PN Adult Medical Surgical Exam .

PN Adult Medical Surgical Exam 2022/2023 PN Adult Medical Surgical Exam 2022/2023 1. A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? Creatine 1.9 mg/dl 2. A nurse is monitoring a client who is take acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? Abdominal Cramps 3. A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent post- procedure complications? Monitor the insertion site for bleeding, Maintain the pressure dressing, Check the client’s peripheral pulses 4. A nurse is contributing to the plan of care for a client wo has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan? Encourage abdominal breathing 5. A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.7 6. A nurse is examining a client’s IV and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client’s manifestations indicate which of the following complications of IV therapy? Thrombophlebitis 7. A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which od the following should the nurse include in the teaching? Increase intake of fiber-rich foods. 8. A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? Perform pin site care daily 9. A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Loosen clothing around the client’s neck. 10. A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? Encourage the client to complete ADLs 11. A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching? Avoid liquids at mealtimes. 12. A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? Decreased shortness of breath 13. A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client? Rephrase client instructions when not understood. 14. A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration? Pinch the NG tube. 15. A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? Encourage weight-bearing exercises. 16. A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? "I don't cross my legs anymore." 17. A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? "I will have my HbA1c checked twice per year." 18. A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? Dispose of radiation implants in a lead container. 19. A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? Allow for 30 min of rest before meals. 20. A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? Pulmonary embolism 21. A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include? "You are at risk for infertility with this infection, regardless of treatment." 22. A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? Keep the client in a side-lying position. 23. A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? Initiate oxygen at 4 L/min via nasal cannula. 24. A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching? "This type of insulin should be given at the same time every day." 25. A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? Bradycardia 26. A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalemia? Bradycardia 27. A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. Which of the following actions should the nurse perform first? Stop the infusion. 28. A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? History of treatment for blood clots 29. A nurse is reinforcing teaching with the family of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? Change the sheepskin liner weekly. 30. A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? Dysrhythmia 31. A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction? Small liquid stools 32. A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? Stop the medication infusion. 33. A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? Apply a mask on the client if transport is needed. 34. A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? "Avoid bending your hips more than 90 degrees." 35. A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching? "I understand that testicular cancer is painless." 36. A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following? Intra-abdominal bleeding 37. A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? Keep a sheepskin pad between the client's extremity and the CPM. 38. A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal? Lack of sensation between the first and second toes 39. A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? "I should call my doctor if my ankles swell." 40. A nurse is providing discharge teaching for the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? Remind the client to avoid watching her feet when walking. 41. A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of the following findings should the nurse expect? Red macular rash 42. A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching? "Limit contact with large groups of people." 43. A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? "Consume foods low in sodium." 44. A nurse is reviewing the medical record of a client who has a prescription for morphine. Which of the following findings should the nurse report to the provider? Urinary retention 45. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take? Position pillows between the bony prominences. 46. A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? "You should have a pneumococcal immunization every 10 years." 47. A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? Apply cold packs to the inflamed joints. 48. A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? (Click on the audio button to listen to the clip.) Hyperactive bowel sounds 49. A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following should the nurse recommend? Lemon juice 50. A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? Dyspnea 51. A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take? Maintain abduction of the client's right leg while in bed. 52. A nurse is caring for a client who is 24 hr postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications? Encourage the client to use an incentive spirometer every hour while awake. 