1. A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the following instructions should the nurse in the teaching?
2. A nurse is reviewing the medication record of a client who is
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1. A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the following instructions should the nurse in the teaching?
2. A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity?
3. A nurse is reinforcing teaching about insulin injections with an adult client who weighs 45.4 kg (100 lb.). Which of the following statements by the client indicates an understanding of the teaching?
4. A nurse is reinforcing discharge teaching for a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching?
5. A nurse is reviewing the medical record for an older adult client who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take? (Click on the “Exhibit” button for additional client information. There are three tabs that contain separate categories of data.)
View the Exhibit
Exhibit 1 Exhibit 2 Exhibit 3
Diagnosis Results
Sodium 142 mEq/
Potassium 4.2 mEq/L
BUN 36 mg/dL
Creatinine 1.4 mg/dL Nurses’ Notes
1200: Alert and oriented x3
Lungs clear to auscultation
Decreased skin turgor
Dry mucous membranes Graphic Record
Temperature
0800: 37.7° C (99.9° F)
1200: 37.2° C (99.0° F)
Pulse
0800: 96/min
1200:105/min
Respiratory rate
0800: 18/min
1200: 20/min
Blood pressure
0800; 118/62 mmHg
1200: 104/65 mm Hg
6. A nurse is providing information regarding transmission-based precautions for a client who has Clostridium difficileto an assistive personnel (AP). Which of the following instructions should the nurse include? (Select all that apply).
7. A nurse is admitting a client who is suspected having active tuberculosis (TB). Which of the following actions should the nurse take first? (chap. 20)
8. A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain. Which of the following actions should the nurse take?
9. A nurse is reinforcing teaching with the parent of a toddler who has type I diabetes mellitus and whose prescription has been changed from regular insulin to lispro insulin. Which of the following information should the nurse include in the teaching?
10. A nurse is reinforcing teaching with a client who has microcytic anemia and is prescribed a daily iron supplement. The nurse tells the client to consume foods containing vitamin C when taking the supplement to enhance iron absorption. Which of the following client food choices indicates an understanding of the teaching?
11. A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. Which of the following interventions should the nurse include in the plan of care?
12. A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should recommend which of the following foods as the best source of fiber?
13. A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client’s therapeutic regimen is effective?
14. A nurse is monitoring a client who has a wrist cast and reports intense itching underneath the cast. Which of the following actions should the nurse take?
15. A nurse is preparing to insert a double-lumen gastric (Salem) sump tube for a client who has peptic disease and has developed gastrointestinal bleeding. Which of the following images indicates the tube that the nurse should select?
16. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Whichof the following findings should the nurse report to the provider?
17. A nurse is caring for a client who has been taking enalapril. The nurse should monitor the client for which of the following adverse effects?
18. A nurse is preparing a client for a cardiac catheterization. Whicj of the following actions should the nurse take first?
19. A nurse is caring for an adult client who has age-related macular degeneration. Which of the following findings should the nurse expect?
20. A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?
21. A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an outcome?
22. A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. Which of the following actions should the nurse take?
23. A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client’s apical pulse, the nurse notes a rate of 58/min. which of the following actions should the nurse takes?
24. A nurse is caring for a client who has neutropenia. Which of the following nursing interventions should the nurse implement?
25. A nurse is caring for client who has an intestinal obstruction and reports a new onset of nausea. The client has an NG tube set at low intermittent suction and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take first?
26. A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the following information should the nurse recommend to include in the pamphlet?
27. A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
28. A nurse is caring for a client who is 24 hr postoperative following an abdominal surgery. Which of the following findings requires immediate attention from the nurse?
29. A nurse is caring for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome?
30. A nurse is assisting with the care of a client who has a stroke and is unable to speak. The nurse should identify that the client’s injury occurred in which of the following lobes of the brain? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
31. A home health nurse is caring for a client who has COPD. The client tells the nurse that he becomes short of breath while eating despite the use of home oxygen. Which of the following instructions should the nurse include?
32. A nurse is reinforcing teaching with a client who has chronic kidney disease about management. Which of the following statements by the client indicates an understanding of the teaching?
33. A nurse is caring for a client who has dementia due to Alzheimer’s disease. Which of the following actions should the nurse take to reduce the client’s confusion?
34. A nurse is caring for a client who has Cushing’s syndrome and expresses concern regarding body image changes. Which of the following should the nurse recognize as a physical change caused by this disease?
