ATI Med Surg Proctored 2023 Exam Questions and Complete Solutions

1. A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?- Ans: Ensure the client has a patient IV The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity 2. A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider? Ans: Hgb 8 g/dL The nurse should report an Hgb level of 8 g/dL, which is below the expected reference range and is an indicator of postoperative hemorrhage or anemia 3. A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect? Ans: - Stone fragments in the urine ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones 4. A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? Ans: Initiate airborne precautions This client is exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions 5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take? Ans: Administer dextrose 10% in water until the new bag arrives TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid a precipitous drop in the client's blood glucose level. 6. A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?- Ans: Calcium Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration. 7. A nurse is caring for a client who has emphysema and is receiving mechani- cal 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." 8. A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication? Ans: Orthostatic hypotension The nurse should identify that dilation of arteries and veins causes orthostatic hypotension, which is an adverse effect of enalapril. 9. A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing? Ans: Urine output 25 mL/hr Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing. 10. A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching? Ans: "You should void every 4 hours to decrease the risk of urinary retention." The nurse should instruct the client to void at least every 4 hr to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics 11. A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first? Ans: Obtain vital signs. The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making. 12. A nurse at a provider's office is caring for a client who is 2 weeks postop- erative following a gastrectomyA nurse is providing teaching for the client. Which of the following instructions should the nurse include? Ans: - Avoid drinking fluids with meals - Eat several small meals per day - Consume high-protein snacks - Avoid highly seasoned foods Ans:Maintain a high carbohydrate intake is incorrect. Dumping syndrome requires a low carbohydrate diet because of reactive hypoglycemia. Eat five servings of fresh fruit per day is incorrect. The client should limit intake to three servings of unsweetened cooked or canned fruit per day. Avoid drinking fluids with meals is correct. The nurse should instruct the client to drink fluids 30 min before or after meals Eat several small meals per day is correct. The nurse should instruct the client to eat several small, frequent meals instead of three large meals per day. Consume high-protein snacks is correct. The client should eat snacks that are high in protein and low in carbohydrates to prevent the gastric food boluses and reactive hypo- glycemia in dumping syndrome. Avoid highly seasoned foods is correct. The nurse should instruct the client to avoid excessive amounts of spices and salt. 13. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? Ans: Bradycardia A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other compo- nents of Cushing's triad are severe hypertension and a widened pulse pressure 14. A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is suc- cessfully coping with the change? Ans: "I used to never worry about my feet. Now, I inspect my feet every day with a mirror." This statement indicates that the client is successfully coping with the change because the client is performing preventive foot care to reduce the risk for compli- cations 15. A nurse in an emergency department is reviewing the provider's prescrip- tions 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 16. A nurse is caring for a client who is receiving dialysis treatment Ans: - Place the client in Trendelenburg position is indicated. The client should be placed in the Trendelenburg position to increase blood flow to the heart, improving cardiac output and organ perfusion. - Administer a 0.9% sodium chloride 200 mL IV bolus is indicated. The nurse should administer 200 mL of 0.9% sodium chloride IV bolus to increase fluid volume and the client's blood pressure. - Apply oxygen at 2 L/min via nasal cannula is indicated. The nurse should administer oxygen at 2 L/min via nasal cannula to increase the amount of oxygen carried in the blood. - Notify the provider immediately is indicated. The nurse should notify the provider immediately as part of the nurse's role to provide an update on the client's condition 17. A nurse is teaching a class about client rights. Which of the following instructions should the nurse include? Ans: A client should sign an informed consent before receiving a placebo during a research trial. A nurse should ensure a client has provided informed consent before administering a placebo. The nurse should not administer a placebo to a client who thinks it is an active medication, because this action is a violation of client rights. 18. A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions? Ans: Suppressing gastric acid production Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production 19. A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? Ans: A client who is receiving preoperative teaching for a right knee arthroplasty The nurse should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions 20. A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? Ans: Wear a mask Bacterial meningitis requires droplet precautions; therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy. 21. A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching? Ans: "I am dieting to lose weight." Excess weight creates increased abdominal pressure that can result in stress incontinence 22. A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect? Ans: Hypoactive bowel sounds Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to decreased peristalsis. 