RNSG 2341 Prep U Quiz 1 Questions & Answers

RNSG 2341 Prep U Quiz 1 Questions & Answers 1. After a bronchoscopy with biopsy, the nurse assesses the client. The nurse should report which finding to the health care provider? • laryngeal stridor 2. A client has a plural chest tube following removal of the lower lobe of the lung. Two days after surgery, the tube is accidentally pulled out of the chest wall. What should the nurse do first? • Apply an occlusive dressing such as petroleum jelly gauze. 3. The client asks the nurse, “Why won’t the health care provider tell me exactly how much of my leg he is going to take off? Don’t you think I should know that?” On which information should the nurse base the response? • the adequacy of the blood supply to the tissues 4. An unlicensed assistive personnel (UAP) tells the nurse, “I think the client is confused. He keeps telling me he has to void, but that’s not possible because he has a catheter in place that is draining well.” What should the nurse tell the UAP? • "The urge to void is usually created by the large catheter, and he may be having some bladder spasms." 5. When assessing a client with advanced chronic obstructive pulmonary disease (COPD) which are expected findings? • increased anteroposterior chest diameter 6. The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. • The SpO2 and PO2 have decreased. • The client is tachycardic with drop in blood pressure. • The face has increased skin breakdown and edema. 7. The nurse is planning care for a client who has just returned to the medical-surgical unit following repair of an aortic aneurysm. What is a priority assessment for this client? • decreased urinary output 8. Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization? • Observe the puncture site for swelling and bleeding. 9. A client has had a cerebrovascular accident, which has affected the left side of the client’s brain. The nurse should assess the client for which symptom? • aphasia 10. The nurse is instructing an unlicensed assistive personnel (UAP) to collect a urine specimen from an indwelling catheter. Which statement indicates that the UAP understands the instructions? • “I’ll get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container.” 11. A client comes to the physician's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse takes this opportunity to evaluate the client's knowledge of the ordered cardiac rehabilitation program. Which evaluation statement suggests that the client needs more instruction? • "Client walks 4 miles (6.4 kilometers) in 1 hour every day." 12. A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's he ad? • elevated 30 degrees 13. After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH) as prophylaxis against tuberculosis. The client's family asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? • 6 to 12 months 14. The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will do which when eating? • Eat food on only half of the plate. 15. A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds based on the knowledge that the client’s first response to pain will be to do what? • Escape the source of pain. 16. The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used. • Ease the client to the floor. • Maintain a patent airway. • Obtain vital signs. • Record the seizure activity observed. 17. The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions? • Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice. 18. A nurse is assigned to care for a client with chest pain in the intensive care unit. The client is reading a book when the nurse observes a flat line on the monitor and the alarm rings. What is the nurse's priority intervention at this time? • assessing the client 19. A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution intravenously over 5 minutes. The client weighs 132 lb (60 kg). How many grams would the nurse administer? Record your answer as a whole number. • 12 20. A client with chronic renal failure receives hemodialysis treatments through a mature arteriovenous (AV) fistula. What intervention will the nurse include in the care plan? • Auscultate the AV fistula for a bruit. 21. A client whose condition remains stable after a myocardial infarction is to gradually increase activity. Which sign best indicates that the activity is appropriate for the client? • respiratory rate 22. A client with heart failure will take oral furosemide at home. To help the client evaluate the effectiveness of furosemide therapy, the nurse should teach the client to: • weigh daily. 23. The client is on a fluid restriction of 500 mL/day plus replacement for urine output. Because the client’s 24-hour urine output yesterday was 150 mL, the total fluid allotment for the next 24 hours is 650 mL. How should the nurses distribute this fluid over the next 24 hours? • given in small amounts throughout each shift 24. The nurse has given a client a nitroglycerin tablet sublingually for angina. Which vital signs should be assessed following administration of nitroglycerin? • blood pressure 25. A client is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left- sided heart failure? • bibasilar crackles 26. A client is receiving captopril for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals • peripheral edema. 27. Which nursing diagnosis takes highest priority for a client with hyperthyroidism? • Imbalanced nutrition: Less than body requirements related to thyroid hormone excess 28. When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of • fresh fruits. 