R N
A d u l t
M e d i c a l
S u r g i c a l
O n l i n e
P r a c t i c e
2 0 2 3
a
nurse
is
caring
for
a
client
who
has
hepatic
encephalopathy
that
is
being
treated
with
lactulose.
the
client
is
experiencing
excessive
stools.
which
of
the
following
findings
is
an
adverse
ef fect
of
the
medication?
-
ANS-hypokalemia
Lactulose
works
by
stimulating
the
production
of
excess
stools
to
rid
the
body
of
excess
ammonia.
These
excessive
stools
can
result
in
hypokalemia
and
dehydration.
a
nurse
is
caring
for
a
client
who
has
emphysema
and
is
receiving
mechanical
ventilation.
the
client
appears
anxious
and
restless,
and
the
high-pressure
alarm
is
sounding.
which
of
the
following
actions
should
the
nurse
take
first?
-
ANS-instruct
the
client
to
allow
the
machine
to
breathe
for
them.
When
providing
client
care,
the
nurse
should
first
use
the
least
restrictive
intervention.
Therefore,
the
first
action
the
nurse
should
take
is
to
provide
verbal
instructions
and
emotional
support
to
help
the
client
relax
and
allow
the
ventilator
to
work.
Clients
can
exhibit
anxiety
and
restlessness
when
trying
to
"fight
the
ventilator ."
a
nurse
is
teaching
a
client
who
has
a
family
history
of
colorectal
cancer .
to
help
mitigate
this
risk,
which
of
the
following
dietary
alterations
should
the
nurse
recommend?
-
ANS-add
cabbage
to
the
diet.
T o
help
reduce
the
risk
for
colorectal
cancer ,
the
client
should
consume
a
diet
that
is
high
in
fiber ,
low
in
fat,
and
low
in
refined
carbohydrates.
Brassica
vegetables,
such
as
cabbage,
cauliflower ,
and
broccoli,
are
high
in
fiber .
a
home
health
nurse
is
assigned
to
a
client
who
was
recently
discharged
from
a
rehabilitation
center
after
experiencing
a
right-hemispheric
stroke.
which
of
the
following
neurological
deficits
should
the
nurse
expect
to
find
when
assessing
the
client?
-
ANS-visual
spatial
deficits
left
hemianopsia
one-sided
neglect
a
nurse
is
caring
for
a
client
who
has
viral
pneumonia.
the
client's
pulse
oximeter
readings
have
fluctuated
between
79%
and
88%
for
the
last
30
min.
which
of
the
following
oxygen
delivery
systems
should
the
nurse
initiate
to
provide
the
highest
concentration
of
oxygen?
-
ANS-nonrebreather
mask The
nurse
should
initiate
a
nonrebreather
mask
to
deliver
between
80%
to
95%
oxygen
to
the
client.
A
client
who
has
an
unstable
respiratory
status
should
receive
oxygen
via
a
nonrebreather
mask.
a
nurse
is
caring
for
a
client
who
has
bilateral
pneumonia
and
an
SaO2
of
85%.
the
client
has
dyspnea
with
a
productive
cough
and
is
using
accessory
muscles
to
breathe.
which
of
the
following
actions
should
the
nurse
take
first?
-
ANS-place
the
client
in
high-fowler's
position.
The
greatest
risk
to
this
client
is
injury
from
airway
obstruction.
Therefore,
the
priority
intervention
the
nurse
should
take
is
to
move
the
client
into
high-Fowler's
position.
High-Fowler's
position
facilitates
lung
expansion
and
improves
ventilation
and
gas
exchange.
a
nurse
is
planning
care
for
a
client
who
has
extensive
burn
injuries
and
is
immunocompromised.
which
of
the
following
precautions
should
the
nurse
include
in
the
plan
of
care
to
prevent
a
Pseudomonas
aeruginosa
infection.
-
ANS-avoid
placing
plants
or
flowers
in
the
client's
room.
Live
plants
can
harbor
P .
aeruginosa,
and
this
bacterium
can
infect
burn
wounds
and
cause
life-threatening
complications.
The
nurse
should
ensure
no
one
brings
live
plants
or
flowers
into
the
client's
room.
an
older
adult
client
is
brought
to
an
emergency
department
by
a
family
member .
which
of
the
following
assessment
findings
should
cause
the
nurse
to
suspect
that
the
client
has
hypertonic
dehydration?
-
ANS-Urine
specific
gravity
of
1.045
A
urine
specific
gravity
greater
than
1.030
indicates
a
decrease
in
urine
volume
and
an
increase
in
osmolarity ,
which
is
a
manifestation
of
hypertonic
dehydration.
a
nurse
in
an
emergency
department
is
reviewing
the
providers
prescriptions
for
a
client
who
sustained
a
rattlesnake
bite
to
the
lower
leg.
which
of
the
following
prescriptions
should
the
nurse
expect?
-
ANS-administer
an
opioid
analgesic
to
the
client.