35. A nurse is delegating the task of repositioning a client who is in skeletal traction to an assistant personnel (AP). Which of the following instructions should the nurse give the AP?
36. A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan?
37. A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine?
38. A nurse is repositioning a client who has lower back pain. Which of the following position is appropriate for the client?
39. A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include in the teaching?
40. A nurse is reinforcing teaching regarding the use of a continuous passive motion motion (CPM) machine with a client who is schedules for a total knee arthroplasty. Which of the following information should the nurse include in the teaching? (Select all that apply.)
41. A nurse is caring for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow. (Move the steps the nurse should take into the box on the right, placing them in order of performance. Use all the steps.)
Reorient and reassure the client. Lower the client to the floor.
Lower the client to the floor. Place a pad beneath the client’s head.
Time the length of the client’s seizure. Loosen the clothing around the client’s neck.
Place a pad beneath the client’s head. Time the length of the client’s seizure.
Loosen the clothing around the client’s neck. Reorient and reassure the client.
42. A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching?
43. A nurse is reinforcing teaching with a client who has coronary artery disease and is taking a statin medication to lower cholesterol levels. Which of the following instructions should the nurse include in the teaching?
44. A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulin should the nurse include?
45. A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort?
46. A nurse is assisting in the plan of care for a client who has a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan?
47. A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction?
48. A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?
49. A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer’s disease. Which ofthe following interventions should the nurse include in the plan?
50. A nurse is reviewing medical record of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery?
51. A nurse is reviewing the medication administration record of a client who has osteoarthritis. Which of the following analgesic prescriptions should the nurse expert to administer when the client reports pain?
52. A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication?
53. A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for calcitonin. Which of the following statements should the nurse make to describe the effect the calcitonin in treating osteoporosis?
54. A nurse is assisting with an educational program for clients who have newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin?
55. A nurse is caring for a client who is suspected of having myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG?
56. A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan?
57. A nurse is reinforcing teaching with a client who has circulatory compromise in the lower extremities due to peripheral vascular disease. Which of the following actions should the nurse take?
58. A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. Which of the following provider prescriptions should the nurse expect?
59. A nurse is preparing to assist a client out of bed 4 hr. following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first?
60. A nurse in a health clinic is reinforcing teaching with a client who has tuberculosis (TB) about transmission of the disease. Which of the following client statements indicates an understanding of the teaching?
61. A nurse is caring for a client undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect?
62. A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking her medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis?
63. A nurse is caring for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury?
64. A nurse is caring for a client who is 2 hr postoperative following an amputation of the foot. Which of the following actions should the nurse take first?
65. A nurse is caring for a client who has a new cast on her left forearm and report severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complication should the nurse suspect?
66. A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify which of the following client statements indicates an understanding of the teaching?
A nurse is reviewing the plan of care for an older adult client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care?
67. A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as a normal change associated with aging?
68. A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate?
69. A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse should document the sound as which of the following? (Click on the audio button to listen to the clip)
70. A nurse is caring for a client who has restricted movement of the chest due to a burn injury. The nurse should anticipate preparing the client for which of the following procedures?
71. A nurse is caring for four clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease?
72. A nurse is caring for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure?
73. A nurse is caring for a female client who is being treated for dehydration due to due to nausea and vomiting. Which of the following findings should the nurse report to the provider?
74. A nurse is contributing to the plan of care for a client who had a cerebrovascular accident (CVA). For which of the following interdisciplinary tem members should the nurse recommend a referral prior to initiating oral intake for the client?
75. A nurse is reinforcing teaching to a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching?
76. A nurse is reinforcing discharge teaching with a client who has Crohn’s disease. Which of the following statements should the nurse include in the teaching?
77. A nurse is caring for a client who has prostate cancer. The client asks the nurse why he is having difficulty with urination. Which of the following responses should the nurse make?
78. A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should he nurse include?
79. A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching?
80. A nurse is caring for a client who is in Buck’s traction for a fractured hip. The client reports increased pain at the sited of the fracture. Which of the following actions should the nurse take?
81. A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response of the medication?
82. A nurse is collecting data from a client who has 30% body surface area partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate?
83. A nurse is reinforcing teaching with a client prior to removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching?
84. A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease plan?
85. A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hrat 1.2 cal/mL. How many calories will the client receive in 12 hr? (Round the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero.)
A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
86. A nurse is
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