1. A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the
following instructions should the nurse include?
a. Flex the foot every hour when awake.
b. Place a pillow un
...
1. A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the
following instructions should the nurse include?
a. Flex the foot every hour when awake.
b. Place a pillow under the knee when lying in bed.
c. Lower the leg when sitting in a chair.
d. Ensure the leg is abducted when resting in bed.
The nurse should instruct the client to flex the foot every hour to reduce the risk for
thromboembolism and promote venous return.
2. A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of
the following findings is an indication of lung re-expansion?
a. The chest tube is draining serosanguineous fluid at 65 mL/hr.
b. The client tolerates gentle milking of the tubing.
c. Bubbling in the water seal chamber has ceased.
d. There is tidaling in the water seal chamber.
Bubbling in the water seal chamber ceases when the lung re-expands.
3. A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation.
Which of the following values should the nurse identify as a desired outcome for this therapy?
a. INR 1
b. INR 2.5
c. aPTT 45 seconds
d. aPTT 90 seconds
Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or
pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must
be monitored to ensure the anticoagulation is within the therapeutic range and prevent
hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation).
An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial
fibrillation.
4. A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater
trochanter of his left hip. Which of the following instructions should the nurse include in the teaching?
a. Clean the wound daily with an antiseptic.
b. Use a donut-shaped pillow when sitting in a chair.
c. Change position every hour.
d. Massage the area two times daily.
Changing position every 1 to 2 hr decreases pressure on bony prominences. The nurse should
also instruct the client to limit the angle of the hips when in a lateral position to no more than
30°. This positioning prevents direct pressure on the trochanter.
5. A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is
the nurse’s priority to report to the provider?
a. Temperature 37.2° C (99° F)
b. Blood pressure 100/70 mm Hg
c. Weight loss
d. Restlessness
Using the urgent vs. nonurgent approach to client care, the nurse should determine that the
priority finding to report to the provider is restlessness, which can be an indication the client is
experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal
of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other
manifestations include nausea, vomiting, fatigue, and headache.6. A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is
unable to void on the bedpan. Which of the following actions should the nurse take first?
a. Document the client's intake and output.
b. Scan the bladder with a portable ultrasound.
c. Pour warm water over the client's perineum.
d. Perform a straight catheterization.
The first action the nurse should take using the nursing process is to assess the client.
Scanning the bladder with a portable ultrasound device will determine the amount of urine in the
bladder.
7. A nurse is planning a health promotional presentation for a group of African American clients at a
community center. Which of the following disorders presents the greatest risk to this group of clients?
a. Multiple sclerosis
b. Skin cancer
c. Urolithiasis
d. Hypertension
When using the safety/risk reduction approach to client care, the nurse should determine that
the disorder with the greatest risk for this group of clients is hypertension. The prevalence of
hypertension is highest among African American clients, followed by Caucasian clients, and
then Hispanic clients.
8. A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse
that the client’s condition is improving?
a. Potassium 3.5 mEq/L
b. pH 7.28
c. Glucose 272 mg/dL
d. HCO3- 14 mEq/L
A glucose reading less than 300 mg/dL indicates improvement in the client's status.
9. A nurse is caring for a client following extubation of an endotracheal tube 10 minutes ago. Which of the
following findings should the nurse report to the provider immediately?
a. Stridor
b. Oral secretions
c. Hoarseness
d. Sore throat
Using the urgent vs. nonurgent approach to client care, the nurse should determine that the
priority finding is stridor. Stridor can indicate a narrowing airway or possible obstruction caused
by edema or laryngeal spasms. The nurse should report the finding immediately and implement
an intervention.
10. A nurse is caring for a client who had a nephrostomy tube inserted 12 hrs ago. Which of the following
findings should the nurse report to the provider?
a. The client's urinary output has increased.
b. The client reports back pain.
c. The client's urine color is red tinged.
d. The client's BUN is 18 mg/dL.
The nurse should notify the provider if the client reports back pain, which can indicate that the
nephrostomy tube is dislodged or clogged.
11. A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission
precautions should the nurse initiate?
a. Airborne
b. Dropletc. Contact
d. Protective environment
Airborne precautions are required for clients who have infections due to micro-organisms that
can remain suspended in air for lengthy periods of time, such as tuberculosis, measles,
varicella, and disseminated varicella zoster.
12. A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the
following interventions should the nurse include in the plan of care?
a. Keep a lead-lined container in the client's room.
b. Limit each visitor to 1 hr per day.
c. Place a dosimeter badge on the client.
d. Remove soiled linens from the client's room each day.
The nurse should keep a lead-lined container and forceps in the client's room in case of
accidental dislodgement of the implant.
13. A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following
findings is the nurse’s priority?
a. Moderate serosanguinous drainage on the dressing
b. Calcium 9.5 mg/dL
c. Temperature 38.9° C (102° F)
d. Decreased bowel sounds
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is an elevated temperature. An elevated temperature is a manifestation of
excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The
nurse should report this finding immediately to the provider because it can lead to seizures and
coma.
14. A nurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of
the following statements by the client indicates understanding of the teaching?
a. "I will eat a salad at least once each day to increase my intake of vitamin K."
b. "I can work in my flower garden as long as I wear gardening gloves to cover my skin."
c. "I will no longer floss my teeth after brushing my teeth."
d. "I can sip on a glass of juice for at least 2 hours before I should discard it."
The nurse should instruct the client to avoid flossing teeth to prevent gum inflammation, which
could create the opportunity for infection.
15. A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil.
Which of the following information should the nurse include in the teaching?
a. "Take this medication on an empty stomach."
b. "Eczema is an immediate expected adverse effect of this medication."
c. "Increase fiber intake to avoid constipation."
d. "Monitor your blood pressure monthly."
The nurse should instruct the client that constipation is an adverse effect of verapamil. The
client should increase fiber intake to promote regular bowel function.
16. A nurse is providing education to a client who is at risk for osteoporosis. Which of the following
instructions should the nurse include?
a. Begin taking glucosamine supplements.
b. Walk for 30 min four times per week.
c. Jog for 15 min two times per week.
d. Avoid taking over-the-counter calcium supplements.
Weight-bearing exercises promote bone mass. Therefore, walking can help the client prevent
osteoporosis.17. A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone
replacement therapy. For which of the following adverse effects should the nurse instruct the client to
notify the provider? (Select all that apply.)
a. Night sweats
b. Calf pain
c. Vaginal dryness
d. Numbness in the arms
e. Intense headache
Calf pain is an indication of deep-vein thrombosis. The client should report this finding to the
provider immediately. Numbness in the arms can indicate a cerebrovascular accident, which is
an adverse effect of hormone replacement therapy. The client should report this finding to the
provider immediately. An intense headache can indicate a cerebrovascular accident, which is an
adverse effect of hormone replacement therapy. The client should report this finding to the
provider immediately.
18. A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should
identify the need to revise the plan for which of the following clients?
a. A client who is taking potassium supplements, has a potassium level of 3.2 mEq/L, and reports
constipation
b. A client who has Alzheimer's Disease (AD), has a room near the nurse's station, and is agitated
c. A client who is postoperative following abdominal surgery and reports feeling that something
"popped" when they coughed
d. A client who has a conductive hearing loss, speaks softly, and is scheduled for a cerumen
removal
A feeling of something popping or loosening with coughing might indicate a wound dehiscence.
This client will need to have revisions to the plan of care, which can include management of the
dehiscence, prevention of evisceration, or possible surgical repair of an evisceration if one
occurs.
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