ALL RN Adult Medical Surgical ATI Tested & Approved Test Prep Study Materials; Validate your Skills with Updated 2021/2022 Test Prep Exam Questions & Answers and Test Engine

ALL RN Adult Medical Surgical ATI Tested & Approved Test Prep Study Materials; Validate your Skills with Updated 2021/2022 Test Prep Exam Questions & Answers and Test Engine ALL RN Adult Medical Surgical ATI Tested & Approved Test Prep Study Materials; Validate your Skills with Updated 2021/2022 Test Prep Exam Questions & Answers and Test Engine RN Adult Med Surg A, Med Surg B, ATI MED SURG, ATI A, ATI B, ATI C A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching? (Correct ans) - Drink 240 mL (8 oz) of water after administration 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? (correct ans) - Glucose 272 mg/dL A nurse is admitting a client who has active TB. Which of the following types of transmission precautions should the nurse initiate? (correct ans) - Airborne A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching? (correct ans) - Holding breath for 10 secs after inhaling A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? (correct ans) - image of a smooth red tongue A nurse on a medsurg unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires re-evaluation of the IV therapy prescription? (correct ans) - BUNA 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? (correct ans) - Restlessness A nurse is receiving report on a client who is postop following an open repair of Zenker's diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations? (correct ans) - A 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? (correct ans) - Ibuprofen can cause gastrointestinal bleeding in older adult clients 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? (correct ans) - Hypertension A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5mL. how many mL should the nurse administer? (correct ans) - 24 mL A nurse is checking the ECG rhythm strip for a client who has temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? (correct ans) - Document that depolarization has occurred A nurse is providing discharge instructions to a client who has active TB. Which of the following information should the nurse include in the instructions? (correct ans) - Sputum specimens are necessary every 2 to 4 weeks until there are 3 negative cultures A nurse is providing preop teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make? (correct ans) - I will refer you to community resources that can provide support A nurse is assessing a client who is postop following a TURP and notes clots in the clients indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? (correct ans) - Irrigate the indwelling urinary catheter A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? (correct ans) - Hair loss on the lower legsA nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? (correct ans) - Use crutches with rubber tips A nurse is reviewing the lab results of a client who has aplastic anemia. Which of the following findings indicates a potential complication? (correct ans) - WBC count 2,000/mm A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect? (correct ans) - constipation A nurse is caring for a client who is receiving TPN and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following acions should the nurse take? (correct ans) - Contact the provider to clarify the prescription A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? (correct ans) - Alternate application of heat and cold to the affected joints A nurse is caring for a client who is 8 hr postop following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? (correct ans) - Scan the bladder with a portable ultrasound A nurse is providing postop teaching for a client who had a total knee arthroplasty. Which if the following instruction should the nurse include? (correct ans) - Flex the foot every hour when awake A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis? (correct ans) - Prednisone A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? (correct ans) - Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hour period A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload? (correct ans) - distended neck veins A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client?(correct ans) - Scan the environment by turning your head from side to side A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following lab values is a manifestation of osteomyelitis and should be reported to the provider? (correct ans) - Sedimentation rate A nurse is caring for a client who has a positive culture for MRSA. Which of the following actions should the nurse take? (correct ans) - Bathe the client using chlorhexidine solution A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? (correct ans) - Low urine specific gravity A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer? (correct ans) - dyspnea A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bass. Which of the following acitons should the nurse anticipate taking? (correct ans) - Slow the infusion rate A nurse is assessing a client who is postop following a thyroidectomy. Which of the following findings is the nurses priority? (correct ans) - Temperature 102 A nurse is providing education to a client who has TB and their family. Which of the following information should the nurse include in the teaching? (correct ans) - Family members in the household should undergo TB testing