53. A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first? Recommend a referral for a speech language pathologist. 54. A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown? Keep the skin dry and free of perspiration. 55. A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective? Hgb 11 g/dL 56. A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? Avoid stopping this medication suddenly. 57. A nurse is performing an ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the nurse place the V1 electrode? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) C 58. A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? Mohs surgery is a horizontal shaving of thin layers of the tumor. 59. A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors? Visitors must don a gown and gloves prior to entering the client's room. 60. A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular disease. Which of the following images indicates the type of cooking fat the nurse should recommend the client use when preparing meals? olive oil 61. A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? Have a designated stethoscope in the client's room. 62. A nurse is caring for an older adult client who has a reddened area over the sacrum. Which of the following actions should the nurse take? Minimize the time the head of the bed is elevated. 63. A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should the nurse review prior to the procedure? BUN 64. A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? Prealbumin 12 mg/dL 65. A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? Instruct the client to swish the medication in her mouth. 66. A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next? Administer epinephrine. 67. A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse make? "Tell me more about the way you are feeling." 68. A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. Which of the following interventions should the nurse include? Dangle the extremities off the side of the bed. 69. A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching? "I should wait at least 2 hours after eating before going to bed." 70. A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching? Report purulent drainage to the provider. 71. Following a blood draw procedure for a fasting blood sugar (FBS) test, a client tells the nurse, "I'm glad they took my blood because I'm really hungry. All I've had since midnight is water and some juice." Which of the following actions should the nurse take? Reschedule the FBS test for early the next morning. 72. A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? Determine the client's understanding of the procedure. 73. A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? Irregular borders 74. A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? Decreased potassium 75. A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first? Ventilate with 100% oxygen. 76. A nurse is participating in a health fair for older adult clients. Which of the following immunizations should the nurse recommend for this age group? Herpes zoster 77. A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? Obtain a raised toilet seat. 78. A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. Which of the following findings should the nurse instruct the client to report to the provider? Onset of nausea 79. A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client? Combination oral contraceptives 80. A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has a loss of appetite because she has sores in her mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? Eat several, small-portioned meals daily. 81. A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first? Determine the client's daily elimination habits. 82. A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? Give the client liquids with increased viscosity. 83. A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Ceftriaxone 84. A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend promoting sleep? Listen to soft music before sleeping. 85. A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.) "I never forget to rinse my mouth after using my budesonide inhaler." "Between office visits, I keep a record of how many times I use my albuterol inhaler." "I use my albuterol inhaler before I go swimming." 86. A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? Mask 87. A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present? The client stops the nurse and asks for pain medication. 88. A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? Palpate the abdomen. 89. A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication? Decreases pain during urination EVERYTHING CORRECT 1. 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 fentanyl b. 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? Lungs clear Apical pulse 82/min Hyperactive bowel sounds Blood pressure 90/50 mm Hg 10. 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? I will spread my protein allowances over the entire day I should increase my intake of canned salmon to three times per week I will season my food with lemon pepper rather than salt I should limit my intake of hard cheese to 3 ounces each day 19. 