29. A client develops decreased renal function and requires a change in antibiotic dosage. On which factor should the physician base the dosage change? • creatinine clearance 30. A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure. The client’s family asks the nurse why the client has developed acute renal failure. What should the nurse tell the family? “Because of the cardiogenic shock, there is: • a decrease in the blood flow through the kidneys.” 31. A sexually active male client has burning on urination and a milky discharge from the urethral meatus. What documentation should be included on the client’s medical record? Select all that apply. • history of unprotected sex (sex without a condom) • length of time since symptoms presented • history of fever or chills • presence of any enlarged lymph nodes on examination • allergies to any medications 32. A client with type 1 diabetes mellitus asks the nurse about taking ginseng at home. What should the nurse tell the client? • "Taking ginseng will increase the risk of hypoglycemia." 33. A client who had transurethral resection of the prostate (TURP) 2 days earlier has lower abdominal pain. What should the nurse do first? • Assess the patency of the urethral catheter. 34. A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client’s abdominal dressing is dry and intact. While sitting up in the chair, the client has severe pain and numbness in her left leg. What should the nurse do first? • Assess color and temperature of the left leg. 35. A nurse is preparing a client for an intravenous pyelography. Which action is the priority? • Assess allergies to iodine. 36. The nurse is caring for a client in the medical unit. The nurse receives a health care provider’s order for hydrocortisone 100 mg intravenously at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse understands that this treatment is common in clients with which disease process? • Addison’s disease 37. A client with a ventricular dysrhythmia is receiving intravenous lidocaine. For which assessment finding should the nurse suspect the client is experiencing toxicity from the medication? • confusion and restlessness 38. The nurse is teaching a client about levothyroxine. Which instruction should a nurse offer the client? • "Take the drug on an empty stomach." 39. A client is returned to the hospital room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside? • tracheostomy set 40. A nurse records a client’s fingerstick blood glucose level and gives 2 units of regular insulin as ordered. At the next scheduled blood glucose assessment, the nurse realizes that the wrong client was tested and given insulin. What is the nurse's priority action related to this incident? • Assess both clients, and call the appropriate healthcare providers to notify them of the errors. 41. Which statement would lead the nurse to determine that a client lacks understanding of the client’s acute cardiac illness and the ability to make lifestyle changes? • “I already have my airline ticket, so I won’t miss my meeting tomorrow.” 42. A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by: • showing the location of the obstruction and the collateral circulation. 43. A client with peripheral artery disease has femoral-popliteal bypass surgery. What goal should the nurse establish with the client immediately after surgery? • Maintain circulation. 44. A client with heart failure is taking furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first- degree atrioventricular block. What other sign should the nurse assess next? • digoxin toxicity. 45. A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement by the nurse best explains the procedure to the client? • ”PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter.” 46. A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. The client's cholesterol profile is as follows: total cholesterol 265 mg/dl (6.845 mmol/L), low-density lipoprotein (LDL) 139 mg/dl (3.603 mmol/L), and high-density lipoprotein (HDL) 32 mg/dl (0.829 mmol/L). The client asks the nurse how to lower their cholesterol. The nurse should tell the client that • the nurse willll ask the dietitian to talk with the client about modifying their diet. 47. Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion site, and the pressure device is removed. The nurse should plan to safely remove the femoral sheath when the partial thromboplastin time (PTT) is: • 50 seconds or less. 48. One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. What should the nurse instruct the client to do to achieve this goal? • Stop smoking. 49. Which client is at risk for pulmonary embolism? A client with: • deep vein thrombosis (DVT). 50. While the nurse is assisting a client to ambulate as part of a cardiac rehabilitation program, the client has midsternal burning. What should the nurse do next? • Stop and assess the client further. 51. A physician orders gentamicin sulfate, 80 mg I.V. every 8 hours for a client with Pseudomonas aeruginosa. The nurse should infuse this drug over at least: • 30 minutes. 52. A staff member on the transplant unit is having problems logging into the computer to chart client information. The staff member asks a nurse for their personal identification number (PIN) to log in. What is the nurse's best response? • "I'll be happy to contact Information Services to assist you with the problem." 