A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing AD? (correct ans) - heart rate 52 A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take (correct ans) - Place a pressure bag around the flush solution A nurse is providing teaching to a client who has AIDS. Which of the following statement by the client indicates an understanding of the teaching? (correct ans) - I will take my temp once a day A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care(correct ans) - Place personal items, such as pictures, at the client's bedside A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? (correct ans) - Ginkgo biloba can cause an increased risk for bleeding A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client meds is a contraindication for the surgery and notify the provider (correct ans) - warfarin A PACU nurse is assessing a client who is postop following a right nephrectomy. The client's initial vital signs were heart rate 80/min, BP 130/70, RR 16/min, and temp 96.8. which of the following vital sign changes should alert the nurse that the client might be hemorrhaging (correct ans) - HR 110 A nurse is reviewing the lab results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? (correct ans) - BUN 34 A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates and understanding of the teaching? (correct ans) - I will eat more high-fiber foods A nurse is caring for a client who has increased ICP and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication? (correct ans) - Crackles heard on auscultation 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? (correct ans) - Keep a lead-lined container in the client's room A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? (correct ans) - PaCO2 56 A home health nurse is providing teaching to a client who has stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? (correct ans) - Change positions every hour A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? (correct ans) - Report of sore throat A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? (correct ans) - Walk for 30 mins 4XweekA 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 (correct ans) - Increase fiber intake to avoid constipation A nurse is caring for a client who is receiving mechanical via a trah tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? (correct ans) - stress ulcers A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitors. Which of the following statements by the client reflects and understanding of the teaching? (correct ans) - This identifies if the pacemaker cells of my heart are working properly A nurse is caring for a client who is 4 hr postop following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? (correct ans) - Extremity cool upon palpation A nurse is reviewing the medical record of a client who is taking warfarin for chronic A. Fib. Which of the values should the nurse identify as a desired outcome for this therapy (correct ans) - INR 2.5 A nurse is providing discharge teaching to a client who is to self-administer heparin subcu. Which of the following statements by the client indicates an understanding of the teaching? (correct ans) - I will use an electric razor to shave 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 (correct ans) - My joints ache because I have lyme disease A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority? (correct ans) - Applying oxygen via face mask A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? (correct ans) - Serum creatinine A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? (correct ans) - I will avoid direct exposure to the sun A nurse is planning care for a client who is postop following a laparotomy and has a closedsuction drain. Which of the following actions should the nurse take to manage the drain? (correct ans) - Compress the drain reservoir after emptyingA nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider? (correct ans) - The client reports back pain A nurse is evaluating the plan of care for 4 clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? (correct ans) - A client who is postop following abdominal surgery and reports feeling that something "pooped" when they coughed A nurse is caring for a client following extubation of an ET tube 10 min ago. Which of the following findings should the nurse report to the provider immediately? (correct ans) - stridor 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? (correct ans) - Bubbling in the water seal chamber has ceased A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? (correct ans) - The client's heart rate increases A nurse is caring for a client who is having a tonic-clonic seizure while in bed and has become cyanotic. Which of the following actions should the nurse take? (SATA) (correct ans) - -prepare to suction the client's airway -loosen restrictive clothing 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? (correct ans) - I will no longer floss my teeth after brushing A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? (correct ans) - Hemodialysis is sometimes required following surgery A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their catheter. Which of the following actions should nurse take to avoid restraining the client? (correct ans) - Keep the client occupied with a manual activity A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? (correct ans) - Encourage the client to take deep breaths after the procedure A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include?