23. The nurse is reviewing the client's diagnostic results. Which of the follow- ing findings requires follow-up by the nurse? Select all that apply Ans: - PCO2 level - WBC count - Chest X-ray - Oxygen saturation level -BUN level PCO2 level is correct. The client has an elevated PCO2 level, which indicates the retention of carbon dioxide. Therefore, this finding requires follow-up by the nurse. WBC count is correct. The client has an elevated WBC count, which indicates an infection. Therefore, this finding requires follow-up by the nurse. Chest x-ray is correct. The client's chest x-ray indicates increased opacity in the bilateral posterior lobes, which is a manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse. Oxygen saturation level is correct. The client's oxygen saturation is decreased, which is a manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse. Calcium level is incorrect. The client's calcium level is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. HCO3- level is incorrect. The client's HCO3- level is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. BUN level is correct. The client's BUN is elevated, which is a manifestation of dehydration or kidney disease. Therefore, this finding requires follow-up by the nurse. 24. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again. - ANSWER- Client is short of breath and has a productive cough with yellow mucus "I could barely breathe when I got up this morning and I had a throbbing headache." Ans: Crackles heard in posterior lungs Client is diaphoretic Client is short of breath and has a productive cough with yellow mucus is correct. Shortness of breath, along with a productive cough with yellow mucus, indicates a potential problem. "I could barely breathe when I got up this morning and I had a throbbing headache" is correct. Difficulty breathing and a throbbing headache indicates a potential problem. Crackles heard in posterior lungs is correct. Crackles heard in the posterior lower lobes indicate a potential problem Capillary refill less than 2 seconds is incorrect. A capillary refill less than 2 seconds is within the expected reference range and indicates adequate perfusion. Client is diaphoretic is correct. Diaphoresis is a manifestation of an elevated temperature or hypoglycemia and indicates a potential problem. Pedal pulses +2 bilaterally is incorrect. Pedal pulses +2 bilaterally is within the expected reference range and indicates adequate perfusion. 25. The nurse should first address the client's .. followed by the client's. Ans: Oxy- gen saturation Temperature Dropdown 1 Oxygen saturation is correct. The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to address the client's oxygen saturation. The client's oxygen saturation is 88%, which indicates hypoxemia and requires supplemental oxygen. Loss of appetite is incorrect. The nurse should address the client's loss of appetite, which is a manifestation of an infection. However, there is another finding the nurse should address first. BUN level is incorrect. The nurse should address the client's BUN level because it is elevated. However, there is another finding the nurse should address first. Dropdown 2 Heart rate is incorrect. The nurse should address the client's elevated heart rate, which can result in decreased cardiac output. However, there is another finding the nurse should address first. Temperature is correct. The nurse should next address the client's elevated temperature, which is a manifestation of an infection. The client's elevated temperature can cause an increase in other vital signs, such as heart rate. Headache is incorrect. The nurse should address the client's headache, which is a manifestation of an infection. However, there is another finding the nurse should address first. 26. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Ans: - Cough and deep breathe every 2 hr is anticipated. The nurse should anticipate a prescription for coughing and deep breathing to promote lung expansion and improve impaired gas exchange. Obtain a sputum culture and sensitivity is anticipated. The nurse should anticipate a prescription for a sputum culture and sensitivity to determine the type of bacteria present and to identify antibiotics to be prescribed. Perform neurological checks every 2 hr is nonessential. The client is alert and oriented to person, place, and time. Therefore, the nurse does not need to perform neurological checks every 2 hr. Administer oxygen at 3 L/min via nasal cannula is anticipated. The client's oxygen saturation level is 88% on room air, which indicates hypoxemia. Therefore, the nurse should administer oxygen at 3 L/min via nasal cannula. Limit the client's fluid intake to 1,500 mL per day is contraindicated. The client has manifestations of dehydration. There- fore, fluid restriction is contraindicated. Acetaminophen 500 mg PO every 6 hr as needed is anticipated. The nurse should anticipate a prescription for acetaminophen to reduce the client's temperature and promote comfort. Famotidine 40 mg PO daily is nonessential. Famotidine is a histamine2 antagonist that is used in short-term therapy for the treatment of peptic ulcers. Therefore, the nurse does not need to administer famotidine 40 mg PO daily. 