53. A client is receiving a unit of packed red blood cells. Before the transfusion started, the client’s blood pressure was 90/50 mm Hg, pulse rate 100 bpm, respirations 20 breaths/min, and temperature 98°F (36.7°C). Fifteen minutes after the transfusion starts, the client’s blood pressure is 92/54 mm Hg, pulse 100 bpm, respirations 18 breaths/min, and temperature is 101.4°F (38.6°C). What should the nurse do first? • Stop the transfusion. 54. A client is receiving a transfusion of packed red blood cells. What should the nurse do to safely administer the blood? • Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction. 55. The nurse is teaching a client about insulin administration. Which statement if made by a client would indicate to the nurse the client understands insulin administration teaching? • "I will use my abdominal injection site if I want to jog." 56. Which indicator is the best for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement? • daily weight 57. Which information should the nurse include in the teaching plan of a female client with bilateral adrenalectomy? • The client will need steroid replacement for the rest of her life. 58. What should the nurse teach the client with neutropenia to avoid? • using suppositories or enemas 59. When developing a teaching plan for women about human immunodeficiency virus (HIV) transmission, the nurse should instruct the group that to reduce the risk of transmission they should: • use latex condoms with sexual intercourse. 60. A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption? • intrinsic factor 61. A nurse is caring for a client who was recently diagnosed with hyperparathyroidism. Which statement by the client indicates the need for additional discharge teaching? • "I will increase my fluid and calcium intake." 62. Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer? • using sterile technique during the dressing change 63. A homeless client is brought to the emergency department by the police after being found unconscious on the street. Following examination and evaluation of laboratory test results, a diagnosis of diabetic ketoacidosis is confirmed. Which information is most crucial to document on the client’s medical record? Select all that apply. • size of pupils and reaction of pupils to light • response to verbal and painful stimuli • skin condition and presence of any rashes, lesions, or ulcers • blood pressure • hourly urine output 64. Which results would indicate that levothyroxine sodium is effectively resolving the symptoms of a client with hypothyroidism? • increased energy, weight loss, and a higher temperature and pulse rate 65. A multidisciplinary oncology team of health care providers, nurses, and the social worker notes that a client who has been undergoing chemotherapy is now experiencing pancytopenia. When reviewing the laboratory data, which values support this diagnosis? Select all that apply. • decreased white blood cells • decreased platelets • decreased RBCs 66. Before supper, an adult client who has type 2 diabetes and requires insulin tells the nurse about having tremors and being weak and anxious. What should the nurse do next? • Have the client drink a glass of milk or orange juice. 67. The client presents to the clinic with severe anemia, and is a Jehovah's Witness with religious beliefs that prohibit the administration of blood products. Which concurrent medications does the nurse teach the client about when receiving blood products? Select all that apply. • epoetin alfa • ferrous sulfate 68. The registered nurse (RN) must assign an unlicensed assistive personnel (UAP) to help care for an oncology client who is on neutropenic precautions. Which factor is most important in making this assignment? • The UAP has had cold symptoms for the last 2 days. 69. A family member of a client who is human immunodeficiency virus (HIV) positive is concerned about the possibility of also being HIV positive. What is the best response by the nurse? • "What's your understanding about how HIV is transmitted?" 70. A nurse is discussing nutrition and weight control with clients during a class about diabetes. Which statement best reflects the purpose of nutritional management of diabetes? • to maintain blood glucose levels close to the normal range to reduce risk for long-term complications 71. Following cardiac bypass surgery, the client has been referred to a cardiac rehabilitation exercise program. The client has type 1 diabetes and has bilateral leg discomfort with walking. The client is exercising using a stationary bicycle. The nurse should evaluate the client’s response to exercise by assessing the presence of which condition? • diabetic neuropathy 72. The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? • confusion, urine output 15 mL over the last 2 hours, orthopnea 73. A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect? • The number of premature ventricular contractions is decreasing. 74. The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first? • Assess the client's orientation and vital signs. 75. Which factor is most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection? • amount of subcutaneous tissue 76. A nurse is reviewing laboratory values for a client diagnosed with hyperlipidemia 6 months ago. Which results indicate that the client has been following their therapeutic regimen? • High density lipoproteins (HDL) increase from 25 mg/dl (0.65 mmol/L) to 40 mg/dl (1.03 mmol/L). 77. The most common site of aneurysm formation is in the • abdominal aorta, just below the renal arteries. 