(SATA) (correct ans) - -follow a smoking cessation program -maintain an appropriate weight-eat a low-fat diet A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for a brachytherapy. Which of the following instructions should the nurse include? (correct ans) - You will need to stay in the bed during each treatment session A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first? (correct ans) - Check for the type and number of units of blood to administer A nurse is reviewing the lab 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 MI? (correct ans) - triponin 75. A nurse is performing a preop assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? (correct ans) - avocados A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry."." Which of the following actions is the nurse's priority? (correct ans) - Check the client's neuro status A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching? (correct ans) - Create complete outfits and allow the client to select one each day A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of the condition? (correct ans) - Pain that increases with passive movement 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? (SATA) (correct ans) - -calf pain -numbness in the arms -intense headache a nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to the audio clip. (correct ans) - Pericardial friction rub A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant IBS. Which of the following instructions should the nurse include in the teaching? (correct ans) - 2. Consume atleast 30 g of fiber daily A nurse is providing discharge teaching to a client who is postop following a modified radical mastectomy. Which of the following instructions should the nurse include? (correct ans) - Numbness can occur along the inside of the affected armA nurse is administered packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? (correct ans) - Low back pain and apprehension A nurse is teaching a client about the use of TENS for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? (correct ans) - A tingling sensation replacing the pain A nurse is caring for a client who has breast cancer and tells the nurse they would like to have acupuncture because it provides greater relief than pain medication. Which of the following statements should the nurse make? (correct ans) - I can speak to the provider about incorporating acupuncture into you treatment plan A nurse is caring for a client who has DKA. Which of the following should the nurse plan to administer? (correct ans) - Regular insulin 20 units IV bolus A nurse is reviewing the medical record of a client who has SLE. Which of the following findings should the nurse expect? (correct ans) - Facial butterfly rash A nurse is planning care for a client who is postop following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? (correct ans) - Place a tracheostomy tray at the bedside A nurse is caring for a client who has terminal cancer. The client tells thenurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make? (correct ans) - Discontinuing with the treatments is your choice if it is your wish to do so A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (correct ans) - 1) administer oxygen 2)initiate IV therapy 3)insert an NG tube 4)administer ranitidine A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first? (correct ans) - check for the type and number of units of blood to administer a nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching? (correct ans) - I am dieting to lose weight A nurse is providing instructions to a client who has type 2 diabetes and a new prescription of metformin. Which of the following statements by the client indicates an understanding of the teaching? (correct ans) - I should take this medication with a meala nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding if the teaching? (correct ans) - i am taking this medication to increase my energy level a nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication? (correct ans) - orthostatic hypotension a nurse is caring for a client who has hypothyroidism. which of the following manifestations should the nurse expect? (correct ans) - constipation a charge nurse is instructing a newly licensed nurse about caring for a client who has MRSA. which of the following statements by the new nurse indicates an understanding of the teaching? (correct ans) - i will leave assessment equipment in the room to use on this patient a nurse is providing teaching to a client who has irritable bowel syndrome (IBS). which of the following instructions should the nurse include in the teaching? (correct ans) - increase fiber intake to at least 30 g/day a nurse is caring for a client who has a positive culture for c. diff. which of the following actions should the nurse take? (correct ans) - implement contact precautions for the client a nurse is caring for a client who has a new diagnosis of hyperthyroidism. which of the following is the priority assessment finding that the nurse should report to the provider? (correct ans) - BP 170/80 a nurse is planning care for a client who is scheduled for a throacentesis. which of the following interventions should the nurse include in the plan? (correct ans) - encourage the client to take deep breaths after the procedure a nurse is assessing a client who has had a suspected cerebrovascular accident. the nurse should place the priority on which of the following findings? (correct ans) - dysphagia a nurse is