27. The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention Ans: Temperature WBC count Potassium level Temperature is correct. The nurse should identify that the client continues to have a fever as a result of the body's immune system fighting the infection. Therefore, this finding requires nursing intervention. WBC count is correct. The nurse should identify that the client's WBC count remains elevated, which indicates an infection. Therefore, this finding requires nursing inter- vention. Heart rate is incorrect. The nurse should identify the client's heart rate is within the expected reference range. Therefore, this finding does not require nursing intervention. Potassium level is correct. The nurse should identify that the client's potassium level is elevated, which places them at risk for cardiac dysrhythmias. Therefore, this finding requires nursing intervention. Oxygen saturation is incorrect. The nurse should identify the client's oxygen satura- tion has improved and is within the expected reference range. Therefore, this finding does not require nursing intervention. 28. The nurse is reviewing the client's medical record from Day 5.Click to highlight the findings below that indicate the client is improving. To deselect a finding, click on the finding again Ans: Heart rate is 72/min Respiratory rate is 20/min Blood pressure is 128/56 mm Hg Oxygen saturation is 95% on room air 29. A nurse is teaching a young adult client how to perform testicular self ex- amination. 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 30. A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider? Ans: Blood pressure 170/80 mm Hg Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm 31. A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer? Ans: Calcium carbonate Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often oc- curring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to administer a calcium supplement, such as calcium carbonate, as a calcium replacement. 32. A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority? Ans: Turn the client to the side The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration 33. A nurse is preparing a client who has supraventricular tachycardia for elec- tive cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion? Ans: Digoxin 34. A nurse in a providers office is caring from a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make? Ans: "You will not be able to use sildenafil if you are taking nitroglycerin." The client should not use sildenafil when taking nitroglycerin because both medica- tions can cause vasodilation and lead to significant hypotension 35. A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor? Ans: Respiratory paralysis The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate. Tachycardia- Magnesium sulfate is used to treat cardiac dysrhythmias, such as tor- sades de pointes and refractory ventricular fibrillation. Depressed cardiac function, including heart block, is an adverse effect of magnesium sulfate. Increased BP- Magnesium sulfate is used to treat cardiac dysthymias, such as tor- sades des pointes and refractory ventricular fibrillation. However, magnesium sulfate administration can result in systemic vasodilation and subsequent hypotension. *hyperreflexia- Hyperreflexia is seen in clients who have hypomagnesemia. De- pressed or absent reflexes are an adverse effect of magnesium sulfate. 36. A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? Ans: "I am taking this medication to increase my energy level." The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance 37. A nurse is caring for a client has who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis? Ans: Hyperkalemia The nurse should identify that a client who has chronic glomerulonephritis can experience hyperkalemia as a result of kidney failure. Kidney failure results in decreased excretion of potassium 38. A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with fever- few? Ans: Naproxen Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding. 39. 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 To 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. 40. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside? Ans: Suction machine The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client's airway as needed and reduce the risk for aspiration. 41. A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment? Ans: History of asthma A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate. 42. A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?- Ans: Report of a night cough The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider. 43. A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan? Ans: Monitor the client's temperature every 4 hr. The nurse should monitor the temperature of a client who has neutropenia every 4 hr because the client's reduced amount of leukocytes greatly increases the client's risk for infection 44. A nurse is caring for a client who was just admitted from the emergency department (ED) Ans: Acute chest syndrome and pneumonia 45. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? Ans: Calcium A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis 46. A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? Ans: "You should cut the opening of the skin barrier one-eighth inch wider than the stoma." The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine. 47. A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? Ans: Heart rate 110/min A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate. 48. A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? Ans: "I will monitor my blood pressure while taking this medication." The client should monitor their blood pressure while taking this medication be- cause hypertension is a common adverse effect and can lead to hypertensive encephalopathy. 49. A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take? Ans: - Instruct the client to splint the abdomen with a pillow for coughing - Plan to ambulate the client as soon as possible - Report urinary output to the provider - - Ask the client to rate their pain on a 0 to 10 pain scale 50. A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan? Ans: Tell the client that it is possible to return to similar previous levels of activity The nurse should help the client develop realistic goals and activities to have a productive life. 51. 