78. Which assessment data should a nurse use to monitor the respiratory status of a client with pulmonary edema? • arterial blood gas (ABG) analysis 79. A client is taking spironolactone to control hypertension. The client's serum potassium level is [6 mEq/L (56mmol/L)]. For this client, the nurse's priority should be to assess their • electrocardiogram (ECG) results. 80. A nurse visits the employee health department because of mild itching and a rash on both hands. During the assessment interview, the employee health nurse should focus on • chemical and latex glove use. 81. When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? • hoarseness of the voice 82. The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next? • Reposition the client off the reddened skin and reassess in a few hours. 83. A physician orders digoxin for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity? • potassium level of 3.1 mEq/L (3.1 mmol/L) 84. A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care? • A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. 85. The nurse is admitting a client who takes digoxin daily, reported seeing green halos around the lights, and has not wanted to eat breakfast. The laboratory report shows that serum sodium = 135 mEq/L, potassium = 3.2 mEq/L, magnesium = 2.5 mg/dL, and calcium = 10.2 mg/dL. Which nursing action is appropriate? • Administer a potassium supplement. 86. A client with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which action should the nurse take? • Assess oxygen saturation using pulse oximetry. 87. The nurse is planning the order of client assessments at the beginning of the shift based on the risk for skin breakdown each client presents. The nurse should assess the clients in which order? All options must be used. • a paraplegic client admitted with dehydration and ordered bedrest • an older adult client with a diagnosis of left hip fracture • a client with diverticulitis who is occasionally incontinent • a client with sickle cell disease who is reporting pain 88. A nurse in the telemetry unit is caring for a client with diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect? • pericardial tamponade 89. The nurse is working as charge on a medical-surgical unit. The nurse is providing orientation for a newly hired RN. Which action by the new RN requires immediate attention? • administering oral tetracycline with milk to a client with cellulitis 90. A client with right-sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity? • Turn the client regularly. 91. A client diagnosed with idiopathic thrombocytopenia purpura needs a peripherally inserted central catheter (PICC) placed. When explaining the catheter to the client, the nurse explains that one advantage of a catheter is that it can be used • to provide long-term access to central veins. 92. A client with iron deficiency anemia is taking iron supplements. What nutrient should the nurse instruct the client to take the supplements with in order to increase the absorption of iron? • orange juice 93. The teaching plan for the client with rheumatoid arthritis includes rest promotion. What position of the involved joints should the nurse tell the client to avoid when at rest? • maintaining the joints in a flexed position 94. A nurse is to give a client heparin 8,000 units subcutaneously. The available vial is 10,000 units/mL. How many milliliters should the nurse draw up into the syringe? Record your answer using one decimal place. • 0.8 95. The nurse is caring for a client who has a history of aplastic anemia. Which information from the nursing history indicates that the anemia is not being managed effectively? • pallor of the skin and mucous membranes 96. A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority? • Risk for injury 97. A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client? • Use the smallest needle possible for injections. 98. Which client is most likely to develop systemic lupus erythematosus (SLE)? • a 27-year-old black female 99. The nurse should assess a client for which complications associated with disseminated intravascular coagulation (DIC)? • pulmonary embolism 100. A client with a pleural effusion has a diagnostic thoracentesis. The nurse notifies the healthcare provider immediately upon discovering what assessment finding? • asymmetrical chest expansion 101. After receiving an oral dose of codeine for an intractable cough, a client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond? • 30 minutes 102. When teaching a client with chronic obstructive pulmonary disease to conserve energy to conserve energy, what instruction should the nurse give the client about breathing when lifting heavy objects? Lift the object by: • exhaling through pursed lips. 103. teaching a client how to instill nose drops, the nurse evaluates that the client’s technique is correct when the client: • lies supine for several minutes after instilling the drops. 104. A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease? • azithromycin 105. While making rounds, the nurse finds a client with chronic obstructive pulmonary disease sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, what should the nurse do next? • Open the client's airway. 