reviewing the ABG results of a client who has advanced COPD. which of the following results should the nurse expect? (correct ans) - PaCO2 56 a nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation treatment. which of the following statements by the client indicates an understanding of the teaching? (correct ans) - i will avoid direct exposure to the sun a nurse is assessing for compartment syndrome in a client who has a short leg cast. which of the following findings should the nurse identify as a manifestation of this condition? (correct ans) - pain that increases with passive movementa nurse is providing teaching to a client who has a gastric ulcer a d a new prescription for omeprazole. the nurse should instruct the client that the medication provides relief by which of the following actions. (correct ans) - suppressing gastric acid production a nurse is assessing a client who has peripheral arterial disease. which of the following findings should the nurse expect? (correct ans) - hair loss on the lower legs 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? (correct ans) - restlessness a nurse is reviewing the medical record of a client who has osteomyelitis and a prescription of gentamicin. which of the following findings from the client's medical record should indicate to the nurse the need to withhold the med? (correct ans) - serum creatinine a nurse is reviewing the medical record of a client who has SLE. which of the following findings should the nurse expect? (correct ans) - facial butterfly rash a nurse is providing teaching to a client who has a new prescription for psyllium. which of the following information should the nurse include in the teaching? (correct ans) - drink 240 mL of water after administration a nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent her headaches. the nurse should identify that which of the following client meds interacts with feverfew? (correct ans) - naproxen a nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. which of the following statements should the nurse make? (correct ans) - you will not be able to use sildenfil if you are taking nitroglycerin a nurse is caring for a client who is receiving TPN. a new bag is not available when the current infusion is nearly completed. which of the following actions should the nurse take? (correct ans) - administer dextrose 10% in water until the new bag arrives a nurse is providing discharge teaching to a client who has HF and a new prescription for a potassium-sparing diuretic. which of the following information should the nurse include in the teaching? (correct ans) - try to walk at least 3 times per week for exercise a nurse is planning care for a client who is postop following a laparotomy and has a closedsuction drain. which of the following actions should the nurse take to manage the drain? (correct ans) - compress the drain reservoir after emptying a nurse in an emergency department is admitting a client who reports dyspnea and SOB. which of the following actions is the priority for the nurse to perform prior to administering oxygen? (correct ans) - determine if the client has a history of COPDa nurse is obtaining a med history from a client who is scheduled to undergo cataract surgery. the nurse should recognize that which of the following client meds is a contraindication for the surgery and notify the provider? (correct ans) - warfarin a nurse is caring for a client following extubation of her endotracheal tube 10 min ago. which of the following findings should the nurse report to the provider immediately (correct ans) - stridor a nurse is providing dietary teaching to a client who is postop following a thyroidectomy with removal of the parathyroid glands. the nurse should instruct the client to include which of the following foods to increase calcium in the diet? (correct ans) - 12 almonds a nurse is preparing to assist with the insertion of a nontunneled percutaneous central venous catheter into a subclavian vein. the nurse should plan to place the client in which of the following positions? (correct ans) - trendelenburg teaching to client with HTN and new med verapamil. what juice should client avoid? (correct ans) - grapefruit client experiencing anaphylactic reaction, after patent airway, which is priority nursing intervention? (correct ans) - apply oxygen vi face mask client had nephrostomy tube inserted 12hrs ago. what should the nurse report to the provider? (correct ans) - client reports back pain teaching to perimenopausal and has hormone replacement therapy. adverse effects to notify provider? (correct ans) - calf pain, numbness in arms, and intense headache older adult with cancer and a new prescription of opioid analgesic. which info should the nurse include in teaching? (correct ans) - you should increase your fiber intake to prevent constipation a nurse is providing med teaching to a group with seizure disorders. instruction about phenytoin? (correct ans) - phenytoin decreases the effectiveness of oral contraceptives a nurse is caring for client with supraventricular tachycardia. which action should nurse take next? (correct ans) - perform synchronized cardioversion change of shift report with four clients. client with greatest risk of developing infection? (correct ans) - COPD and receiving steroid therapy teach with self administration of heparin? (correct ans) - use electric razor client having seizure, nurse priority? (correct ans) - turn client on the side female client