ATI RN MED SURG EXAM PACK

ATI RN MED SURG EXAM PACKA nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy? Lymphedema A nurse is preparing to administer lactated Ringer's via continuous IV infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/mL. How many gtt/min should the nurse set the IV ump to administer? 33 A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching? I should lie down when I take this medication A nurse is providing discharge teaching to an older adult client following total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? Install a raised toilet seat in your bathroom A nurse is planning care for a client following a cardiac catheterization. which of the following actions should the nurse take? Maintain the client's affected extremity in extension A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. which of the following client statements indicates that the client is adapting to their role change? I will need to have my partner take over shopping for groceries and cooking the meals for us A nurse is providing teaching to a client who has an impaired immune system due to chemotherapy. which of the following information should the nurse include in the teaching? Change your pet's litter box daily a nurse is caring for a client who has a contusion and reports thirst. The client's urinary output was 4,000 ml over past 24 hr. the nurse should anticipate a prescription for which of the following IV medications? Desmopressin A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports nagging dry cough. Which of the following responses by the nurse is appropriate? Sucking on a lozenge may reduce the frequency of your cough A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a parenteral trigger for exacerbation of Raynaud's? Using nicotine transdermal patch A nurse is caring for a client who has a central venous device and notes the tubing has become disconnected. the client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? A nurse is completing an assessment of an older client and notes reddened areas over the bony prominences, but the client's skin is intact. which of the following interventions should the nurse include in the plan of care? Support bony prominences with pillows A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take? List strategies for family coping when dealing with possible role changesA nurse in the emergency department is assessing a client. which of the following actions should the nurse take first? Initiate airborne precautions A nurse is reviewing the medical record of a client to identify factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk? History of Crohn's disease A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make? I can give you additional information about the procedure A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow. 1. obtain venous access using a 19-gauge needle 2. Obtain the unit of a packed RBCs from blood bank 3. verify blood compatibility with another nurse 4. Initiate transfusion of the unit of packed RBCs 5. Remain with the client for the first 15 to 30 minutes A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching? I should expect less than 25 ml of secretions per day in the drainage devices A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing and makes incomprehensible sounds. which of the following Glasgow Coma scale scores should the nurse assign the client? 5 A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching? I can have a frozen fruit juice bar for dessert A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first? Instill 0.9% sodium chloride solution into the affected eye A nurse is assessing a client following extubation from a ventilator for which of the following findings should the nurse intervene immediately? Stridor A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect? Elevated blood glucose A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect? Urine specific gravity 1.001 A nurse is planning care for a client who has a pulmonary embolism. which of the following interventions should the nurse include? Initiate a continuous IV heparin infusionA nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. which of the following instructions should the nurse include? Avoid extremely hot or cold temperatures A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first. Insert a large-bore IV catheter A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation on of the graft? Palpable thrill A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following finding indicates hypokalemia? Muscle weakness A nurse is caring for a client in diabetic ketoacidosis (DKA) Which of the following is the priority intervention by the nurse? Infuse 0.9% normal saline A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching? I will expect my stools to be loss A nurse is caring for a client who is receiving total parenteral nutrition through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take? Switch the infusion to a 10% dextrose solution A nurse is caring for a client who is 6hr postoperative following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of the following electrolyte imbalance? Hypocalcemia A nurse in a provider office is caring for a client who has total vision loss and is the handler of a service dog. which of the following actions should the nurse take to show consideration for the client and the service animal? Consult the client before approaching the dog. A nurse is reviewing medications taken at home with a client who has angina. which of the following statements by the client indicates an understanding of the teaching? I should lie down before taking a dose of isosorbide dinitrate A nurse in the post anesthesia care unit is assessing a client following an appendectomy and finds a 2 cm (3/4 in) area of blood on the postoperative dressing. which of the following actions should the nurse take? Apply pressure A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement? a. Empty water from the ventilator tubing daily. b. Suction the client's airway every 4 hr. c. Maintain the client in supine position. d. Perform oral care every 2 hr.A nurse is planning care for a client who has full thickness burns on the lower extremities. Which of the following interventions should the nurse include? Apply new gloves when alternating between wound care sites. A nurse is providing teaching for a client who has tuberculosis and a new prescription for pyrazinamide. The nurse should instruct the client to notify the provider if which of the following adverse effects occurs? Jaundice A nurse is planning care for a client who has left-side hemiplegia following a stroke. which of the following actions should the nurse include in the plan of care? Position the client's table on the left side A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take? Point the type of the syringe toward the top of the ear canal A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy? Ondasteron A nurse is preparing to discharge a client who has a halo device and is reviewing new prescription from the provider. The nurse should clarify which of the following prescriptions with the provider? May operate a motor vehicle when no longer taking analgesics A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following information should the nurse include in the teaching? You will return in 2 weeks to provide a sputum specimen. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? Frothy sputum A nurse is planning care for a client who has osteoarthritis of the knees. Which of the following interventions should the nurse include in the plan? Place a large pillow under the client's knees when resting. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first? Check the client's urine output A nurse is providing instructions about foot care for a client who has a peripheral arterial disease. The nurse should identify that which of the following statements by the client indications understanding of the teaching "I rest in my recliner with my feet elevated for about an hour every afternoon" A nurse in a provider's office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include? Sleep with the head of the bed elevated 6 inches A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider? High-pitched sound on inspirationA nurse is caring for a client who is 2 days postoperative following a below the knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse? Why do you think your life is over? A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. which of the following assessments should the nurse plan to perform first? Measure the client's core body temperature A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan? You will need to be monitor for 15 minutes after receiving each medication close A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client? Feet elevated A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing? Dark red granulation tissue A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? I'll cut a slit in a clean gauze pad to use as a stoma dressing A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contraindication for receiving the medica on? Potassium 3.2 mEq/L A nurse is caring for a client admitted with a skull fracture. which of the following assessment findings should be greatest concern to the nurse? Glasgow coma scale score changes from 14 to 9 A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy? I have a hard time with brushing my hair A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following information should the nurse include regarding needle disposal? You can discard needles in an empty bleach bottle with a lid A nurse is assessing a client who has an arteriovenous (AV) graft in the le forearm. Which of the following findings should indicate to the nurse a complication of vascular access? a. Presence of a palpable thrill b. Dilated appearance of the AV site c. 2+ le radial pulse d. Absence of a bruit A client who is ideal and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take? Request an interpreter during the initial assessmentA nurse is teaching a client. about the nurse of the incentive spirometer. which of the following instructions should the nurse include in the teaching? Hold breaths 3 to 5 seconds before exhaling A nurse is caring for a client who sustained a spinal cord injury in a diving accident. which of the following actions should the nurse take? Monitor urine output hourly A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care? a. Flush the catheter using a 10-ml syringe b. Use clean technique when changing the dressing c. Cleanse the site with povidone-iodine d. Change the dressing every 24hr A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following action should the nurse take first? a. Prepare the client for peritoneal lavage b. Check the color of the client's skin c. Administer an opioid analgesic d. Remove all of the client's clothing A nurse is caring for a client following a bronchoscopy. Which of the following action should the nurse take first? a. Provide the client with sips of water. b. Instruct the client to report bleeding. c. Inform the client they might experience a low-grade fever. d. Check the client's gag reflex A nurse is teaching a client about using a metered-dose rescue inhaler. which of the following statements should the nurse include in the teaching? Exhale fully before bringing the inhaler to your lips A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick- day rules. Which of the following statements by the client indicates an understanding of the teaching? a. "I will consume 250grams of carbohydrates daily while I'm sick." b. "I will monitor my blood glucose every 8hours." c. "I will not take my diabetes medica ons while I am sick." d. I will check my urine for ketones if my blood glucose is greater than 240 mg/dL A nurse is reviewing ABG results for a client who has COPD. Which of the following findings should the nurse expect? a. HCO3-25 mEq/L b. PaO2 85mmHg c. pH 7.38 d.PaCO2 48 mm Hg A nurse is admi ng a client to a medical unit following placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse? a. Hiccups b. Sneezing c. Presence of a sharp spike prior to the QRS complex on the ECG d. Presence of intrinsic P waves following a QRS complex on the ECGA nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. which of the following routine medications to give at 0800 should the nurse withhold? a. Metformin b. Metoprolol c. Valporic acid d. Fluticasone A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care? a. Place pillows under the client's knees b. Apply compression stocking socks c. Avoid use of anticoagulants b. Discourage leg exercises while in bed A nurse is caring for a client who has duodenal ulcer. which of the following actions should the nurse take? Infused packed RBCs A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority? In the last day, I have had a severe headache and pain around my right eye. A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse anticipate? a. BUN 8mg/dL b. Creatinine 0.4mg/dL c. Hgb 