106. A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) who is being discharged after treatment for an acute exacerbation. Which statement by the client indicates proper understanding of the discharge instructions? • “I should try to eat several small meals during the day.” 107. A client’s pulmonary function tests note an increased residual volume and a decreased vital capacity. Which is the best nursing diagnosis? • risk for activity intolerance 108. A nurse is reviewing the medications used by a client who has chronic bronchitis and a history of high blood pressure and prostate enlargement. The nurse should verify that the client understands how to use which medications? Select all that apply. • guaifenesin with dextromethorphan liquid • generic pseudoephedrine tablets 109. The nurse has received a change of shift report on clients. Which client should the nurse assess first? • a client with asthma with respirations of 36 breaths/min whose wheezing has diminished 110. The nurse is caring for a client that is having an anaphylactic reaction. The client is wheezing, dyspneic, and cyanotic. Place the interventions in chronological order. All options must be used. • Provide supplemental oxygen. • Administer epinephrine 1:1000 subcutaneously. • Start a peripheral IV. • Administer normal saline. • Document interventions and response to treatment. • Educate the client about prevention of anaphylaxis. 111. A client requires long-term ventilator therapy. The client has a tracheostomy in place and requires frequent suctioning. Which technique should the nurse use? • intermittent suction while withdrawing the catheter 112. A nurse is caring for a client on mechanical ventilation who's restless and trying to remove the endotracheal (ET) tube. Which action should the nurse perform next? • Assess the client for pain and medicate as appropriate. 113. The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority? • teaching the client about the disease and its treatment 114. The nurse is preparing to suction a tracheostomy for a client with methicillin-resistant Staphylococcus aureus (MRSA) (see figure). What should the nurse do next? • Proceed to suction the client’s tracheostomy. 115. A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs? • Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation. 116. A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? • Suction the client's artificial airway. 117. A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? • Use diaphragmatic breathing. 118. As status asthmaticus worsens, the nurse would expect which acid–base imbalance? • respiratory acidosis 119. The nurse evaluates the client's understanding of nutritional modifications to manage hypertension. The nurse knows the teaching was successful when the client makes what statement? • "Limiting my salt intake to 2 grams per day will lower my blood pressure." 120. The nurse is completing the preoperative checklist for a client going to surgery. Which client statement would be of the most concern to the nurse and require that the surgeon be notified immediately? • “I had a few sips of water with dabagatran this morning.” 121. The nurse is caring for a client with cystic fibrosis (CF) who has increased dyspnea. Which intervention should the nurse include in the plan of care? • Perform chest physiotherapy. 122. A client comes to the emergency department with symptoms of chest pain radiating down the left arm, dyspnea, and diaphoresis. An electrocardiogram (EKG) shows ST segment elevation and the client is diagnosed with an ST segment-elevation myocardial infarction (STEMI). To determine if the client is a candidate for thrombolytic therapy, which question should the nurse ask? • “What time did your chest pain start?” 123. The nurse is assessing a client with an atrial septal defect (ASD). Which finding requires immediate nursing intervention? • client having an uneven smile and facial droop 124. When a client has a troponin level of 0.9 ng/mL, which nursing intervention should be implemented? • Notify the healthcare provider. 125. A client returns from a left heart catheterization. The right groin was used for catheter access. In which location should the nurse palpate the distal pulse on this client? • dorsal surface of the right foot 126. A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden onset of shortness of breath and chest pain that increases with a deep breath. What should the nurse do first? • Assess the oxygen saturation. 127. The nurse is evaluating an electrocardiogram (ECG) tracing. Which graphic shows the QT interval? 128. A home care nurse is making the initial home visit to a client with lung cancer who had a peripherally inserted central catheter placed during hospitalization for an upper respiratory infection. During the visit, the nurse must administer an antibiotic, teach the client how to care for the catheter, and provide information about when to notify the home care agency and physician. When the nurse arrives at the client's home, the client's face is flushed and he complains of feeling tired. Which actions should the nurse take first? • Obtain the client's vital signs and assess breath sounds. 129. A client diagnosed with ulcerative colitis also experiences obsessive compulsive anxiety disorder (OCD). In helping the client understand her illness, the nurse should respond with which statement? • "It’s possible that your desire to have everything be perfect has caused stress that may have worsened your colitis, but there is no proof that either disorder caused the other." 