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 tachypnea. In which of the following positions should the nurse place the client? a. Reverse Trendelenburg b. Side Lying c. High Fowlers d. Feet elevated 25. A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make? a. “This finding may indicate possible medication toxicity” b. “Your provider will prescribe a different medication regimen” c. “This is an expected adverse effect of this medication.” d. “You will need to increase your fluid intake to resolve this problem” 26. A nurse is preparing to administer a unit of packed RBCs for a client who is receiving a continuous IV infusion of 5% dextrose in water. Which of the following actions should the nurse take? a. Administer the unit through secondary IV tubing b. Verify the blood product with assistive personnel c. Begin an IV infusion of 0.9% sodium chloride d. Insert another 22-gauge IV catheter 27. A nurse is planning care for a client who is 12 hr. postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care? Check the client’s blood pressures every 8 hr. Administer opioids PO Assess urine output hourly Monitor for hypokalemia as a manifestation of acute rejection 28. A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding? a. Captopril b. Ibuprofen c. Digoxin d. Phenytoin 29. A nurse is assessing the extremities of a client who has Raynaud’s disease. Which of the following findings should the nurse expect? a. Blanching of the hands b. Hyperactive reflexes c. Calf pain with foot dorsiflexion d. Vitiligo on affected extremities 30. A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients? a. A client who has a peripherally inserted central catheter in the left arm b. A client who has left-sided Bell’s palsy c. A client who has a right upper extremity arteriovenous fistula d. A client who has right-sided weakness due to Parkinson’s disease 31. A nurse is providing teaching to a client who has DVT. Which of the following findings should the nurse identify as a risk factor for the development of DVTs? a. Hypertension b. Cirrhosis c. NSAIDS use d. Oral Contraceptive Use 32. A nurse is caring for client who has Cushing’s disease. Which of the following actions should the nurse take first? (Click Exhibit button for additional information) a. Check the client’s medication administration record for antihypertensive medication. b. Verify the client’s understanding of sodium restriction. c. Auscultate the client’s lung sound d. Determine the need for further glucose monitoring. 33. A nurse is assessing a client who has nephrotic syndrome. Which of the findings should the nurse expect? a. Proteinuria b. Flank pain c. Hyperalbuminemia d. Hypotension 34. 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. Oliguria b. S3/S4 galloping heart sounds c. Poor skin turgor d. Pitting edema 35. A nurse is caring for a client who has newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider? a. Notify the provider when tidaling ceases. b. Assisting the client out of bed three times daily. c. Vigorously strip the chest tube twice daily. d. Administer morphine 2 mg IV bolus every 3 hr PRN for pain. 36. A nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of the following instructions should the nurse include for home management of heart failure? a. Obtain daily weight. b. Use of salt substitute. c. Monitor Intake and Output d. Limit daily activity. 37. A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? a. I need to maintain pressure over the pacemaker site with an elastic bandage. b. I need to check my pulse rate every day for a full minute. c. The pacemaker will deliver shock if I develop a dysrhythmia d. When a microwave oven is in use, I need to stay out of the room. 38. A nurse in a clinic is providing preventive teaching to an older adult client during well visit. The nurse should instruct the client that which of the following immunization are recommended for healthy adults after age 60? Select all the Apply. a. Herpes Zoster b. Influenza c. HPV d. Meningococcal e. Pneumococcal Polysaccharide 39. A nurse is assessing a client who is 4hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report immediately? a. Bruising around the incision site b. Pallor in the affected extremity c. Urine output 150mL over 4hr d. Temperature of 37.9 (100.2) 40. A nurse is caring for an older adult client who has not been eating. Which of the following findings indicates dehydration? a. Crackles auscultated bilaterally b. Capillary refill of 2 seconds c. Diminished peripheral pulses d. Engorged neck veins 41. A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider? a. Increase intake of fiber rich foods b. May operate a motor vehicle when no longer taking analgesics c. Take tub baths instead of showers d. May place a small pillow under the head when sleeping 42. A nurse is assessing for elderly signs of compartment syndrome for a client who has a short leg fiberglass cast. Which of the following findings should the nurse expect? a. Bounding distal pulses b. Capillary refill less than 2 seconds c. Erythema of the toes d. Intense pain with movement 43. A nurse is caring for a client who is postoperative following coronary artery bypass surgery and reports shortness of breath. The nurse administers oxygen at 3L/min and obtains arterial blood gases 60 min later. Which of the following lab findings indicates a positive response to the oxygen therapy? a. PaCO2 34 mmHg b. Bicarbonate 20 mEq/L c. PaO2 90 mmHg d. ph 7.32 44. A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear (VIII)? a. Loss of the peripheral vision b. Disequilibrium with movement c. Deviation of the tongue from midline d. Inability to smell 45. A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse? a. Glasgow coma scale score changes from 14 to 9 b. Bilateral pupil diameter changes from 4 to 2 mm c. Pulse pressure changes from 30 to 20 mm Hg d. WBC count changes from 9000 