20g/dL d. Potassium 6.8 A nurse is planning care for an older adult client who has Meniere’s disease. Which of the following interventions should the nurse include in the plan? Encourage the client to change positions slowly A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect assess the stoma at which of the following locations? B. on top A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? a. Insert a urinary catheter b. Administer IV fluids to the client c. Prepare the client for an intravenous pyelogram d. Initiate beta-blocker therapy A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following actions should the nurse plan to take? a. Slow the transfusion rate if the client reports itching b. Prime the IV tubing with 0.45% sodium chloride c. Complete the transfusion within 2hr d. d. Administer through a 22-gaugeA nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include? a. Decrease carbohydrate intake b. Increase phosphorus intake c. Increase potassium intake d. Decrease protein intake A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's abstract thinking? a. "Can you count backwards from 10 in intervals of 7?" b. "Can you tell me the state where you were born?" c. "What do you understand about your condition?" d. What is mean by the saying "Don't beat around the bush?" A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take? Keep soiled bed linens in the client's room A nurse is preparing a client for a lumbar puncture which of the following images indicates the position the nurse should assist the client into for this procedure? B. A nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of the following actions should the nurse take? Attach a dosimeter badge to the client's gown A nurse is teaching a client who has Grave's disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching? Increased temperature A nurse is caring for a client who is postoperative following a complete thyroidectomy, which of the following findings is the priority for the nurse to report to the provider? Muscle twitching A nurse is reviewing ECG rhythm strips for a group of clients. the nurse should identify that which of the following rhythms indicates bradycardia? C A nurse is caring for a client who is receiving epidural analgesia. Which of the following assessment finding is the nurse's priority? Hypotension A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse's priority to include? Turn the client lateral position during the seizure activity. A nurse is caring for a client following a below the knee amputation. The client states, "my life is over". Which of the following responses should the nurse take? Why do you think your life is over?A nurse in a clinic is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adult after age 60? Pneumococcal polysaccharide Herpes zoster Influenza A nurse is planning care a client who has dementia. Which of the following interventions should the nurse plan to include? Turn off the lights in the client's rom at night Assist the client with toiling at least once every 4 hr A nurse is assessing a client who has new diagnosis of DM1. Which of the following findings indicate that the client is experiencing hypoglycemia? Increased perspiration A nurse in the PACU is assessing a client who is post-operative following general anesthesia. Which of the following findings is the priority to address? Vomiting upon arousal A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding? Weight gain A nurse is teaching about measure to prevent recuring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? Wipe the perineal area from front to back after urinating. Drink 3L of fluids daily Drink low-fructose cranberry juice A nurse is caring for a client following a cardiac-catherization who has hives and urticaria following administration of IV contrast dye. Which of the following Medication should the nurse plan to administer? Diphenhydramine A home care nurse to use non-pharmacological pain relief measures for an adult client who has severe chronic back pain. which of the following guideline should the nurse use? Discontinue opioids before trying nonpharmacological methods of pain relief A nurse is caring for a female client who is receiving total parenteral nutrition without fat emulsion. Which of the following findings should the nurse report.? Crackles in the bilateral lung bases1. A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation? a. Encourage the client to lean forward when attempting to stand b. Remove the wedge device when turning c. Elevate the knees than the hips when sitting d. Place two bed pillows between the legs when in bed 2. A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer. Which of the following actions should the nurse plan to take? a. Ensure that the client has 22-gauge for IV line in place b. Provide ketorolac for abdominal pain c. Insert a large-bore nasogastric tube d. Administer nitroprusside IV based on the client’s weight 3. A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the ff assessment findings supports this suspicion? a. Acetone breath b. Increased urine output c. Kussmaul respiration d. Cool, clammy skin 4. A nurse is caring for a client who has chronic renal failure. The client displays the following ABG results: pH 7.24, PaCO2 44 mmHg, PaO2 84 mm HG, HCO3 18 mEq/L, base excess -2, and O2 saturation 95%. The nurse should conclude that the client has which of the following acid-base imbalance? a. Metabolic acidosis b. Respiratory alkalosis c. Respiratory acidosis d. Metabolic alkalosis 5. A nurse is providing discharge teaching for a client who has asthma and a new prescription for a metered-dose inhaler. Which of the following client statements indicates an understanding of the teaching? a. “I should wait 15 seconds between puffs” b. “I should inhale the medication quickly” c. “I should clean the cap of the inhaler once per week” d. “I should shake the inhaler before i use it.” 6. A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?a. headaches b. urticaria c. Mouth sores d. lymphedema 7. A nurse is caring for a client who has advanced liver disease. Which of the ff laboratory results should the nurse monitor when assessing this client? a. Phosphate level b. Serum troponin c. Serum ammonia d. Glucose level 8. A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy? a. Anticonvulsant b. diuretic c. antithrombotic d. Opioid analgesic 9. A nurse is planning care for an older adult client who has Meniere’s disease. Which of the following interventions should the nurse include in the plan? a. Perform range-of-motion exercise to the client’s neck every 4 hr b. Limit the client’s fluid intake to 1,500 mL/day c. Administer aspirin if the client reports a headache. d. Encourage the client to change positions slowly 10. A nurse in a provider’s office is caring for a client who has total vision loss and is the handler of a service dog. Which of the ff actions should the nurse take to show consideration for the client and the service animal? a. Offer the dog a bowl of water to demonstrate caring. b. Command the dog to sit while talking with the client. c. Consult the client before approaching the dog. d. Pet the dog briefly to demonstrate acceptance. 