eye shield on operative eye during the day d. Administer eye ointment before applying eye drops ANS:B 3 of 55 A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first? a. Obtain a sputum sample for culture b. Check his oxygen saturation level c. Administer an oral antipyretic d. Auscultate bilateral lung sound ANS:A 4 0f 55 An elder male client tells the nurse that he is loosing sleep because he has to get up several times at night to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? a. collect a urine specimen for culture analysis b. obtain a fingerstick blood glucose level c. palpate the bladder above the symphysis pubis d. review the client fluid intake ANS: C 5 of 55 An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? a. blood ph of 7.30 b. glucose of 350 mg /dl c. white blood cell count of 15000mm d. potassium of 2.5 meq/l ANS: D 6 of 55 A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cell. When notifying the healthcare provider what information should the nurse provide first using the SBAR communication process? a. explain specific reason for urgent notification b. preface the report by stating the clients name and admitting diagnosis c. communicate the pre-transfusion temperatures d. optain prn prescription for acetaminophen for fever 101f ANS: A 7 of 55 An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for discharge what important aspect regarding his medication therapy should the nurse explain? a. AZT therapy must be stopped when IV aerosol pentamine is being used. b. IV pentamine will be given until oral pentamine can be tolerated c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month d. Iv pentamine may offer protection to others aids related conditions such as kaposis sarcoma ANS:C 8 of 55 A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? a) ct a clean catch specimen b) te the suprapubic region c) uct to wipe from front to back d) re about recent sexual activity ANS: A 9 of 55 A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? a) offer the client reassurance that this information indicates that the clients cancer cells are benign b) explain that these tissue cells often respond more effectively to radiation than to chemotherapy c) ask the client in the healthcare provider has giving her any information about the classification of her cancer d) help the client make plans to begin inmediate treatment since her cancer is likely to spread quickly ANS: C 10 of 55 A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first? a. monitor bp q45 minutes b. lower the head of the chair and elevate feet c. stop dialysis treatment d. administer 5%albumin IV ANS: C 11 of 55 A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage should be increase 900 units/hr. The nurse should program the infusion pump to deliver how many ml/hr? =9 12 of 55 The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this diagnosis? a. upper mid abdominal gnawing and burning pain b. severe abdominal cramps and diarrhea after eating spicy foods c. marked loss of weight and appetite over the last few months d. use of chewable and liquid antacids for indigestion ANS: A 13 of 55 The nurse is providing preoperative education for a jewish client schedule to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? xenograft is taken from nonhuman sources ing increases the risk for bacterial infection the burn heals the graft permanently attaches s are later removed by debriding procedure ANS: A 14 of 55 A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report? a. jaundice sclera b. intestinal cramping c. weakness and fatigue d. weight loss ANS: A 15 of 55 During a home visit the nurse assesses the skin of a client with eczema who reports than an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? a. an old friend with eczema came for visit b. recently received an influenza immunization c. corticosteroid cream was applied to eczema d. a grandson and his new dog recently visited ANS: D 16 of 55 When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching? a. select a protein rich food daily b. restrict sodium intake c. eat high potassium foods d. Avoid foods high in carbohydrate ANS: B 17 of 55 A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt? a. discontinue intravenous therapy b. Assess for abdominal distension and tenderness c. Obtain a prescription for a diet change d. Auscultate bowel sound in all four quadrants ANS: D 18 of 55 A client diagnose with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart? a. drive to the nearest emergency department b. take another NTG SL tablet and lie down until angina subsides c. call primary healthcare provider d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – -50. Two days following abdominal surgery a client begins to complain of cramping abdominal pain, and the nurse’s inspection of the abdomen indicates slight distention. Which action should the nurse implement