The
nurse
should
expect
a
prescription
for
an
opioid
analgesic
to
promote
comfort
following
a
rattlesnake
bite.
a
nurse
is
assessing
a
client
who
has
had
a
suspected
stroke.
the
nurse
should
place
the
priority
on
which
of
the
following
findings?
-
ANS-dysphagia Dysphagia
indicates
that
this
client
is
at
greatest
risk
for
aspiration
due
to
impaired
sensation
and
function
within
the
oral
cavity .
Therefore,
the
nurse
should
place
priority
on
this
finding.
a
nurse
is
teaching
a
young
adult
client
how
to
perform
testicular
self-examination.
which
of
the
following
instructions
should
the
nurse
include?
-
ANS-roll
each
testicle
between
the
thumb
and
fingers.
The
nurse
should
instruct
the
client
to
roll
each
testicle
horizontally
between
the
thumbs
and
fingers
to
feel
for
any
lumps
deep
in
the
center
of
the
testicle.
a
nurse
is
providing
instructions
to
a
client
who
has
type
2
diabetes
mellitus
and
a
new
prescription
for
metformin.
which
of
the
following
statements
by
the
client
indicates
an
understanding
of
the
teaching?
-
ANS-"I
should
take
this
medication
with
a
meal."
The
client
should
take
metformin
with
or
immediately
following
meals
to
improve
absorption
and
to
minimize
gastrointestinal
distress.
a
nurse
is
teaching
a
client
who
has
venous
insuf ficiency
about
self-care.
which
of
the
following
statements
should
the
nurse
identify
as
an
indication
that
the
client
understands
the
teaching?
-
ANS-"I
will
wear
clean
graduated
compression
stockings
every
day ."
The
client
should
apply
a
clean
pair
of
graduated
compression
stockings
each
day
and
clean
soiled
stockings
with
mild
detergent
and
warm
water
by
hand.
a
nurse
is
assessing
a
client
who
has
acute
cholecystitis.
which
of
the
following
findings
is
the
nurse's
priority?
-
ANS-tachycardia
When
using
the
urgent
vs.
nonurgent
approach
to
client
care,
the
nurse
should
determine
that
the
priority
finding
is
tachycardia.
T achycardia
is
a
manifestation
of
biliary
colic,
which
can
lead
to
shock.
The
nurse
should
position
the
head
of
the
client's
bed
flat
and
report
this
finding
immediately
to
the
provider .
a
nurse
is
reviewing
the
health
record
of
a
client
who
is
scheduled
for
allergy
skin
testing.
the
nurse
should
postpone
the
testing
and
report
to
the
provider
with
if
the
following
findings?
-
ANS-current
medications
A d u l t
M e d i c a l
S u r g i c a l
O n l i n e
P r a c t i c e
2 0 2 3
a
nurse
is
caring
for
a
client
who
has
hepatic
encephalopathy
that
is
being
treated
with
lactulose.
the
client
is
experiencing
excessive
stools.
which
of
the
following
findings
is
an
adverse
ef fect
of
the
medication?
-
ANS-hypokalemia
Lactulose
works
by
stimulating
the
production
of
excess
stools
to
rid
the
body
of
excess
ammonia.
These
excessive
stools
can
result
in
hypokalemia
and
dehydration.
a
nurse
is
caring
for
a
client
who
has
emphysema
and
is
receiving
mechanical
ventilation.
the
client
appears
anxious
and
restless,
and
the
high-pressure
alarm
is
sounding.
which
of
the
following
actions
should
the
nurse
take
first?
-
ANS-instruct
the
client
to
allow
the
machine
to
breathe
for
them.
When
providing
client
care,
the
nurse
should
first
use
the
least
restrictive
intervention.
Therefore,
the
first
action
the
nurse
should
take
is
to
provide
verbal
instructions
and
emotional
support
to
help
the
client
relax
and
allow
the
ventilator
to
work.
Clients
can
exhibit
anxiety
and
restlessness
when
trying
to
"fight
the
ventilator ."
a
nurse
is
teaching
a
client
who
has
a
family
history
of
colorectal
cancer .
to
help
mitigate
this
risk,
which
of
the
following
dietary
alterations
should
the
nurse
recommend?
-
ANS-add
cabbage
to
the
diet.
T o
help
reduce
the
risk
for
colorectal
cancer ,
the
client
should
consume
a
diet
that
is
high
in
fiber ,
low
in
fat,
and
low
in
refined
carbohydrates.
Brassica
vegetables,
such
as
cabbage,
cauliflower ,
and
broccoli,
are
high
in
fiber .
a
home
health
nurse
is
assigned
to
a
client
who
was
recently
discharged
from
a
rehabilitation
center
after
experiencing
a
right-hemispheric
stroke.
which
of
the
following
neurological
deficits
should
the
nurse
expect
to
find
when
assessing
the
client?
-
ANS-visual
spatial
deficits
left
hemianopsia
one-sided
neglect
a
nurse
is
caring
for
a
client
who
has
viral
pneumonia.
the
client's
pulse
oximeter
readings
have
fluctuated
between
79%
and
88%
for
the
last
30
min.
which
of
the
following
oxygen
delivery
systems
should
the
nurse
initiate
to
provide
the
highest
concentration
of
oxygen?