11. A nurse is caring for a client who is experiencing a hypertensive crisis. Which of the ff actions should the nurse take? a. Begin an IV bolus of lactated Ringer’s. b. Initiate an IV dopamine infusion c. Perform neurological assessments. d. Place the client supine 12. A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change?a. “Its going to be difficult to tell my parents i can’t take them to their appointment anymore” b. “These crutches will make it impossible to care for my child” c. “I will need to have my partner take over shopping for groceries and cooking the meals for us.” d. “I feel bad that i have to ask my partner to keep the house clean.” 13. A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client’s abstract thinking? a. “What is meant by the saying, “don't beat around the bush” b. “Can you count backwards from 100 in intervals of 7?” c. “What do you understand about your condition?” d. “Can you tell me the state where you were born?” 14. A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a pain scale of 0 to 10., which of the following interventions should the nurse take? a. Apply an ice pack to the client’s knees b. Place pillows under the client’s knees c. Perform ROM exercises to the client’s knees. d. Gently massage the area around the client’s incision 15. A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take? a. Apply pressure to venipuncture sites for 10 mins b. Instruct the client to avoid eating raw fruit c. Move the client to a negative pressure room d. Use contact isolation while providing care. 16. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse? a. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site b. The clients has oral temperature of 38.3 (100.9 F) c. The client has 100 mL blood in the closed suction drain. d. The client’s capillary refill in the left toe is 6 seconds. 17. A nurse is providing teaching to a client who is receiving opioids for pain management. Which of the following information should the nurse include in the teaching? a. “Monitor urinary output for retention” b. “Itching indicates you are having an allergic reaction to the medication.” c. “Avoid taking antibiotics with this medication” d. “Restrict fluid intake if you experience constipation.” 18. A nurse is assessing a client who has pericarditis. In which of the following areas of the client’s chest should the nurse place the stethoscope to hear a pericardial friction rub?a. Answer: D 19. A nurse is assessing a client who has heart failure. Which of the following client statements should indicate to the nurse that the client needs a referral for cardiac rehabilitation ? a. “I hate how i feel all the time.” b. “I will weigh myself daily.” c. “I’m too tired to brush my teeth.” d. “I need to start eating a low-sodium diet.” 20. A nurse is assessing a client who has cirrhosis. Which of the ff findings is the priority for the nurse to report? a. Clay-colored stools b. Platelets 70,000/mm3 c. Alkaline phosphate 125 units/L d. Distended abdomen 21. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client? A. Reverse trendelenburg B. Feet elevated C. side-lying D. high-fowler’s 22. A nurse is caring for a client who has anemia. Which of the ff assessment findings should the nurse anticipate with the client’s condition? A. headache B. heat intolerance C. Bradycardia D. Flushed skin color 23. A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicate to the nurse that the medication is effective? A. respiratory rate of 24/min B. elevation in blood pressure C. adventitious breath sounds D. weight loss of 1.8 kg (4lb) in the past 24 hr24. A nurse is caring for a client who is 6 hr postoperative ff application of an external fixator for tibial fractures. Which of the ff actions should the nurse take? A. Palpate the dorsalis pedis pulse B. wrap sterile gauze on the sharp point of the pins C. Maintain the affected extremity in a dependent position D. Adjust the clamps on the fixator frame 25. A nurse is caring for a client in the emergency dept. Who experienced a full-thickness burn injury to the lower torso 1 hour ago. Which of the ff findings should the nurse expect? A. Bradycardia B. Urinary diuresis C. Decreased resp rate D. hypotension 26. A nurse is providing preoperative teaching for a client who is having a left-sided cardiac catheterization. Which of the following information should the nurse include in the teaching? A. “You should expect a warm sensation after the injection of the contrast dye during the procedure.” B. “You should plan to remain in bed for 18 hours after the procedure.” C. “You will receive a general anesthetic during the procedure.” D. “You will have blood pressure measurements every 5 minutes for the first 2 hours after the procedure.” 27. A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the ff findings should the nurse report to the provider as a contraindication to receive heparin? A. Thalassemia B. Rheumatoid Arthritis C. Thrombocytopenia D. COPD 28. A nurse is caring for a female client who has toxic syndrome. Which of the ff findings should the nurse suspect? A. generalized rash B. decreased total bilirubin C. hypertension D. elevated platelet count 29. A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? A. “Wash your toothbrush in the dishwasher once each month.” B. “Wash your perineal area two times each day with antimicrobial soap.” C. “Change the water in your drinking glass every 4 hours.”D. “Change your pet’s litter box daily.” 