A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following
interventions should the nurse recommend?
1) Apply topical antifungal agents.
2) Apply fresh ice packs every 4 h
...
A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following
interventions should the nurse recommend?
1) Apply topical antifungal agents.
2) Apply fresh ice packs every 4 hr.
3) Wash daily with an antibacterial soap.
4) Keep draining lesions uncovered to air dry.
A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established.
Which of the following instructions should the nurse include in the teaching?
1) Empty the pouch immediately after meals.
2) Change the entire appliance once a day.
3) Limit fluid intake.
4) Avoid medications in capsule or enteric form.
A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an
escharotomy and wants to know what the procedure involves. Which of the following statements is
appropriate for the nurse to make?
1) "An escharotomy surgically removes dead tissue."
2) "A cannula will be inserted into the bone to infuse fluids and antibiotics."
3) "A piece of skin will be removed and grafted over the burned area."
4) "Large incisions will be made in the burned tissue to improve circulation."
A nurse is collecting data from a client who has a possible cataract. Which of the following
manifestations should the nurse expect the client to report?
1) Decreased color perception
2) Loss of peripheral vision
3) Bright flashes of light
4) Eyestrain
A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving
continuous gastrointestinal decompression using a nasogastric tube. Which of the following
interventions should the nurse include in the plan of care?
1) Measure abdominal girth daily.
2) Use sterile water to irrigate the nasogastric tube..
3) Maintain the client in Fowler’s position.
4) Moisten the client’s lips with lemon-glycerin swabs.
A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations
should the nurse expect to observe? (Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
4) Tremors
5) Obese extremities
A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?
1) A dry raised rash
2) Excessive salivation
3) Periorbital edema
4) Hardened skin
A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following
actions should the nurse take?
1) Instruct the client to tilt her head back when she swallows.
2) Place food on the left side of the client's mouth.
3) Add thickener to fluids.
4) Serve food at room temperature.
A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should
recognize which of the following is the priority risk to the client?
1) Airway obstruction
2) Infection
3) Fluid imbalance
4) Contractures
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine.
Which of the following instructions should the nurse include in the teaching?
1) Take the medication 45 minutes before eating.
2) Expect diaphoresis as a side effect of the neostigmine.
3) If a medication dose is missed, wait until the next scheduled dose to take the medication.
4) Treat nasal rhinitis with an over-the-counter antihistamine.
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-
way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of
the following actions should the nurse perform first?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Offer oral fluids.
4) Determine the patency of the tubing.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the
nurse if the biopsy will hurt. Which of the following responses should the nurse make?
1) "You must be very worried about what the biopsy will show."
2) "You'll be asleep for the whole biopsy procedure and won't be aware of what’s happening."
3) "Your provider scheduled this, so she will want to know you still have questions about the procedure."
4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible."
A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following
interventions should the nurse include in the plan?
1) Control impulsive behavior.
2) Compensate for left visual field deficits.
3) Re-establish communication.
4) Improve left-side motor function.
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the
following manifestations?
1) Hypotension
2) Polyphagia
3) Hyperglycemia
4) Bradycard
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