& Answers) 202223
A - Answer--A nurse is receiving report on a client who is postoperative following an
open repair of Zenker's diverticulum. The nurse should anticipate the surgical incision to
be in which of the following locations? (You will find hot spots to select in the artwork
below. Select only the hot spot that corresponds to your answer.)
Hypoactive bowel sounds - Answer--A nurse is caring for a client who has a potassium
level of 3 mEq/L. Which of the following assessment findings should the nurse expect?
Wrap fingers with individual dressings. - Answer--A nurse is providing discharge
instructions to a client who has a partial-thickness burn of the hand. Which of the
following instructions should the nurse include?
Respiratory paralysis - Answer--A nurse is assessing a client following the
administration of magnesium sulfate 1 g IV bolus. For which of the following adverse
effects should the nurse monitor?
Distended neck veins - Answer--A nurse is assessing a client's hydration status. Which
of the following findings indicates fluid volume overload?
flushing - Answer--A nurse is assessing a client following the administration of IV
penicillin G. Which of the following findings should indicate to the nurse that the client is
experiencing an anaphylactic reaction?
"My joints ache because I have Lyme disease." - Answer--A nurse is providing teaching
to a client who has a severe form of stage II Lyme disease. Which of the following
statements made by the client reflects an understanding of the teaching?
, Obtain vital signs.
-if portal HTN, can develop esophageal varices, which can rupture, resulting in blood
loss. Vitals can sway that. - Answer--A nurse is caring for a client who has portal
hypertension. The client is vomiting blood mixed with food after a meal. Which of the
following actions should the nurse take first?
Swollen lips
-r/t an anaphylactic reaction to contrast media - Answer--A nurse is assessing a client
following IV urography. Which of the following findings is the priority?
"I will count my heart beats before taking this medication." - Answer--A nurse is
providing teaching to a client who has hypertension and a new prescription for
verapamil. Which of the following statements by the client indicates an understanding of
the teaching?
"I will monitor my blood pressure while taking this medication." - Answer--A nurse is
providing teaching to a client who is receiving chemotherapy and has a new prescription
for epoetin alfa. Which of the following client statements indicates an understanding of
the teaching?
Regular insulin 20 units IV bolus - Answer--A nurse is caring for a client who has
diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer?
Troponin I 8 ng/mL - Answer--A nurse is reviewing the laboratory findings of a client who
developed chest pain 6 hr ago. The nurse should identify which of the following findings
as an indication of a myocardial infarction (MI)?
Remain with the client for the first 15 min of the infusion. - Answer--A nurse is preparing
to administer a unit of packed RBCs to a client. Which of the following actions should
the nurse take?
Stone fragments in the urine - Answer--A nurse is assessing a client who had
extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings
should the nurse expect?
"Ibuprofen can cause gastrointestinal bleeding in older adult clients." - Answer--A nurse
is teaching a group of newly licensed nurses about pain management for older adult
clients. Which of the following statements by a newly licensed nurse indicates an
understanding of the teaching?