with hx of UTI, nurse include in teaching ? (correct ans) - clean perineum front to backcardiac assessment with MI 2 days ago. action after hearing this sound? (correct ans) - listen with client on left side client on bed rest and enoxaparin subcut, actions nurse take? (correct ans) - administer med at the same time each day postop following parathyroidectomy. priority action? (correct ans) - place a trach tray at bedside pt with arterial line, following actions should nurse taking? (correct ans) - place a pressure bag around the flush solution teaching client about a fib and purpose of wearing a holter monitor. info should nurse include in the teaching? (correct ans) - this device can detect when you have an irregular HR client with DKA, client condition improving? (correct ans) - glucose 272 stroke on right hemisphere. nurse expect? (correct ans) - impulsive behavior client who has external fixation device for fracture. instruction for nurse plan of care? (correct ans) - use crutches with rubber tips receiving mechanical ventilation via trach tube. nurse recognizes complications with long term mechanical ventilation? (correct ans) - stress ulcers teaching about asthma use of metered-dose inhaler. understand teaching? (correct ans) - holding breath for 10 secs after inhaling graves disease, picture with exophthalmos? (correct ans) - big eyes, last picture leg cast and demonstration w/crutches on climbing stairs. identify steps (correct ans) - body weight on crutches, advance unaffected leg onto stair, shift weight from crutch to unaffected, bring crutches and affected leg up to the stair older adult with fractured wrist following fall. last week i crashed my car bc my vision suddenly blurry. (correct ans) - check for neuro status performing dressing change recovering from hemicolectomy. large part of bowel is protruding, action take first? (correct ans) - call for help older adult about osteoporosis prevention. meds increase risk for developing osteoporosis? (correct ans) - fludrocortisone client having modified radical mastectomy of right breast. intervention for plan of care? (correct ans) - instruct the client that the drain is removed when there is 25mL of output or less over a 24hr periodclient with anemia and a prescription for an oral iron supplement. which of the following statements by teaching? (correct ans) - i will eat more high fiber foods program about prevention of atherosclerosis at health fair. recommendations plan to include? (correct ans) - follow smoking cessation, maintain appropriate weight, eat low fat diet TPN 2000kcal per day. 500kcal/L; mL/hr (correct ans) - 167 client with chronic glomerulonephritis with oliguria. manifestation? (correct ans) - hyperkalemia reviewing lab results with aplastic anemia. potential complication? (correct ans) - WBC 2,000/mm3 ED with full thickness burns over 20% of total body surface. administer first after patent airway and administer O2? (correct ans) - IV fluids client with UTI and prescription ciprofloxacin. instructions? (correct ans) - avoid taking magnesium containing antacids with this med teaching with AIDS. understanding of teaching? (correct ans) - i will take my temp once a day compound fracture 3 weeks ago, unexpected finding lab value of manifestation of osteomyelitis and report to provider? (correct ans) - sedimentation rate bilateral pneumonia, client is dyspneic with productive cough. action nurse take first? (correct ans) - place the client in high-fowlers position client who is hypokalemia. manifestations? (correct ans) - decreased peristalsis client with suctioning the clients trach tube. indication for hypoxia? (correct ans) - the clients HR increases med hx who undergo allergy testing. nurse should discontinue which med before testing? (correct ans) - prednisone client with type 1 DM and new prescription for insulin lispro. understands teaching? (correct ans) - i will need to take the lispro in addition to my other prescribed insulin. client postop total hip arthroplasty. lab value should nurse report? (correct ans) - hgb 8g/dL checking ECG rhythm strip for client has temp pacemaker. spike followed by QRS complex. Action take first? (correct ans) - document the depolarization has occured ED client reports vomiting and diarrhea past 3 days. findings client experience fluid volume deficit? (correct ans) - HR 110/minPACU nurse client postop right nephrectomy. VS changes alert nurse client might be hemorrhaging? (correct ans) - HR 110/min ED planning care for flail chest on right side in motor vehicle crash. action plan to take? (correct ans) - prepare the client for positive pressure ventiliation providing discharge w patient with active TB, nurse teach? (correct ans) - sputum specimens are necessary every 2-4 wks until there are three neg cultures client who is 12hr postop following total hip arthroplasty. action nurse take? (correct ans) - place a pillow between the client's legs reviewing lab results w client has acute leukemia. expected finding? (correct ans) - increased WBC count client has venous insufficiency about self-care. client understands teaching? (correct ans) - i will wear clean graduated compression stockings every day client has end stage kidney disease about organ donation. nurse include in teaching? (correct ans) - the client who receives a kidney from a live donor has a lower rate of transplant rejection client is exhibiting manifestations of a febrile reaction while receiving blood transfusion. meds should nurse