first? A. Encourage the client to ambulate B. Offer ice chips or warm liquids C. Assess the clients temperature D. Auscultate the clients abdomen 51. A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. It is most important for the nurse to emphasize the need to observe for changes in which characteristic. Elasticity of the skin Pigmentation of the skin Muscle aches and pain Appearance of any mole 52. A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider? Low back pain and hypotension Rhinitis and nasal stuffiness Delayed painful rash with urticaria Arthritic joint changes and chronic pain 53. The nurse plans to administer naloxone (Narcan) 1mg .the label of the 10 ml vial indicates that the drug concentration is 0.4 mg/mL how many ml should the nurse administer R/ 2.5 Ml 54. Which nursing problem has the highest priority when planning care for a client whit ostemalacia? Altered tissue perfusion Risk of infection Rick for injury Sleep pattern disturbance 55. The nurse is providing preoperative educationfor a Jewish client schedule to receive a xenograft to promote burn healing .Which information should the nurse provide this client? The xenograft is taken from nonhuman sources 56. A client with pheochromocytoma reports the onset of a severe headache The nurse observe that the client is very diaphoretic. Which assessment data should the nurse obtain next? Blood pressure 57. A client develops subcutaneous emphysema following a thoracotomy. To evaluate the progression of subcutaneous emphysema,which assements should the nurse make select all that apply Measure the oxygen saturation Palpate skin around the chest tube Auscultate breath sounds bilaterally Assess for deviation of the sternum Observe appearance of the neck 58. The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. what action would be best for the nurse to take? A Obtain a specimen of the drainage for culture B Maintain the current IV antibiotic schedule C Milk the tube to remove any clots D – Schedule a portable chest X ray per PRN protocol 59. Which action is most important for the nurse to implant to reduce the risk for deep vein thrombosis in a postoperative client? A change the client IV access site at least 72 h B assist the client in turning from side to side q 2h C Advise the client to perform leg exercise regular 60. An adult female whit multiple sclerosis (MS) fell while walking to the bathroom. On transfer to the intensive care unit ,she is confused and has projectile vomiting twice Which intervention should the nurse implemented first? A administer a PRN ANTIEMETEC as prescribed B Determine client last dose of corticosteroids C Determine neurological baseline prior to the fall D Complete head -to toe neurological assessment 61. A Fame client whit chronic syndrome of inappropriate ant diuretic hormone (SIADH) report to the nurse that she is constantly thirsty. What action should the nurse take ? Encourage the client to use hard candy frequently to help relieve her thirst 62. The nurse is assessing a group of older adults. What factor in a male clients history puts him at greatest risk for developing colon cancer? A -smoker cigarette B- Eats a high fat diet C- Has intestinal polyps D- Is excessively exposed to sunlight 63. The nurse should include which information in the teaching plan for a client recently diagnosed whit primary open -angle glaucoma? SELECT ALL THE APPLY A -Limit salt intake to reduce increased intraocular pressure (iop) B -Regular eye examine are necessary tomonitor IOP and visual field C -Daily eye medication is instilled to lower intraocular pressure D -expect vision loss to progress Fromm central vision to peripheral vision E -Vigorous exercise such as jogging or running should be avoided 64. A client with stage IV bone cancer is admitted to the hospital for pain control the client verbalizes continuous severe pain 8 on a 1 to 10 scale which intervention should the nurse implement A Alternate IV AND IM analgesic medication B Admitter opioid and no opioid medication simultaneously C -Educate client on signs and symptoms of narcotic dependency D Give maximum dosage when score when score reaches 10 65. The nurse completes the admission assessment of female client whit systemic lupus erythematosus Which finding requires the most immediate follow -up assessment by the nurse ? Fatigue Joint pain Alopecia Hematuria 66. What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? Light housekeeping is permitted. but avoid heavy lifting 67. A client who has been takin finasteride (proscar) an enzyme ( 5 alpha reductase) inhibitor used to shrink the gland , is admitted because of continuing begin prostatic hypertrophy(BPH0 symptoms when planning care which nursing problem should the nurse plan to address first? disturbed sleep patters Urinary retention Chronic pain Risk for infection [Show less]
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