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 52. A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority? Ans: Increased respiratory secretions Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. These secretions place the client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the ALS and the pneumonia 53. A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experi- encing a role change? Ans: A client who has multiple sclerosis and is experiencing progressive difficulty ambulating The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change as the client becomes less independent 54. 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 effect of this 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 55. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? Ans: BUN 32 mg/dL DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine 56. Select the 4 findings that require follow-up by the nurse. Ans: Virtual distur- bances Tingling of the lips Hand grasps Expressive aphasia 57. A nurse is caring for a client who has a migraine. Which of the following interventions should the nurse anticipate? Ans: Administer sumatriptan Dim the lights in the client's room 58. A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? Ans: Demonstrate ways to deep breathe and cough. The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complica- tions 59. A nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching? Ans: Take daily cranberry supplements. The client should take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI. 60. A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care? Ans: Wear a lead apron while providing care to the client. The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure. 61. A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? Ans: "I will use my hands rather than a washcloth to clean the radiation area." The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation 62. A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider? Ans: Heart rate 55/min The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider. 63. A nurse is providing instructions to a client who has type 2 diabetes mel- litus 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 64. 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 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. *Normal range Ans: 1.010 - 1.020 65. A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following informa- tion should the nurse provide? Ans: Increase fluid intake Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test. 66. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? Ans: Remain with the client for the first 15 min of the infusion. The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood 67. A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take? Ans: Check that one finger fits between the cast and the leg. To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application 68. A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take? Ans: Inject the medication into the anterolateral abdominal wall. The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation 69. A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse assess first? Ans: A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet When using the stable vs. unstable approach to client care, the nurse should assess this client first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual nitroglycerin tablet could be unstable. This client might be experiencing angina or could be having another MI 70. A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority? Ans: Apply firm pressure to the insertion site The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding 71. 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. Tachycardia 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 72. A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect? Ans: Elevated bilirubin level Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice 73. A nurse is caring for a client in the emergency department (ED) Ans: Administer morphine Ensure the patient is NPO Cholecystitis Monitor the color of the client's stools Monitor the client for dark urine 74. A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first? Ans: Call for help Evidence-based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock; therefore, the nurse should obtain immediate assistance 75. A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid? Ans: Aged cheese Foods that contain tyramine, such as aged cheese and sausage, can trigger mi- graine headaches 76. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.) Ans: Sleepiness exhibited by the client Widening pulse pressure Decerebrate posturing 77. A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take? Ans: Use a 30-mL syringe The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi. 78. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Ans: Loosen restrictive cloth- ing. The nurse should loosen tight, restrictive clothing to prevent injury and suffocation. 79. 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. 