to 16,000 mm3 46. A nurse is caring for a client who is taking furosemide. The client has a potassium level of 3.1 mEq/L. Which of the following should the nurse assess first? a. Urine output b. Level of orientation c. Cardiovascular status d. Muscle weakness 47. A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse should plan to take which of the following actions? a. Instruct the client to take deep breaths and hold them during the procedure b. Administer a stool softener following the procedure c. Ask the client to empty his bladder prior to the procedure d. Assist the client into the left lateral position during the procedure 48. A nurse is caring for a client who is 6 hours postoperatively following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of following electrolytes imbalances? a. Hyperatremia b. Hypermagnesemia c. Hypokalemia d. Hypocalcemia 49. A nurse is assessing a client 15 min after the start of a transfusion of 1 unit of packed RBC’s. Which of the following findings is an indication of a hemolytic transfusion reaction? a. Hypotension b. Bradypnea c. Bradycardia d. Hypothermia 50. A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first? a. Prepare the client for temporary pacing. b. Initiate IV fluid therapy for the client c. Measure the client’s blood pressure d. Administer atropine to the client 51. A nurse is caring for a client who has a prescription to discontinue a peripherally inserted central catheter. Which of the following actions should the nurse take? a. Apply slight pressure when resistance is met b. Measure the catheter after removal c. Remove the catheter with one continuous motion d. Place a dry sterile dressing to the site after removal 52. A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take? a. Provide humidified oxygen b. Implement fluid restriction c. Administer antibiotic medication d. Administer acetaminophen orally 53. A nurse is teaching a group of newly licensed nurses about acute respiratory failure. Which of the following manifestations should the nurse include in the teaching? a. Hypoxemia b. Hyperventilation c. Hypocarbia d. Hypervolemia 54. A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first? a. Obtain the client’s vital signs b. Clear items from the client’s surrounding area c. Loosen the client’s restrictive clothing d. Lower the client to the floor 55. A nurse is teaching a client who is receiving total parenteral nutrition at home through a central venous access device about transparent dressing changes. Which of the following instructions should the nurse include in the teaching? a. Change the dressing every 48 hr. b. Replace the extension tubing with each dressing change c. Use clean technique when changing the dressing d. Wear a mask during dressing change 56. A nurse is caring for a client in the emergency department who experienced a full- thickness burn injury to the lower torso 1 hr ago. Which of the following findings should the nurse expect? a. Decreased respiratory rate b. Hypotension c. Bradycardia d. Urinary diuresis 57. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding? a. Spider angiomas b. Palmar erythema c. Mental confusion d. Yellow Sclera 58. A nurse is providing instructions about foot care for a client who has a peripheral arterial disease. The nurse should identify which of the following statements by the client indicates an understanding of the teaching? a. “I apply a lubricating lotion to the cracked areas on the soles of my feet every morning” b. “I use my heating pad on a low setting to keep my feet warm.” c. “I soak my feet in hot water before trimming my toenails” d. I rest in my recliner with my feet elevated for about an hour every afternoon” 59. A nurse is teaching a client who has a new prescription for alendronate to treat osteoporosis. Which of the following instructions should the nurse include in the teaching? a. Swallow the medication with 120mL (4 oz) of water b. Take the medication with a vitamin E supplement c. Sit upright for 30 min after taking the medication d. Take the medication with lunch 60. 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 therapy b. Insert a urinary catheter c. Prepare the client for intravenous pyelogram d. Administer IV fluids to the client 61. A nurse is completing an assessment of an older adult client and notes redness 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. Manage the redness areas three times daily c. Support bony prominences with pillows d. Turn and reposition the client every 4 hr. 62. A nurse is caring for a client who has completed 10 daily cycles of Total parenteral Nutrition (TPN). Which of the following findings indicates that the client is receiving adequate TPN supplementation. a. Improved Mobility b. Weight gain of 9.1 kilograms to 20 pounds c. Potassium level of 2.5 meq/l d. BUN level of 15 mg/dL 63. A nurse is providing teaching to a client who is post-operative following a partial glossectomy. Which of the following statements by the client indicates an understanding of the teaching? a. I will consume can soup whenever sores appear in my mouth b. I will drink orange juice to increase my vitamin C intake c. I will rinse my toothbrush with hydrogen peroxide and water after each use d. I will inspect my mouth once each week for sores. 64. A nurse is performing ear irrigation for a client. Which of the following actions should the nurse take? a. Tilt the client's head 45 degrees b. Insert the tip of the syringe to .5 centimeters 1 inch into the ear canal c. Point the tip of the syringe toward the top of the ear canal d. Use cool fluid for irrigation 65. 