30. A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the ff intervention should the nurse include? A. Apply new gloves when alternating between wound care sites. B. Provide a diet of fresh fruits and vegetable for the client C. Limit visitation time for the client’s children to 40 min/day D. clean the equipment in the client’s room once per week. 31. A nurse is assessing a client admitted with peripheral vascular disease. Which of the following findings indicates a venous vascular disorder? A. Edema of the ankle B. Hair loss distal to the client’s calves C. Leg pain at rest D. An ulcer on the tip of toe 32. A nurse is caring for a client who has sealed radiation implant. Which of the ff actions should the nurse take? A. Remove soiled linens from the room air each change B. Give the dosimeter badge to the oncoming nurse at the end of the shift C. Limit family member visits to 20 mins per day D. Apply a second pair of gloves before touching the client’s implant if it dislodges 33. A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax? A. Irregular heart rate B. Distended neck veins C. Diminished breath sounds D. Itching over the incision 34. A nurse is teaching a client who has asthma about the use of a peak flow meter. After setting the meter to the zero baseline, what is the sequence of steps the nurse should instruct the client to take? IN ORDER A. Stand upright B. Seal your lips around the mouthpiece C. Fill your lungs with a deep breath D. Exhale forcefully and quickly E. Record the highest of the three consecutive readings 35. A nurse is caring for a client who is scheduled for abdominal paracentesis. The nurse should plan to make which of the ff actions? A. Instruct the client to take deep breaths and hold them during the procedure. B. Ask the client to empty his bladder prior to the procedure C. Assist the client into the left lateral position during the procedureD. Administer a stool softener following the procedure. 36. A nurse is administering potassium chloride via IV infusion to a client who has severe hypokalemia. Which of the ff actions should the nurse take? A. Check the infusion site at least every 4 hr B. Monitor the client for adequate urine output C. Start the infusion at 30 meq/hr D. Assess the client for a positive chvostek’s sign 37. A nurse is planning care for a client who has left-sided hemiplegia of a stroke. Which of the ff actions should the nurse include in the plan of care? A. Place a plate guard on the client’s meal tray B. Provide the client with a short-handed reacher C. Remind the client to use a cane on his left side while ambulating D. Position the bedside table on the client’s left side 38. A nurse is caring for a client who had an arterial revascularization of the right lower extremity. Which of the following is the priority action the nurse should plan to take after contacting the provider? A. Increase heparin infusion rate per protocol B. Start an IV fluid bolus of 0.9% NA Chloride 500 ml to infuse C. Increase insulin infusion rate per protocol D. Change the PCA timing of the patient control bolus to every 15 mins 39. A nurse is preparing to administer 2 units of packed RBCs to a client. Which of the following actions should the nurse take? A. Transfuse each unit of blood over 5 hr B. Change the IV tubing after each unit of blood is transfused C. Prime the tubing with 0.9% sodium chloride D. Administer the blood through a 22-gauge intravenous catheter 40. A nurse is preparing to administer naloxone 10 mcg/kg via IV bolus to a client who weighs 220 lb. The amount available is 0.4 mg/mL. How many mL should the nurse administer? Answer: 2.5 41. A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless. Which of the ff assessment should the nurse perform first A. Blood pressure B. Blood glucose C. Urinary output D. Motor responses42. A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation.. Which of the following assessment findings is the nurse’s priority? A. Warmth of extremities B. Level of pain C. temp D. Gag reflex 43. A nurse in the ED is caring for a client who was involved in an explosion. Which of the following actions should the nurse plan to take first? A. Notify the Rapid Response Team B. Calculate the extent of burns using the rule of nines. C. Initiate peripheral IV access D. Obtain an ECG 44. A nurse is reviewing a cardiac rhythm strip of a client who has atrial flutter. Which of the following findings should the nurse expect? A. Progressively longer PR durations B. Undetectable P waves C. A saw-tooth pattern with atrial rate of 250 to 400/min D. Absent PR intervals which ventricular rate of 40 to 60/min 45. A nurse is preparing to administer piperacillin 3.375 g by intermittent IV bolus every 6 hr. Available is piperacillin 3.375 g in dextrose 5% in water (D5W) 100 mL to infuse over 30 min. The nurse should set the IV pump to deliver how many mL/hr? Answer: 200 46. A nurse is providing discharge teaching about blood glucose monitoring for a client who has a new DX of DM2. the nurse should instruct the client to obtain which of the ff supplies? A.Hand mirror B. Toenail clippers C.sterile lancets D. compression stockings 47. A nurse is caring for a client who has just undergone a total laryngectomy. Which of the ff findings is the nurse’s priority for immediate intervention? A. IV infiltration B. fever C. Blood-tinged secretions D. tachypnea 48. A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? a. Initiate beta blocker therapyb. Insert a urinary catheter c. Administer IV fluids to the client d. Prepare the client for an intravenous pyelogram 49. A charge nurse receives a call from the house supervisor requesting room assignments for 4 new clients. Based on the admission diagnosis, which of the following clients requires a private room? A. An older client who was admitted with aspiration pneumonia B. A client who has DM and is presenting with acute ketoacidosis. C. A client who has compound FX of the RT femur D. A client who reports having fever, night sweats, and cough for 2 days. 50. A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take? a. Avoid administering IV pain medication b. Determine the client blood type c. Institute bleeding precautions d. Implement airborne precautions 51. A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long-term glycemic control? A. Glycosylated hemoglobin level B. Fasting blood glucose C. Oral glucose tolerance D. Postprandial blood glucose level 52. A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning. The nurse should recognize these assessment findings as indicating Which of the following? A. Aspiration B. Pleural effusion C. Fluid volume excess D. Increased cardiac output 53. A nurse in an emergency dept. Is preparing a client for emergency surgery. The client’s blood alcohol level is 180mg/dL. Which of the following actions is the nurse’s priority? A. Obtain contest for surgery B. Apply antiembolic stocking C. Insert an NG tube D. Insert an indwelling urinary catheter54. A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client’s skin is intact. Which of the following interventions should the nurse include in the plan of care? A. Apply an occlusive dressing B. Turn and reposition the client every 4 hrs C. Support bony prominences D. Massage the reddened areas three times daily 55. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate.. The client reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take? A. Administer ibuprofen 400 mg for pain relief B. Remove the indwelling urinary catheter. C. Decrease traction on the catheter. D. Flush the catheter manually with 0.9% sodium chloride 56. A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse? A. Initiate a continuous IV insulin infusion B. Administer 0.9% sodium chloride C. Begin bicarbonate continue IV infusion D. Check potassium levels 57.A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis which of the following manifestations should the nurse identify as the earliest indication of this complication? A. Cloudy effluent B. Increased heart rate C. Fever D. Generalized abdominal pain 58. A nurse is caring for a client admitted with a skull fracture. Which of the following findings should be of greatest concern to the nurse? A. Bilateral pupil diameter changes from 4 to 2 mm B. Pulse pressure changes from 30 to 20 mm Hg C. WBC count changes from 9000 to 16000/mm3 D. Glasgow Coma Scale Scale score changes from 14 to 9 59. A nurse finds a client in bed, unresponsive and breathing. Which of the following actions should the nurse take first? A. Initiate cardiac monitoring for the client. B. Establish an IV access C. Apply a blood pressure cuff D. Palpate for the client’s carotid pulse60. A nurse in the PACE is caring for a client. Which of the ff assessment is the nurse’s priority? A. Surgical site B. Level of consciousness C. Respiratory Status D. Pain Level 61. A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the ff substances? A. Adhesive tape B. latex C. anesthetics D. Povidone-iodine 62.a nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications? A. Diphenhydramine B. pantoprazole C. furosemide D. acetaminophen 63. A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? A. Back pain B. hypertension C. bradycardia D. chills 64. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The current infusion is almost complete and the new solution is not available. Which of the following actions should the nurse take? A. Decrease the TPN infusion rate B. Administer lactated Ringer’s through a peripheral IV site C. Disconnect and flush the IV access line D. Infuse dextrose 10% in water 65. A nurse is reviewing the medication list of a client who is being admitted with diabetes insipidus. Which of the following medications places the client at an increased risk for developing diabetes insipidus? A. Propranolol B. Lithium C. AtorvastatinD. Ranitidine 66. A nurse is planning to teach a client whose provider has prescribed a low-purine diet. The nurse should plan to instruct the client that he can include which of the following foods in his diet. A. nuts B. apricots C. scallops D. Sardines E. liver 67. A nurse is assessing a client who has a new diagnosis of colon cancer. Which of the following findings should the nurse expect? A. steatorrhea B. hematochezia C. Elevated hemoglobin D. Weight gain 68. A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care? A. Change the dressing every 24 hr B. Use clean technique when changing the dressing C. Cleanse the site with povidone-iodine D. Flush the catheter using a 10-mL syringe 69. A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching? A. “I should expect to take my medication for 3 weeks.” B. “I should apply antibiotic ointment to the lesions.” C. “I should use natural skin condoms during sexual intercourse.” D. “I should expect my lesions to resolve in 6 weeks.” 70. A nurse is providing teaching to a client who has a deep-vein thrombosis (DVT). Which of the following findings should the nurse identify as a risk factor for the development of DVTs? A. Oral contraceptive use B. hypertension C. NSAID use D. cirrhosis 71. A nurse is reviewing the medical record of a client who is scheduled for a CT scan with contrast media. Which of the following medications should the nurse instruct the client to withhold for 48 hr following the procedure? A. carvedilol B. furosemide00C. metformin D. clopidogrel 72. A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find? A. Poor skin turgor B. oliguria C. Pitting edema D. S3/S4 galloping heart sounds 73. A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take? A. Wear a lead apron when providing client care. B. Leave the door to the client’s room open C. Allow visitors to hold the client’s hand D. Place the dosimeter film badge on the client’s door 74. A community health nurse is reviewing home care instructions with an older adult client who has a new DX of heart failure. Which of the ff is the priority topic for the nurse to review with the client? A. Daily exercise routine B. Fluid intake record C. Change in weight D. Daily sodium restrictions 75. A nurse is preparing to perform gastric lavage for a client who has bleeding gastric ulcer. Which of the ff equipment should the nurse plan to use for the procedure? Answer: C76. A nurse is providing discharge teaching to a client ff a modified left radical mastectomy with breast expander. Which of the ff statements by the client indicates an understanding of the teaching? A. I will keep my left arm flexed at the elbow as much as possible. B. I will have to wait 2 months before additional saline can be added to my breast expander. C. I will perform strength-building arm exercises using 15 pound weight. D. I should expect less than 25 ml of secretion per day in the drainage device. 