80. A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? Ans: Remind the client to scan their complete range of vision during ambulation. The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls. 81. A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take? Ans: Instruct the client on alternative therapies for pain reduction. The nurse should respect the client's concerns and offer nonpharmacologic alter- natives to pain management, such as relaxing activities and distraction 82. A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an UNEXPECTED finding for which of the following LABORATORY VALUES is a manifestation of OSTEOMYELITIS and should be reported to the provider? Ans: An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis 83. A nurse is reviewing the medical records of a client who is taking WAR- FARIN for chronic arterial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? Ans: INR 2.5 Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be monitored to ensure the anticoagulation is within the ther- apeutic range and prevent hemorrhage (levels of anticoagulation) or stroke, MI, PE (low levels of anticoagulation). An INR 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation. 84. A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following dis- orders presents the greatest risk to this group of clients? Ans: Hypertension When using the safety/risk reduction approach to client care, the nurse should deter- mine that the disorder with the greatest risk for this group of clients is hypertension. The prevalence of hypertension is highest among African American clients, followed by Caucasian clients, and then Hispanic clients 85. A nurse is reviewing the laboratory results of a client who has aplastic ane- mia. Which of the following findings indicates a potential complication? Ans: WBC count 2,000/mm3 A WBC count of 2,000/mm3 is below the expected reference range and indicates a risk for severe immunosuppression 86. A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove the IV catheter. Which of the following actions should nurse take to avoid restraining the client? Ans: Keep the client occupied with a manual activity The nurse should provide the client with a manual activity such as a puzzle or an art project. This can help to distract the client from the IV catheter 87. A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? Ans: Keep a lead-lined container in the client's room The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant. 88. A nurse reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? Ans: PaCO2 56 mm Hg A client who has COPD retains PaCO2 duet to the weakening and the collapse of the alveolar sacs, which is decreases the area in the lings for gas exchange and causes the PaCO2 to increase above the expected reference range 89. A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? Ans: Hair loss on the lower legs The nurse should expect a client who has a peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth 90. A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have acupuncture because it provides greater relief than pain medication Which of the following statements should the nurse make? Ans: I can speak to the provider about incorporating acupuncture into your treatment plan." The nurse should serve as an advocate for the client by acting on behalf of the client and offering to speak with the provider. The client has the right to make choices and decisions about their treatment and the nurse should support these decisions and assist the client to carry them out 91. A nurse is providing teaching to a client who has hypertension and a NEW prescription for verapamil. Which of the following information should the nurse include in the teaching? Ans: Increase fiber intake to avoid constipation. The nurse should instruct the client that constipation is an adverse effect of vera- pamil. The client should increase fiber intake to promote regular bowel function 92. A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? Ans: - Encourage the client to take deep breaths after the procedure After a thoracentesis, the client should deep breathe to re-expand the lung 93. A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? Ans: Serum Creatinine A client who has an elevated serum creatinine level should not receive gentamicin because the medication is nephrotoxic. 94. A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse in- clude? Ans: Flex the foot every hour when awake The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return. 95. A nurse is teaching a group of newly licensed nurses about pain manage- ment for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? Ans: "Ibuprofen can cause gastrointestinal bleeding in older adult clients." 96. A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis? Ans: Prednisone The nurse should instruct the client that prednisone can increase the risk of de- veloping osteoporosis due to suppression of bone formation, and an increase in bone resorption by osteoclasts. Prednisone can also reduce intestinal absorption of calcium. 97. A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulation, the nurse should provide which of the following instructions to the client? Ans: Scan the environment by turning your head from side to side. Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head from side to side helps enlarge a client's visual field. This technique is also useful for the client during mealtimes 98. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? Ans: The nurse should instruct the client to alternate heat and cold applications to decrease join inflammation and pain. Then application of cold can relieve joint swelling and the application of heat can decrease joint stiffness and pain. 99. A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? Ans: Low urine specific gravity An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys responsive- ness to the hormone 100. A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. which of the following statements should the nurse make?