administer? (correct ans) - acetaminophen client receiving plasmapheresis through venous access site. action nurse take? (correct ans) - check electrolyte levels before and after therapy client at client for a 1 week follow up visit after HF. nurse report to provider? (correct ans) - HR 55/min preop teaching for client with scheduled for open cholecystectomy, action nurse take? (correct ans) - demonstrate ways to deep breathe and cough acute care facility caring for client at risk for seizures. precautions nurse implement? (correct ans) - ensure that the client has a patent IV client has bladder cancer and undergo cutaneous diversion procedure to establish ureterstomy. nurse include in teaching? (correct ans) - cut the opening of the skin barrier 1/8inch wider than the stoma assessing male client for inguinal hernia. which area should the nurse palpate to verify has inguinal hernia? (correct ans) - C client is 8hr postop total hip arthroplasty, client unable to void on bedpan. action nurse take first? (correct ans) - scan bladder with portable ultrasound1. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? 1) Take temperature once a day. 2) Wash the armpits and genitals with a gentle cleanser daily. 3) Change the litter boxes while wearing gloves. 4) Wash dishes in warm water. (correct ans) - 1) Take temperature once a day 2. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? 1) Provide humidified oxygen. 2) Perform chest physiotherapy prior to suctioning. 3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway. 4) Hyperventilate the client with 100% oxygen before suctioning the airway.. (correct ans) - 1) Provide humidified oxygen. 3. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? 1) Rub the client's feet briskly for several minutes. 2) Obtain a pair of slipper socks for the client. 3) Increase the client's oral fluid intake. 4) Place a moist heating pad under the client's feet. (correct ans) - 2) Obtain a pair of slipper socks for the client. 4. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? 1) Emesis of 100 mL 2) Oral temperature of 37.5° C (99.5° F) 3) Thick, red-colored urine 4) Pain level of 4 on a 0 to 10 rating scale (correct ans) - 3 5. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? 1) Shivering 2) Infection 3) Burns 4) Hypervolemia (correct ans) - 1 6. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will carry a complex carbohydrate snack with me when I exercise." 2) "I should exercise first thing in the morning before eating breakfast." 3) "I should avoid injecting insulin into my thigh if I am going to go running."4) "I will not exercise if my urine is positive for ketones (correct ans) - 4 7. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? 1) Cover the client's wound with a moist, sterile dressing. 2) Have the client lie supine with knees flexed. 3) Check the client's vital signs. 4) Inform the client about the need to return to surgery. (correct ans) - 1 8. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? 1) Cool, clammy skin. 2) Hyperventilation 3) Increased blood pressure 4) Bradycardia (correct ans) - 2 9. A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? 1) Avoid bending at the waist. 2) Remove the eye shield at bedtime. 3) Limit the use of laxatives if constipated. 4) Seeing flashes of light is an expected finding following extraction. (correct ans) - 1 10.A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? 1) Suggest that the client rests before eating the meal. 2) Request a dietary consult. 3) Check the client's vital signs. 4) Request an order for an antiemetic (correct ans) - 3 11.A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? 1) Sanguineous 2) Serous 3) Serosanguineous 4) Purulent (correct ans) - 4 12.A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. 2) Place the client's affected leg into the CPM machine with the machine in the flexed position. 3) Place the client into a high Fowler's position when initiating the CPM exercises. 4) Align the joints of the CPM machine with the knee gatch in the client's bed. (correct ans) - 113.A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations 5) Bradycardia (correct ans) - 1 2 3 4 14.A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first? 1) Take the client's temperature. 2) Place a dressing under the client's nose. 3) Notify the charge nurse. 4) Test the drainage for glucose. (correct ans) - 4 15.A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? 1) Monitor for elevated blood pressure. 2) Provide analgesia for headaches. 3) Prevent bladder distention. 4) Elevate the client's head. (correct ans) - 3 16.A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? 1) Hot flashes 2) Recurrent urinary tract infections 3) Blood in the stool 4) Abnormal vaginal bleeding (correct ans) - 4 17.A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? 1) Altered level of consciousness 2) Oral temperature of 37.7° C (100° C) 3) Muscle spasms 4) Headache (correct ans) - 1 18.A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? 1) Abdomen is distended 2) Chest tube drainage of 70 mL in the last hour 3) Subcutaneous emphysema is noted to the left chest wall 4) Pain level of 6 on a 0 to 10 scale (correct ans) - 119.A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? 1) Change the ostomy pouch daily. 2) Empty the ostomy pouch when it is 2/3 full. 3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma. 4) Apply lotion to the peristomal skin when changing the ostomy pouch. (correct ans) - 1 20.A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? 