77. A nurse is assessing a client who has a new DX of diverticulosis and reports that he uses multiple complementary and alternative healing therapies. Which of the ff complementary therapies should the nurse identify as contraindicated for the client? A. colonics B. Saw palmetto C. acupuncture D. Guided imagery 78. A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following lab results should the nurse identify as a contraindication for receiving the medication? A. Potassium 3.2 mEq/L B. BUN 18 C. Sodium 136 D. Creatinine 0.8 79.A nurse is teaching a client who has Aids and wishes to continue self care at home,despite living alone.Which of the following actions by the nurse demonstrate client advocacy? A. Initiate a referral for the client to a home health agency B. Tell the client to avoid places where there are large crowds of peopleC. Remind the client of the importance of medication adherence D. Instruct the client to avoid eating raw vegetables 80.A nurse in clinic is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adults after 60? SATA A. Pneumococcal polysaccharide B. Human papillomavirus C. Influenza D. Meningococcal E. Herpes zoster 81.A nurse in the emergency department is reviewing a clients ECG reading, which of the following findings should the nurse identify as an indication that the client has first degree heart block? A. No correlation betweenP and QRS B. Prolonged PR intervals C. More P waves than QRS complexes D. Nondiscernible P waves 82.A nurse is providing instruction about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching A. I use my heating pad on a low setting to keep my feet warm. B. I soak my feet in hot water before trimming my toenails. C. I apply a lubricating lotion to the cracked areas on the soles of my feet every morning. D. I rest in my recliner with my feet elevated for about an hour every afternoon 83. A nurse in a provider’s office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include? A. “Eat a light meal 1 hour before bedtime.” B. “Sleep with the head of your bed elevated 6 inches.” C. “Lie down for 30 minutes after each meal.” D. “Increase your caloric intake by 250 calories per day.” 84. A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake. Which of the following choices should the nurse recommend as containing the least potassium? A. ½ cup nonfat yogurt B. 1 cup white rice C. 2 tbsp peanut butter D. 1 medium baked potato with skin85. A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first? A. Instill 0.9% sodium chloride solution into the affected eye B. Collect information about the irritant that caused the injury. C. Administer proparacaine eyedrops into the affected eye D. Place a strip of pH paper onto the cul-de-sac of the affected eye 86. A nurse is teaching a client about the use of an incentive spirometer. Which of the ff instructions should the nurse include in the teaching? A. Position the mouthpiece 2.5 cm (1 inch) from the mouth B. Hold breaths about 3-5 sec before exhaling C. Place hands on the upper abdomen during inhilation D. Exhale slowly through pursed lips. 87. A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first? A. A client who has multiple sclerosis and reports ataxia and vertigo B. A client who has thrombocytopenia and reports a nosebleed C. A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% D. A client who has left-sided paralysis and slurred speech from a prior stroke 88. A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse’s priority to include? A. Administer diazepam intravenously to the client. B. Administer phenytoin IV bolus to the client C. Provide the client oxygen at 6 L/min using a nasal cannula D. Turn the client to the lateral position during seizure activity 89. A nurse is caring for a client who has a chest tube. The client asks why the fluid in the waterseal chamber rises and falls. Which of the following statements should the nurse include? A. “Your breathing pattern causes this.” B. “This means your lung is fully re-expanded.” C. “This indicates a possible air leak.” D. “Suction pressure that is too high causes this.” 90. A nurse is teaching a client who has endometriosis about the adverse effect of leuprolide. Which of the ff manifestations should the nurse include in the teaching? A. hypoglycemia B. pallor C. Increased appetite D. Bone loss91. A nurse is caring for an older adult client who is suspected of having septicemia. Which of the following actions is the nurse’s priority? A. Obtain a blood specimen for culture and sensitivity testing. B. Obtain a WBC count with differential C. Obtain a history to determine recent injuriesWhich of the following D. Obtain a broad-spectrum antibiotic for rapid administration. 92. A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching? A. “I will wipe up areas soiled with bloody fluids with alcohol and immediately dispose of the trash” B. I will need to take my clothes to the dry cleaners to sterile them C. I will increase the amount of fresh fruit and vegetables I consume D. I will be sure to wear gloves and wash my hands when I change my cat’s litter box 93. A nurse is monitoring a client’s heart rhythm following insertion of a permanent pacemaker, which of the ff images should the nurse expect? Answer: A 94.A nurse is caring for a client who is receiving radiation. The client reports nausea since the therapy was initiated. Which of the following considerations should the nurse include when planning the client’s meals? A. Offer frequent high carbohydrate meals B. Offer hot beverage with meals C. Offer highly seasoned foods D. Offer a snack prior to radiation therapy 95.A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include? A. “Use a heating pad to keep your feet warm at night” B. “Wash your feet twice per day with antibacterial soap and hot water”C. “Wear loose fitting slippers around the house” D. “Wear cotton rather than nylon socks” 96. A nurse is completing discharge teaching with a client who has peripherally inserted central catheter (PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching. A. Use a 10 ml syringe to flush the line B. Change the catheter dressing daily C. Clean the insertion site using 20ml of hydrogen peroxide D. Do not elevate the arm above the level of the heart 97. A nurse is planning a staff education session about Hepatitis A. Which of the following information should the nurse include? A. Hepatitis A is transmitted is through blood to blood exposure B. Clients who have hepatitis A require broad spectrum antibiotic C. The incubation period of hepatitis A is 5-10 days D. Immunization for hepatitis A is recommended prior to travel to high risk area. 98. A nurse is caring for a client who has cancer. The client tells the nurse. “ I would prefer to try vitamins and minerals instead of chemotherapy. Which of the following responses should the nurse make? A. “ I have never heard of any holistic treatment that is effective B. “You should ask your provider about your plan” C. “Tell me what you know about chemotherapy” D. “The best way to treat your cancer is chemotherapy” 99. A nurse is caring for a client who has pancreatitis and has been receiving total parenteral nutrition. Which of the following laboratory tests should the nurse monitor for overall nutritional status? A. Creatinine B. Lipase C. Prealbumin D. C-reactive protein 100. A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing? A. Wound tissue firm to palpation B. Dry brown eschar C. Dark red granulation tissue D. Light yellow exudate1. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon? a. Heart rate 90/min b. Absent bowel sounds c. Hgb 8.2 g/dl d. Gastric pH of 3.0 2. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? a. Desmopressin b. Regular insulin c. Furosemide d. Lithium carbonate 3. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following test should the nurse monitor? a. Fasting blood glucose b. Stool for occult blood c. Urine for white blood cells d. Serum calcium 4. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) a. Obtain a sputum sample for culture b. Prepare the client for a chest x-ray c. Initiate airborne precautions d. Administer ondansetron. 5. A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain. Which of the following prescriptions should the nurse anticipate? a. Transmucosal fentanylb. Intramuscular meperidine c. Oral acetaminophen d. Intravenous dexamethasone 6. A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction? a. PR interval b. QRS duration c. T wave d. ST segment 7. A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of the following instructions should the nurse include? a. Pat the skin on the radiation site to dry it b. Apply OTC moisturizer to the radiation site c. Cover the radiation site loosely with a gauze wrap before dressing d. Use a soft washcloth to clean the area around the radiation site 8. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications? a. Diphenhydramine b. Acetaminophen c. Pantoprazole d. Furosemide 9. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia. Which of the following findings indicates effectiveness of the medication? a. Lungs clear b. Apical pulse 82/min c. Hyperactive bowel sounds d. Blood pressure 90/50 mm Hg10. A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse should recognize these findings as indication of which of the following conditions? a. Metabolic acidosis b. Metabolic alkalosis c. Compensated respiratory alkalosis d. Uncompensated respiratory acidosis 11. A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of the following labs should the nurse expect during the first 24 hours a. Decreased BUN b. Hypoglycemia c. Hypoalbuminemia d. Decreased Hematocrit 12. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following actions should the nurse takes? a. Offer the client high carbohydrate meal options b. Provide the client with four full meals a day c. Encourage the client to drink at least 360 ml of fluids with meals d. Have the client lie down for 30 minutes after meals 13. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? SATA a. Born with a high weight b. Chronic infections of the middle ear c. Use a loop diuretic such as furosemide and antibiotics like aminoglycoside and gentamicin d. Perforation of the ear drum e. Frequent exposure to low volume noise 14. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?a. Administer the plasma immediately after thawing b. Transfuse the plasma over 4 hours c. Hold the transfusion if the client is actively bleeding d. Administer the transfusion through a 24-gauge saline lock 15. A nurse is assessing a client who reports numbness and tingling of his toes and exhibits a positive trousseau. Which of the following electrolyte imbalance should the nurse suspect? a. Hyponatremia b. Hyperchloremia c. Hypermagnesemia d. Hypocalcemia 16. A home health nurse is teaching a client how to care for a peripherally central catheter in his right arm. Which of the following statements should the nurse include in the teaching? a. Change the transparent dressing over the insertion site every 48 hours b. Clean the insertion site with mild soap and water c. Measure your right arm circumference once weekly d. Use a 10milliliter syringe when flushing the catheter 17. A nurse is caring for a client who has a central venous access device. Which of the following assessment findings should the nurse report to the provider? a. RBC count of 4.7 million/mm b. BUN 22-mg/ dl c. WBC count of 16,000/ mm d. Blood glucose of 120 mg/dl 18. A nurse is providing dietary teaching to a client who has chronic kidney disease and a decreased glomerular filtration rate. Which of the following statements by the client indicates an understanding of the teaching? a. I will spread my protein allowances over the entire day b. I should increase my intake of canned salmon to three times per week c. I will season my food with lemon pepper rather than salt d. I should limit my intake of hard cheese to 3 ounces each day19. A nurse is caring for a client who has a peripherally inserted central catheter. The client is receiving an antibiotic via intermittent IV bolus. Which of the following actions should the nurse take? a. Administer 20 ml of 0.9 sodium chloride after each dose of medication b. Flush the catheter using a 5 ml syringe c. Verify the placement with an x-ray prior to the initial dose d. Change the transparent membranes dressing daily 20. A nurse is teaching a client using a metered dose rescue inhaler. Which of the following statements should the nurse include in the teaching? a. Do not shake your inhaler before use. b. Exhale fully before bringing the inhaler to your lips c. Depress the canister after you inhale d. Use peroxide to clean the mouthpiece if your inhaler 21. A nurse is assessing the pain status of a group of clients. Which of the following findings indicate a client is experiencing referred pain? a. A client who has angina reports substernal chest pain b. A client who has pancreatitis reports pain in the left shoulder c. A client who is postoperative reports incisional pain d. A client who has peritonitis reports generalized abdominal pain 22. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessments findings requires immediate intervention by the nurse? a. The client reports a pain level of 7 on a scale from 0 -10 at the operative site. b. The client’s capillary refill in the left toe is 6 c. The client has an oral temperature of 38.3 (100.9 F) d. The client has 100 ml of blood in the closed suction drained. 23. A nurse is assessing a client who has acute pancreatitis and has been receiving total parenteral nutrition for the past 72 hours. Which of the following findings requires the nurse to intervene?a. Right upper quadrant pain b. Capillary blood glucose level of 164 mg/dl c. WBC counts 13,000/mm3 d. Crackle in bilateral lower lobes 24. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tach