- Ans: "I will refer you to community resources that can provide support The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body image changes 101. A nurse is providing teaching to a client who has a new perscription for psyllium. Which of the following information should the nurse include in the teaching? Ans: Drink 240 mL (8 oz) of water after administration 102. A nurse is preparing to present a program about prevention of ather- osclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.) Ans: - Follow a smoking cessation program - Maintain an appropriate weight - Eat a low-fat diet 103. A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include. Ans: Walk for 30 min four times per week Weight-bearing exercises promote bone mass. Therefore, walking can help the client prevent osteoporosis. 104. Client presents with abdominal pain in the upper left quadrant for the past 2 days. States pain became worse this morning and is radiating to the back. Rates pain as 8 on a scale of 0 to 10 Ans: Drop down 1 Ans: Pancreatitis Drop down 2 Ans: Amylase and lipase The client's laboratory results, and physical assessment indicate the client is experi- encing manifestations of pancreatitis. Clients who have pancreatitis experience and increase in pancreatic enzymes, amylase and lipase. 105. A nurse is caring for a client following extubation of an endotracheal tube 10 min ago. Which of the following findings should the nurse report to the provider immediately? Ans: Stridor Urgent vs. nonurgent, stridor can indicate a narrowing airway or possible obstruction caused by edema or laryngeal spasms 106. A nurse is assessing a client who has advanced lung cancer and is re- ceiving palliative care. the client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer? Ans: Dyspnea Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the clients breathing and improve comfort 107. A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? Ans: Place a tracheostomy tray at bedside The priority action the nurse should take when using the airway, breathing, circula- tion approach to client care is to place a tracheostomy tray at the client's bedside in case of airway obstruction 108. A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? Ans: Place personal items, such as pictures, at the client's bedside The nurse should plan to have the family bring personal items such as pictures to place at the client's bedside for cognitive support 109. A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statement should the nurse make? Ans: "Ginkgo biloba can cause increased risk for bleeding." Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with peripheral artery disease 110. A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following should the nurse identify as the priori- ty? Ans: Report of sore throat Sore throat, which could be a manifestation of an infection. 111. A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? Ans: A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed 112. A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? Ans: BUN 34 mg/dL 113. A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? Ans: Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures After 3 negative sputum cultures, the client is no longer considered infectious. 114. A nurse is caring for a client who is 4 hr postoperative following a total vaginal hysterectomy Ans: Perineal pad saturated with blood, large clots present Change of blood pressure, heart rate of 102/min 115. A nurse is caring for a client who has a positive culture for methicillin resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? Ans: Bathe the client using chlorhexidine solution The nurse should bathe the client using Chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body 116. A nurse is assessing a client following the completion of hemodialy- sis. Which of the following findings is the nurse's priority to report to the provider? Ans: Restlessness Restlessness, which can be an indication the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other manifesta- tions include nausea, vomiting, fatigue, and headache 117. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription Ans: capillary blood glucose AC and HS. Which of the following ac- tions should the nurse take? Ans: Contact the provider to clarify the prescription. Mealtimes do not pertain to this client due to the NPO status 118. A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? (Select all that apply) Ans: - Calf pain - Numbness in the arms - Intense headache 119. During the emergent phase of burn care, the client is at risk for develop- ing Ans: Hypovolemia and Respiratory failure Hypovolemia is indicated by the client's blood pressure declining and heart rate increasing. The client has burns to the face and chest, which will compromise respiratory function, placing them at risk for respiratory failure. 120. A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first? Ans: Check for the type and number of units of blood to administer 121. A nurse is assessing a clients hydration status. Which of the following findings indicates fluid volume overload? Ans: Distended neck veins 122. A nurse is assessing a client who is postoperative following a thyroidec- tomy. Which of the following findings is the nurse's priority? Ans: Temperature 38.9 C (102 F) An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate 123. A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following Instructions should the nurse include in the plane of care? Ans: Use crutches with rubber tips. Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls. 124. A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long term mechanical ventilation? Ans: Stress ulcers Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. 125. A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? Ans: Pain that increases with passive movement Client who has compartment syndrome experiences pain that increases with pas- sive movement. 