and output Correct Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the physician's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician to confirm the prescription for warfarin sodium because: Warfarin sodium amplifies the effect of levothyroxine Levothyroxine amplifies the effect of warfarin sodium Correct Warfarin sodium is contraindicated with the use of levothyroxine A severe allergic reaction may occur if warfarin sodium is administered concurrently with levothyroxine Iodine solution (Lugol solution) is prescribed to a client who is scheduled for subtotal thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the mouth and soreness of the gums and teeth. The nurse most appropriately tells the client: To contact the physician Correct That these are expected side effects of the medication That these discomforts will resolve with continued therapy To stop the medication for the next 24 hours and then continue as prescribed Levothyroxine (Synthroid) is prescribed to a client with hypothyroidism. One week after beginning the medication, the client calls the physician's office and tells the nurse that the medication has not helped. The nurse most appropriately tells the client that: The medication will need to be changed The full therapeutic effect may take 4 weeks Correct An additional medication will have to be added to the regimen The blood levels of the client’s thyroid hormones will need to be rechecked A nurse provides instructions to a client who will be taking levothyroxine (Synthroid) for hypothyroidism. The nurse tells the client that it is best to take the medication: With milk At bedtime With an antacid In the morning, before breakfast Correct A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat the client. Which type of insulin does the nurse take from the medication supply room for intravenous (IV) administration? NPH (Humulin N) Lente (Humulin L) Regular (Humulin R) Correct NPH/regular 50%/50% (Humulin 50/50) A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R) insulin for a client with diabetes mellitus who will be administering his own insulin but has difficulty seeing and accurately preparing doses. The nurse places the medication in the client's refrigerator with the syringes: Lying flat In a horizontal position In a vertical position with the needles pointing up Correct In a vertical position with the needles pointing down Tolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitus has not been controlled with diet and exercise alone. The nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction? "I need to maintain my exercise program." "I need to stay on my calorie-restricted diet." "I can take the medication with food if it upsets my stomach." "I can have a beer or glass of wine as long as I stay within my daily dietary restrictions." Correct A nurse is transcribing a physician's prescription for oral prednisone 5 mg/day that was written in the chart of a client with type 2 diabetes mellitus who is already taking an oral hypoglycemic medication. The nurse contacts the physician to ask about the prescription because: Prednisone can lower the blood glucose level Prednisone can increase the blood glucose level Correct Prednisone is contraindicated with the use of oral hypoglycemic medications For prednisone to be effective in a client taking an oral hypoglycemic agent, a higher dosage of prednisone is required Oral prednisone 10 mg/day is prescribed for a client with an acute exacerbation of rheumatoid arthritis. The nurse, providing information to the client about the medication, tells the client that it is best to take it: At bedtime With lunch In the evening, after 9 p.m. In the morning, before 9:00 a.m. Correct A child with growth hormone deficiency will be receiving somatropin (Humatrope). The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring? Creatinine Hemoglobin Blood urea nitrogen (BUN) Thyroid-stimulating hormone (TSH) Correct Laboratory studies are performed on a client with suspected sickle cell disease, and electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory finding will the nurse expect to note that is a characteristic of this disease? Low reticulocyte count Low total bilirubin level Increased hematocrit count Increased white blood cell (WBC) count Correct A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are performed because the physician suspects iron-deficiency anemia. Which finding indicative of this type of anemia does the nurse expect to find on reviewing the laboratory results? An increased RBC count An increased hematocrit level An increased hemoglobin level Microcytic red blood cells (RBCs) Correct Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis. The nurse provides information on the medication to the client. When does the nurse tell the client to take the alendronate? At bedtime With orange juice, to enhance absorption at night Every morning before breakfast, with a full glass of water Correct Every morning after breakfast, after which the client should lie down for 30 minutes Calcium carbonate (Os-Cal 500) is prescribed for a client with mild hypocalcemia. What food does the nurse instruct the client to avoid consuming while taking this medication? Fish Milk Spinach Correct Watermelon An emergency department nurse is caring for a client in hypovolemic shock, a result of external hemorrhage caused by a gunshot wound. Which nursing interventions should the nurse take? Select all that apply. Maintaining the client in a high Fowler’s position Checking the client's vital signs every hour until stable Ensuring that direct pressure is applied to the external hemorrhage site Correct Ensuring a patent airway and supplying oxygen to the client as prescribed Correct Inserting an intravenous (IV) catheter and administering fluids as