1) Position the client supine while in bed. 2) Change the nasal drip pad as needed. 3) Encourage frequent brushing of teeth. 4) Encourage the client to cough every 2 hr following surgery. (correct ans) - 2 21.A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? 1) To provide analgesia 2) To reduce inflammation 3) To prevent blood clotting 4) To prevent fever (correct ans) - 3 22.A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? 1) Loss of peripheral vision 2) Headache 3) Halos around lights 4) Discomfort in the eyes (correct ans) - 1 23.A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? 1) Weight loss of 3% of total body weight. 2) Blood glucose 150 mg/dL. 3) Potassium 2.5 mEq/L 4) Urine specific gravity 1.035 (correct ans) - 3 24.A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching? 1) "I should increase my intake of protein and vitamin C." 2) "I will no longer have menstrual periods." 3) "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience discomfort." 4) "I will take a tub bath instead of a shower." (correct ans) - 425.A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? 1) Loosen the knots on the ropes if the client is experiencing pain. 2) Ensure the client's weights are hanging freely from the bed. 3) Check the client's bony prominences every 12 hr. 4) Cleanse the client's pin sites with povidone-iodine. (correct ans) - 2 26.A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? 1) Take this medication between meals. 2) Limit intake of Vitamin C while taking this medication. 3) Take this medication with milk. 4) Limit intake of whole grains while taking this medication (correct ans) - 1 27.A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? 1) Take this medication between meals. 2) Limit intake of Vitamin C while taking this medication. 3) Take this medication with milk. 4) Limit intake of whole grains while taking this medication (correct ans) - 1 28.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 (correct ans) - 3 29.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. (correct ans) - 4 30.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." (correct ans) - 4 31.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 perception2) Loss of peripheral vision 3) Bright flashes of light 4) Eyestrain (correct ans) - 1 32.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. (correct ans) - 3 33.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 (correct ans) - 1 2 3 34.A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? 1) Provide a diet high in protein. 2) Provide ibuprofen for retroperitoneal discomfort. 3) Monitor intake and output hourly 4) Encourage the client to consume at least 2 L of fluid daily (correct ans) - 3 35.A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? 1) "A flexible tube is introduced through the nose during the procedure." 2) "During the procedure you are in a sitting position." 3) "You will remain NPO for 8 hours before the procedure." 4) "You will be awake while the procedure is performed." (correct ans) - 3 36.A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? 1) Aura phase 2) Presence of automatisms 3) Postictal phase 4) Presence of absence seizures (correct ans) - 3 37.A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make? 1) "The pain results from lying in one position too long during surgery." 2) "The pain occurs as a residual pain from cholecystitis."3) "The pain will dissipate if you ambulate frequently." 4) "The pain is caused from the nitrous dioxide injected into the abdomen." (correct ans) - 3 38. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) 1) Encourage fluid intake. 2) Monitor the puncture site for hematoma. 3) Insert a urinary catheter. 4) Elevate the client's head of bed. 5) Apply a cervical collar to the client. (correct ans) - 1 2 38.A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? 1) Notify the provider. 2) Verify that the suction regulator is on. 3) Continue to monitor the client because this is an expected finding. 4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. (correct ans) - 2 40.A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? 1) Relieve the client's pain. 2) Check the client's pressure points for redness. 3) Provide oral hygiene. 4) Prevent aspiration. (correct ans) - 4 41.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 (correct ans) - 4 42.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. (correct ans) - 3 43.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 imbalance4) Contractures (correct ans) - 1 44.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. (correct ans) - 1 45.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. (correct ans) - 4 46.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." (correct ans) - 4 47.A nurse is assisting with planning care for a client who is recovering from a lefthemispheric 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. (correct ans) - 3 48.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) Bradycardia (correct ans) - 1 49.A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include:pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make? 1) Metabolic acidosis 2) Respiratory acidosis 3) Metabolic alkalosis 4) Respiratory alkalosis (correct ans) - 2 50.A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching? 1) "I will avoid crossing my legs at the knees." 2) "I will use a thermometer to check the temperature of my bath water." 