126. A nurse is providing teaching to a client who has stage II cervical can- cer and is scheduled for brachytherapy. Which of the following instructions should the nurse include? Ans: "You will need to stay still in the bed during each treatment session. Excessive movement can cause the radioactive source to become dislodged 127. Client has a penetrating wound to the anterior upper right chest. Client is alert and oriented with a Glasgow Coma Scale score of 15. Clients' shirt covered with bright red blood. Client reports pain as 6 on a scale of 0 to 10. Shortness of breath noted Ans: Oxygen saturation Pain level Wound drainage 128. For each potential providers prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Ans: - Transfuse packed RBCs is anticipated - Prepare the client for chest tube insertion is anticipated - Initiate NPO status is anticipated 129. The nurse is caring for the client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? Ans: - Place the client in high-fowler's position - Place two rubber-tipped hemostats in the client's room - Palpate the chest tube insertion site for subcutaneous emphysema - Ensure that all chest tube connections are securely attached 130. The nurse is caring for the client 1 hour following chest tube insertion Ans: - Client reports pain as 3 on scale of 0 to 10 - Client reports shortness of breath has decreased - Wound dressing is dry and intact - Respiratory rate, Blood pressure, and oxygen saturation 131. A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr. ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? Ans: Troponin I 8 ng/mL Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury 132. A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. which of the following findings is an indication of lung re-ex- pansion? Ans: Bubbling in the water seal chamber ceases when the lung re-expands 133. A nurse is administering packed RBCs to a client. Which of the following assessment findings indicate a hemolytic transfusion reaction? Ans: Low back pain and apprehension Hemolytic transfusion reactions result from the infusion of incompatible blood prod- ucts and create a systemic inflammatory response 134. A nurse is providing discharge teaching to a client who is to self-admin- ister heparin subcutaneously. Which of the following statements by the client indicates an understanding of the teaching? Ans: I will use an electric razor to shave. 135. A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? Ans: My joints ache because I have Lyme disease. Lyme disease is a vector-borne illness transmitted by the deer tick. 136. A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? Ans: Place a pressure bag around the flush solution The pressure from an artery is greater than that of the line. 137. A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? Ans: Document that depolar- ization has occurred 138. The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching? select all that apply Ans: "I will need to do the breathing exercises every 1 to 2 hours after the surgery" "I will be sure to ask for pain medication before my knee starts to hurt too bad" "I will probably be going home with a walker" 139. A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? Ans: Avocados Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity. 140. A nurse is caring for a client who's is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? Ans: Extremity cool upon palpation 141. A nurse is admitting a client who has active tuberculosis. Which of the fol- lowing types of transmission precautions should the nurse initiate? Ans: Airborne 142. A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider? Ans: Warfarin Increases the client's risk for bleeding and is contraindicated for a client scheduled for eye or central nervous system surgery 143. A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, " Last week I crashed my car because I my vision suddenly became blurry." Which of the following actions is the nurses priority? Ans: Check the clients neurologic status 144. A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching? Ans: Holding breath for 10 seconds after inhaling The client should hold their breath for 10 seconds after inhaling so the medication can move deep into the airways. 145. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions that the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress Ans: INSERT A LARGE-GAUGE IV and INITIATE A FLUID CHALLENGE because the client is most likely experiencing hypovolemia. The nurse should monitor the clients URINE OUTPUT and BLOOD PRESSURE to evaluate the effectiveness of treatment. 146. A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication? Ans: Crackles heard on auscultation Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus increasing urinary output. 147. A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the following information should the nurse include in the teaching? Ans: Family members in the household should undergo TB testing. Family members who live in the same household with the client have been exposed to TB. therefore, the nurse should recommend TB screening to foster early detection and treatment of TB. 148. A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? Ans: Scan the bladder with a portable ultrasound 149. A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? Ans: Slow the infusion rate. Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. 150. A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? Ans: I will eat mor high fiber foods To help prevent constipation, which is a common adverse effect of oral iron supple- ments 151. The nurse is caring for the client who has manifestation of therefore, the priority finding for the nurse to report is Ans: Peritonitis Laboratory values Manifestations of peritonitis, including rigid abdomen and elevated WBC count and ESR. Peritonitis is an inflammation and infection of the abdominal cavity that can occur when bacteria enter the peritoneum through a perforation in the bowel as a complication of Crohn's disease 152. The nurse is planning care for the client who has peritonitis and Crohn's disease. For each potential providers