prescribed Correct Ensuring that the call bell is in place for the client's use when the nurse is out of the room A child with a diagnosis of Wilms’ tumor is being admitted to the pediatric unit. The nurse prepares the room for the child and places a sign at the child's bedside that tells staff to avoid: Palpating the abdomen Correct Taking temperatures rectally Turning the child to the right side Measuring blood pressure in the right arm A client with multiple sclerosis has been started on baclofen (Lioresal) for muscle spasms. The client calls the physician's office 1 week after beginning the medication and tells the nurse that she feels extremely drowsy. The nurse most appropriately tells the client: That she will need to be seen by the physician That the medication will need to be discontinued That drowsiness usually diminishes with continued therapy Correct To stop the medication for 2 days and then resume it at the prescribed dosage Alprazolam (Xanax) is prescribed for a client to treat an anxiety disorder. Which side effect does the nurse warn the client of? Headache Urine retention Lightheadedness Correct Increased salivation View video. The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution? Flushing the tube with 30 mL of tap water Checking urine output in the previous 24 hours Scrubbing the port with povidone-iodine (Betadine) solution Checking for gastric residual volume and assessing tube placement Correct A nurse is caring for a client who has had a cast applied to the left leg and is at risk for acute compartment syndrome. For which early sign of this complication does the nurse monitor the client? Paresthesia Correct Cold, bluish toes Weak pedal pulse Severe pain relieved by medication A physician writes a prescription for 1000 mL of 0.9% normal saline solution to be administered intravenously (IV) to a client over 10 hours. The drop factor for the infusion set is 15 gtt/mL. At what drip rate does the nurse set the infusion? Type answer in the box provided. _______________ gtt/min Incorrect Correct Responses: "25" A nurse is performing an assessment of a client being admitted to the hospital with a diagnosis of multiple sclerosis. The client tells the nurse that she took baclofen (Lioresal) for the past 9 months but completely stopped the medication 2 days ago because it was making her feel weak. On the basis of this information, the nurse notes in the plan of care that the client should be monitored most closely for: Spasticity Drowsiness Muscle spasms Seizure activity Correct A nurse is caring for a client who is immobilized in skeletal traction after sustaining a leg fracture in a motor vehicle crash. The nurse notes that the client is restless, and the client complains of being bored. Which problem does the nurse identify on the basis of this information? Lack of control Lack of physical mobility Lack of adequate diversional activity Correct Lack of energy to bathe and feed self A client is found to have posttraumatic stress disorder (PTSD) after witnessing a terrorist attack that caused the deaths of hundreds of people. The nurse, developing a plan of care for the client, identifies posttrauma syndrome as a concern and identifies a client outcome that states, "The client will cope effectively with thoughts and feelings of the event." Which nursing interventions will assist the client in achieving this outcome? Select all that apply. Being honest, nonjudgmental, and empathetic Correct Assessing the immediate posttraumatic reaction Correct Encouraging the client to keep a journal focused on the trauma Correct Asking the client about the use of alcohol and drugs before and since the event Correct Promoting discussion of the reasons the client was responsible for the traumatic event Discouraging the use of support groups until the client is able to use effective coping techniques A nurse reviews the results of a total serum calcium determination in a client with renal failure. The results indicate a level of 12.0 mg/dL. In light of this result, which finding does the nurse expect to note during assessment? Decreased urine output Hyperactive bowel sounds Bounding, full peripheral pulses Correct Hyperactive deep tendon reflexes A nurse is preparing to provide information to a client who has been found to have stable angina. The nurse plans to tell the client that this type of angina: Requires surgical treatment Can be cured with medication Will eventually need to be treated with a coronary artery bypass graft Is often managed medically with medications such as calcium channel blockers and beta-blocking medications Correct While being seen by a physician, a client complains of persistent fever, malaise, and night sweats. On physical examination, the physician palpates enlarged lymph nodes, and the client states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic studies are performed. Which characteristic of this type of lymphoma does the nurse expect to note while reviewing the results of the diagnostic studies? Blast cells in the bone marrow Epstein-Barr virus in the blood Increased blood urea nitrogen (BUN) Reed-Sternberg cells on biopsy of a lymph node Correct A nurse is preparing medication instructions for a client who will be taking a daily oral dose of digoxin (Lanoxin) 0.25 mg in the treatment of congestive heart failure (CHF). Which instructions should the nurse include on the list? Select all that apply. Take your pulse before taking each dose. Correct Avoid eating foods that contain potassium. Take the digoxin at the same time each day. Correct Take the digoxin with a chewable antacid to prevent nausea. If you forget to take your daily dose, double the dose on the next day. Notify the physician if you experience loss of appetite, muscle weakness, or visual disturbances. Correct