-
ANS-nonrebreather
mask The
nurse
should
initiate
a
nonrebreather
mask
to
deliver
between
80%
to
95%
oxygen
to
the
client.
A
client
who
has
an
unstable
respiratory
status
should
receive
oxygen
via
a
nonrebreather
mask.
a
nurse
is
caring
for
a
client
who
has
bilateral
pneumonia
and
an
SaO2
of
85%.
the
client
has
dyspnea
with
a
productive
cough
and
is
using
accessory
muscles
to
breathe.
which
of
the
following
actions
should
the
nurse
take
first?
-
ANS-place
the
client
in
high-fowler's
position.
The
greatest
risk
to
this
client
is
injury
from
airway
obstruction.
Therefore,
the
priority
intervention
the
nurse
should
take
is
to
move
the
client
into
high-Fowler's
position.
High-Fowler's
position
facilitates
lung
expansion
and
improves
ventilation
and
gas
exchange.
a
nurse
is
planning
care
for
a
client
who
has
extensive
burn
injuries
and
is
immunocompromised.
which
of
the
following
precautions
should
the
nurse
include
in
the
plan
of
care
to
prevent
a
Pseudomonas
aeruginosa
infection.
-
ANS-avoid
placing
plants
or
flowers
in
the
client's
room.
Live
plants
can
harbor
P .
aeruginosa,
and
this
bacterium
can
infect
burn
wounds
and
cause
life-threatening
complications.
The
nurse
should
ensure
no
one
brings
live
plants
or
flowers
into
the
client's
room.
an
older
adult
client
is
brought
to
an
emergency
department
by
a
family
member .
which
of
the
following
assessment
findings
should
cause
the
nurse
to
suspect
that
the
client
has
hypertonic
dehydration?
-
ANS-Urine
specific
gravity
of
1.045
A
urine
specific
gravity
greater
than
1.030
indicates
a
decrease
in
urine
volume
and
an
increase
in
osmolarity ,
which
is
a
manifestation
of
hypertonic
dehydration.
a
nurse
in
an
emergency
department
is
reviewing
the
providers
prescriptions
for
a
client
who
sustained
a
rattlesnake
bite
to
the
lower
leg.
which
of
the
following
prescriptions
should
the
nurse
expect?
-
ANS-administer
an
opioid
analgesic
to
the
client.
The
nurse
should
expect
a
prescription
for
an
opioid
analgesic
to
promote
comfort
following
a
rattlesnake
bite.
a
nurse
is
assessing
a
client
who
has
had
a
suspected
stroke.
the
nurse
should
place
the
priority
on
which
of
the
following
findings?
-
ANS-dysphagia Dysphagia
indicates
that
this
client
is
at
greatest
risk
for
aspiration
due
to
impaired
sensation
and
function
within
the
oral
cavity .
Therefore,
the
nurse
should
place
priority
on
this
finding.
a
nurse
is
teaching
a
young
adult
client
how
to
perform
testicular
self-examination.
which
of
the
following
instructions
should
the
nurse
include?
-
ANS-roll
each
testicle
between
the
thumb
and
fingers.
The
nurse
should
instruct
the
client
to
roll
each
testicle
horizontally
between
the
thumbs
and
fingers
to
feel
for
any
lumps
deep
in
the
center
of
the
testicle.
a
nurse
is
providing
instructions
to
a
client
who
has
type
2
diabetes
mellitus
and
a
new
prescription
for
metformin.
which
of
the
following
statements
by
the
client
indicates
an
understanding
of
the
teaching?
-
ANS-"I
should
take
this
medication
with
a
meal."
The
client
should
take
metformin
with
or
immediately
following
meals
to
improve
absorption
and
to
minimize
gastrointestinal
distress.
a
nurse
is
teaching
a
client
who
has
venous
insuf ficiency
about
self-care.
which
of
the
following
statements
should
the
nurse
identify
as
an
indication
that
the
client
understands
the
teaching?
-
ANS-"I
will
wear
clean
graduated
compression
stockings
every
day ."
The
client
should
apply
a
clean
pair
of
graduated
compression
stockings
each
day
and
clean
soiled
stockings
with
mild
detergent
and
warm
water
by
hand.
a
nurse
is
assessing
a
client
who
has
acute
cholecystitis.
which
of
the
following
findings
is
the
nurse's
priority?
-
ANS-tachycardia
When
using
the
urgent
vs.
nonurgent
approach
to
client
care,
the
nurse
should
determine
that
the
priority
finding
is
tachycardia.
T achycardia
is
a
manifestation
of
biliary
colic,
which
can
lead
to
shock.
The
nurse
should
position
the
head
of
the
client's
bed
flat
and
report
this
finding
immediately
to
the
provider .
a
nurse
is
reviewing
the
health
record
of
a
client
who
is
scheduled
for
allergy
skin
testing.
the
nurse
should
postpone
the
testing
and
report
to
the
provider
with
if
the
following
findings?
-
ANS-current
medications