3) "I will not go barefoot." 4) "I will wear stockings with elastic tops." (correct ans) - 4 51.A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? 1) Turn the water on and ask the client to test the temperature. 2) Obtain assistance to place mitten restraints on the client. 3) Firmly tell the client that good hygiene is important. 4) Calmly ask the client if he would like to listen to some music (correct ans) - 4 52.A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? 1) Decreased perfusion 2) Infection 3) Granulation tissue 4) An inflammatory response (correct ans) - 3 53.A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3 . Which of the following food items brought by the family should the nurse prohibit from being given to the client? 1) Baked chicken 2) Bagels 3) A factory-sealed box of chocolates 4) Fresh fruit basket (correct ans) - 454.A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan? 1) Perform the client's personal care activities for her. 2) Limit the client's fluid intake. 3) Monitor the Homan's sign. 4) Maintain abduction of the right hip. (correct ans) - 4 55.A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? 1) Establish IV access. 2) Feel for a carotid pulse. 3) Establish an open airway. 4) Auscultate for breath sounds. (correct ans) - 2 56.A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? 1) "Why have you changed your mind about the surgery?" 2) "Bypass surgery must be very frightening for you." 3) "Your provider would not have scheduled the surgery unless you needed it." 4) "I will call your doctor and have him discuss your surgery with you." (correct ans) - 2 57.A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take? 1) Walk the client back to bed immediately and get the client a bedpan. 2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair. 3) Warn the client she might have to be restrained if she gets up without assistance. 4) Keep the bathroom door open to ensure the client is okay. (correct ans) - 2 58.A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take? 1) Fully recollapse the reservoir after emptying it. 2) Empty the reservoir once per day. 3) Replace the drainage plug after releasing hand pressure on the device. 4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr. (correct ans) - 1 59.A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will not eat fried foods." 2) "I will abstain from sexual intercourse." 3) "I will refrain from international travel." 4) "I will not order a salad in a restaurant." (correct ans) - 260.A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? 1) Rest in a supine position. 2) Consume a low-protein diet. 3) Breathe in through her nose and out through pursed lips. 4) Limit fluid intake throughout the day. (correct ans) - 3 61.A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of the following manifestations should the nurse monitor? 1) Hypernatremia 2) Hypotension 3) Bradycardia 4) Hypokalemia (correct ans) - 2 62.A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) 1) Decreasing anxiety 2) Controlling emesis 3) Relaxing skeletal muscles 4) Preventing surgical site infections 5) Reducing the amount of narcotics needed for pain relief (correct ans) - 1 2 5 63.A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? 1) Vitamin D 2) Vitamin A 3) Iron 4) Niacin (correct ans) - 3 64.A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? 1) Malnourishment related to NPO status and dysphagia 2) Impaired verbal communication related to the tracheostomy 3) High risk for infection related to surgical incisions 4) Ineffective airway clearance related to thick, copious secretions (correct ans) - 4 65.A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? 1) Walk with leg braces and crutches. 2) Drive an electric wheelchair with a hand-control device. 3) Drive an electric wheelchair equipped with a chin-control device. 4) Propel a wheelchair equipped with knobs on the wheels. (correct ans) - 466.A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer? 1) Exposure to environmental pollutants 2) Sun exposure. 3) History of viral illness 4) Scars from a severe burn (correct ans) - 2 : 67.Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? 1) "Do you sleep well at night?" 2) "Have you been experiencing chills?" 3) "Have you experienced increased hair growth?" 4) "When did you begin your menses?" (correct ans) - 1 68.A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching? 1) Cottage cheese 2) Fresh berries 3) Bran cereal 4) Skim milk (correct ans) - 2 69.A nurse is assisting with caring for a client who has a new concussion following a motorvehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Polyuria 2) Battle's sign 3) Nuchal rigidity 4) Lethargy (correct ans) - 4 70.A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? 1) "Tonometry is performed to evaluate peripheral vision." 2) "This test will diagnose the type of your glaucoma." 3) "Tonometry will allow inspection of the optic disc for signs of degeneration." 4) "This test will measure the intraocular pressure of the eye." (correct ans) - 4 71.A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider? 1) Increase in serum glucose 2) Increase in serum creatinine3) Decrease in white blood cell count 4) Decrease in platelets (correct ans) - 2 72. A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? 1) Apical pulse rate different than the radial pulse rate 2) Increase in heart rate by 20% when standing 3) Drop in systolic BP