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? a. Check the client's urine output b. Reposition the client in bed c. Increase the client's fluid intake d. Administer PRN pain medication 66. A nurse is providing teaching for a client who has diabetes mellitus about the self- administration of insulin. The client has prescriptions for regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? a. I will draw up regular insulin into the syringe first b. I will insert the needle at a 15-degree angle c. I will store prefilled syringes in the refrigerator with the needle pointing downward d. I will shake the NPH vial vigorously before drawing up the insulin 67. A nurse is caring for a client who is receiving Total parenteral Nutrition (TPN). Which of the following nursing actions are appropriate? (Select all the apply) a. Obtain the client's weight daily b. Increase the rate of infusion if Administration is delayed c. Monitor serum blood glucose during infusion d. In to use 0.9% sodium chloride if the solution is not available e. Verify the solution with another RN prior to infusion 68. A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse? a. Check potassium levels b. Administer 0.9% sodium chloride c. Begin bicarbonate continuous IV infusion d. Initiate continuous IV insulin infusiond 69. A nurse is reviewing the laboratory results of a female client who asked about acupuncture treatment for chemotherapy-induced nausea and vomiting. Which of the following laboratory results contraindication to receiving acupuncture? a. Absolute neutrophil count 5000/mm3 b. C-reactive protein 0.7 mg/dl c. Platelets 160,000/mm3 d. Hemoglobin 12g /dl 70. 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 should the nurse take? a. Gently massage the area around the client’s incision b. Place pillows under the client's knee c. Apply an ice pack to the client’s knee d. Perform range of motion exercises to the client’s knee 71. A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia? a. Hypertension b. Positive Chvostek’s sign c. Muscle weakness d. Oliguria 72. A nurse at a long-term care facility is assessing an older adult client. Which of the following findings should the nurse identify as an indication that the client has recall memory impairment? a. Inability to state what he has for dinner last night b. Inability to Name the members of his family c. Inability to count backwards from 10 d. Inability to state his current age 73. A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer? a. Chlorpromazine b. Dobutamine c. Mannitol d. Propanol 74. 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 thrombocytopenia and reports and nosebleed b. A client who has chronic obstruction pulmonary disease and oxygen saturation of 89% c. A client who has multiple sclerosis and Ataxia and vertigo d. A client who has left-sided paralysis and slurred speech from a prior stroke 75. A home care nurse is planning to use non-pharmacological pain relief measures for an older client who has severe chronic back pain. Which of the following guidelines should the nurse use? a. Use imagery with clients who have difficulty with focus and concentration b. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus c. Discontinue opioids before trying non-pharmacological methods of pain relief d. Distraction changes the client's perception of pain but does not affect the cause 76. A nurse is caring for a client who has pneumothorax and a chest tube with closed water seal drainage system. Which of the following actions should the nurse take? a. Strip or clear the chest tube every 8 hours b. Refill the water chamber if the fluid is low c. Empty the system at least every 8 hr d. Change the chest to site dressing every 24 hour. 77. A nurse is in an emergency department is reviewing a client's ECG reading. Which of the following findings should the nurse identify as an indication that the client has first-degree heart block? a. Prolonged PR intervals b. More p waves than QRS complexes c. Non-discernible p waves d. No correlation between p and QRS waves 78. A nurse is preparing to administer a unit of packed RBC's to a client who is anemic. Identify the sequence of steps the nurse should follow. a. Obtain venous access using a 19-gauge needle 3 b. Obtain the unit of packed rbc's from Blood Bank 1 c. Verify blood compatibility with another nurse 2 d. Initiate transfusion of the unit of packed rbc's 4 e. Remain with the client for the first 15 to 30 minutes of the infusion 5 79. A nurse is teaching a client who is to begin chemotherapy about peripherally inserted central catheter. Which of the following statements should the nurse include in the teaching? a. We will replace the PICC every month b. We can draw blood samples from the PICC for diagnostic test c. We will change the dressing daily d. We can measure your blood pressure in either arm 80. A nurse is assessing a client who has Pyelonephritis and reports flank pain. Which of the following actions should the nurse take? a. Assist the client to a sitting position b. Percuss the side of tenderness first c. Auscultate for a bruit over the coastal vertebral area d. Thump the area of tenderness directly with a closed fist 81. A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider? a. Peripheral pulses 2 + bilaterally b. Weight gain 1.1 kilogram to 2.4 pound in 24-hour c. Urine specific gravity 1.045 d. Creatinine 0.8 milliliter 82. A nurse is caring for an older adult client who is 72 hr. postoperative following a total hip arthroplasty. The client requires a PRN medication prior to ambulation. Which of the following medications should the nurse anticipate administering? a. Indomethacin b. Meperidine c. Naproxen d. Oxycodone 83. A nurse is caring for a client who has Haemophilus Influenzae type B. which of the following types of isolation should the nurse implement? a. Droplet b. Contact c. Airborne d. Protective 84. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should the nurse include, as an indication the client is no longer infectious? a. Mantoux skin test reveals and induration of less than 1mm b. Client no longer coughing up blood tinged sputum c. Positive Quantiferon TB d. Negative sputum culture for acid fast bacillus 85. A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's Airway which of the following interventions should the nurse take first? a. Cleanse the client wound b. Administer Analgesic medication c. Increase the room temperature d. Start an IV with a large bore needle 86. A nurse is caring for a client who has a central venous access 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. Obtain ABG values b. Perform an ECG c. Turn the client to his left side d. Clamp the catheter 87. A nurse is providing discharge teaching to a client who has impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? a. Wash your perineal area 2 times each day with antimicrobial soap b. Change the water in your drinking glass every 4 hours c. Wash your toothbrush in the dishwasher once each month d. Change your pet litter box daily 88. A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing the client? a. Serum Ammonia b. Glucose level c. Phosphate level d. Serum troponin 89. A nurse is caring for a client who has admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider? a. The client reports being extremely thirsty with a sore throat b. The amount of drainage is gradually decreasing c. The clients abdomen becomes distended and firm d. The drainage is bright green in color with brown fecal material 90. A nurse is caring for a client who takes Lisinopril for HTN. Which of the following client statements indicates an adverse effect of the medication? a. I have a heightened sense of taste b. I have a nagging, dry cough c. I have to urinate frequently d. I seem to be bruising more easily 91. A nurse is caring for a client who has an endotracheal tube. Which of the following actions should the nurse take to verify tube placement? a. Deflate the cuff to check the tube placement b. Place the client’s head and neck in a flexed position c. Observe for symmetry of chest expansion d. Document the tube length where it passes the chin 92. A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching? a. Take a laxative to prevent constipations b. Take an antacid 30 min before taking the medication c. Monitor heart rate once daily d. Drink 2 to 3 L of fluid daily 93. A nurse is caring for a client who presents to the emergency department after experiencing a heat stroke. Which of the following actions should the nurse take? a. Apply a cooling blanket. b. Assess axillary temperature every 15 min. c. Administer an antipyretic d. Administer lactated Ringers. 94. A nurse is presenting an in-service program about Parkinson’s disease (PD). Which of the following statements should the nurse include in the teaching? a. PD cause clients to have an increased sympathetic nervous system response b. PD results in the development of neurofibrillary tangles within the client’s brain c. PD results from a decreased amount of dopamine in the client’s brain d. PD manifestations worse due to the clients decreased production of acetylcholine. 95. A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin? a. Thrombocytopenia b. Thalassemia c. Rheumatoid arthritis d. COPD 96. A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are testing on the floor. Which of the following actions should the nurse take? a. Pull the client up in bed b. Tie knots in the ropes near the pulleys to shorten them c. Increase the elevation of the affected extremity d. Remove one of the weights 97. A nurse is reviewing a medical record of a client who has acute gout. The nurse expects an increase in which of the following laboratory results? a. Intrinsic factor b. Chloride level c. Uric acid d. Creatinine kinase 98. A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication? a. “I will check my pulse before I take this medication.” b. “I’ll check my blood pressure so it doesn’t get too high.” c. “I’m going to include more cantaloupe in my diet.” d. “I will try to limit foods that contain salt.” PN Med - Surg part MED-SURG PART A 1. A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching? a) Administer an analgesic following wound care. (The nurse should remind the family member to administer an analgesic prior to wound care to prevent discomfort.) b) Irrigate the wound with povidone iodine. (The nurse should remind the family member to irrigate the wound with 0.9% sodium chloride.) c) Cleanse the wound with a cotton-tipped applicator. (The nurse should remind the family member to avoid using a cotton- tipped applicator to cleanse the wound because the fibers can become embedded in the wound, cause infection, and delay wound healing.) d) Report purulent drainage to the provider. (The nurse should remind the family member to report signs of infection, including purulent drainage.) 2. A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of the following findings should the nurse expect? a) Flaccid neck (The nurse should recognize that nuchal rigidity, rather than a flaccid neck, is a manifestation of meningitis.) b) Stooped posture with shuffling gait (The nurse should recognize that a stooped posture with shuffling gait is a manifestation of Parkinson's disease, not a manifestation of meningitis.) c) Red macular rash (The nurse should expect to find a red macular rash, sometimes called a petechial rash, which is a manifestation of meningococcal meningitis.) d) Masklike facial expression (The nurse should recognize that a masklike expression is a manifestation of Parkinson's disease, not a manifestation of meningitis.) 