130. The nurse is developing a plan of care for a client who has joint stiffness due to rheumatoid arthritis. Which measure will be the most effective in relieving stiffness? • a warm shower before performing activities of daily living 131. Allopurinol is prescribed for a client who has chronic gout. Which comment indicates that the client understands how to take the allopurinol? • "I should drink plenty of fluids when taking allopurinol. 132. A client’s stools are light gray in color. What additional information should the nurse obtain from the client? Select all that apply. • intolerance to fatty foods • fever • jaundice 133. Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? • anaphylactic reaction 134. Which nursing recommendation is most appropriate for a client to decrease discomfort from hemorrhoids? • Use warm sitz baths. 135. To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? • "Avoid coffee and alcoholic beverages." 136. A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? • Acute pain related to biliary spasms 137. The nurse is caring for a client that has undergone a colon resection. While turning the client, wound dehiscence with evisceration occurs. What is the nurse's first response? • Place saline-soaked sterile dressings on the wound. 138. A nurse asks a client who had abdominal surgery 3 days ago if they have moved their bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene? • Encourage the client to ambulate at least three times per day. 139. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? • platelet count, prothrombin time, and partial thromboplastin time 140. The couple with the lowest risk of having a child with sickle cell anemia disease is the one in which the • father is HbA and the mother is HbS. 141. The nurse is instructing the client with a new colostomy about protecting the skin around the colostomy. Which skin barrier should the nurse tell the client is best to apply around the colostomy? • adhesive skin barrier 142. A client has vomited several times over the past 12 hours. The nurse should recognize the risk of what complication? • metabolic alkalosis 143. A nurse is caring for several clients on an oncology unit. Which client should the nurse see first? • client with a white blood cell count of 2000 µL 144. The nurse is developing a care plan for a client who has had radiation therapy for Hodgkin’s lymphoma. What is the primary goal of care for this client? • Prevent infection. 145. A client had a colon resection yesterday. The client’s hemoglobin was 14.1 g/dL yesterday and today it is 7.2 g/dL. The client’s oxygen saturation is 87%. After reviewing the chart (see chart) and notifying the health care provider (HCP), what should the nurse do first? • Administer oxygen at 2 liters per minute. 146. Two days following a colon resection, an elderly client shows new onset of confusion. When contacting the health care provider, the nurse should make which recommendation? • “Shall I collect and send a urine sample for culture and sensitivity?” 147. On the fourth day after surgery, a client’s incision is red and inflamed. There is moderate drainage from the incision. The client has a temperature of 102°F (38.9°C). The total white blood cell (WBC) count is 10,000/mm 3 (10 × 109/L). What should the nurse do first? • Notify the health care provider (HCP). 148. A client takes prednisone, as ordered, for rheumatoid arthritis. During follow-up visits, the nurse should assess the client for common adverse reactions to this drug, such as • fluid retention and weight gain. 149. A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation? • Offer a face mask to the person with the cold and use this as an opportunity for further teaching. 150. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m. (1400), the client has a capillary glucose level of 250 mg/dl for which the client receives 8 units of regular insulin. The nurse should expect the dose's • onset to be at 2:30 p.m. (1430) and its peak to be at 4 p.m.(1600). 151. A client with severe arthritis has been receiving maintenance therapy of prednisone 10 mg/day for the past 6 weeks. The nurse should instruct the client to immediately report which symptom? • respiratory infection 152. A parent asks the nurse if a child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which principle? • Children with iron deficiency anemia are more susceptible to infection than are other children. 153. The nurse is developing a teaching plan the client with viral hepatitis. What information should the nurse include in the plan? • Obtain adequate bed rest. 154. When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which physiologic functions? • bleeding tendencies 155. The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following? • Reed-Sternberg cells. 156. The nurse has been assigned to a client who has had diabetes for 10 years. The nurse gives the client's usual dose of regular insulin at 7 a.m. At 10:30 a.m., the client has light-headedness and sweating. The nurse should contact the physician, report the situation, background, and assessment, and recommend intervention for: • Hypoglycemia. 157. An elderly client who is receiving steroids has secondary diabetes and chronic kidney disease (CKD) and takes insulin. The client has had episodes of hypoglycemia. The nurse should: • continue to monitor the client's blood glucose values. 158. The nurse is caring for a client with multiple organ failure who is in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? • lungs and kidneys 159. The nurse is teaching a client with type I diabetes self-administration of insu