3. A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? a) Increase fluid intake. (Fluid intake is beneficial for general health and wellness, and it helps to treat some disorders. Caffeine and alcohol intake can increase the client's risk of developing osteoporosis. However, fluid intake does not prevent bone loss.) b) Encourage range-of-motion exercises. (Range-of- motion exercises are beneficial for general health and 36 wellness, and they help to maintain flexibility and prevent contractures. However, range-of-motion exercises do not prevent bone loss.)   c) Massage bony prominences. (Massaging bony prominences should be avoided because it can traumatize deep tissues.) d) Encourage weight-bearing exercises. (Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis.) 4. A nurse is collecting data from a client and notices several skin lesion. Which of the following findings should the nurse report as possible melanoma? a) Scaly patches (The nurse should report scaly patches as possible basal or squamous cell carcinoma. b) Silvery white plaques (The nurse should report silvery white plaques as possible psoriasis.) c) Irregular borders (The nurse should report irregular borders of a skin lesion to the provider because it can indicate malignant melanoma.) d) Raised edges (The nurse should report raised edges of a skin lesion as possible basal cell carcinoma.) 5. A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching? a) Avoid liquids at mealtimes. (The nurse should remind the client to avoid drinking liquids at mealtimes to prevent the food from emptying into the small bowel too quickly.) 38 b) Exclude eating starchy vegetables. (The nurse should remind the client to include starchy vegetables in the meal plan to slow gastric emptying.)   c) Avoid eating high-protein meals. (The nurse should remind the client to eat high-protein meals to help slow gastric emptying.) d) Plan to increase intake of sweetened fruits. (The nurse should remind the client to exclude sweetened fruits from the diet to help slow gastric emptying.) 6. A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should the nurse review prior to the procedure? a) Albumin (Albumin levels determine the amount of protein the liver produces in the body and is an indication of hepatic function and nutritional status. However, it is not impacted by contrast media used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level prior to a cardiac catheterization.) b) Phosphorus (Phosphorus is an electrolyte that combines with calcium to maintain bone health and is involved as an energy source in metabolism. However, it is not impacted by contrast media used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level prior to a cardiac catheterization.) c) TSH (TSH levels determine thyroid function. However, it is not impacted by contrast media used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level prior to a cardiac catheterization.) 40 d) BUN (BUN levels indicate kidney function. Contrast media used during cardiac catheterization can cause renal failure. The nurse   should review this laboratory level to determine if the client can tolerate the IV contrast dye during the procedure.) 7. A nurse is reinforcing glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? a) "The HbA1c test should be performed 2 hr after I eat a meal that is high in carbohydrates." (The nurse should remind the client that carbohydrate consumption is not required for HbA1c testing.) b) "The HbA1c test can help detect the presence of ketones in my body." (The nurse should remind the client that urine testing can detect ketone bodies.) c) "I will have my HbA1c checked twice per year." (An HbA1c test provides the client's average glucose level for the preceding 3 months. The nurse should instruct the client to have her HbA1c tested twice yearly to manage her glucose.) d) "I will plan to fast before I have my HbA1c tested." (The nurse should remind the client that fasting is not required for HbA1C testing.) 8. A nurse is examining a client’s IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client’s manifestations indicate which of the following complications of IV therapy? a) Thrombophlebitis (The nurse should identify pain, warmth, and a red streak up the arm as indications of thrombophlebitis.) b) Infiltration (The nurse should identify swelling and cool skin at the IV site as indications of infiltration.) c) Hematoma (The nurse should identify swelling and bruising as indications of a hematoma that can develop by not holding enough pressure after discontinuing the IV.) d) Venous spasms (The nurse should identify cramping at or above the insertion site and numbness as indications of venous spasms.) 9. A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following should the nurse include in the teaching? a) Increase intake of fiber-rich foods. (The nurse should instruct the client to increase the amount of fiber-rich foods in his diet. Dried beans and brown rice are examples of fiber-rich foods.) b) Take a laxative every morning. (The nurse should instruct the client to initially take a laxative in the evening to stimulate the evacuation of stool. However, the nurse should instruct the client to use laxatives sparingly.) c) Maintain a fluid intake of 1200 mL per day. (The nurse should instruct the client to increase his fluid intake to 2,000 mL per day to maintain soft stools.) d) Limit activity to preserve energy. (The nurse should instruct the client to increase activity to stimulate the evacuation of stool.) 43 10. A nurse is caring for a client who is at risk for devel