The nurse is assisting a client out of bed for the first time after surgery. What action
should the nurse do first?
A. Place a chair at a right angle to the bedside.
B. Encourage deep breathing prior to standing.
C. Help the client to sit and dangle legs on the side of the bed.
D. Allow the client to sit with the bed in a high Fowler's position.
Give this one a try later!
, D. Allow the client to sit with the bed in a high Fowler's position.
Rationale
The first step is to raise the head of the bed to a high Fowler's position,
which allow venous return to compensate from lying flat and the
vasodilation effects of perioperative drugs. This helps prevent the client
from becoming light-headed and decreases the chance of a client fall.
A client has a staging procedure for cancer of the breast and ask the nurse which
type of breast cancer has the poorest prognosis. Which information should the nurse
offer the client?
A. Stage II.
B. Invasive infiltrating ductal carcinoma.
C. T1N0M0.
D. Inflammatory with peau d'orange.
Give this one a try later!
D. Inflammatory with peau d'orange.
Rationale
Inflammatory breast cancer onset is very rapid and a very rare form of
breast cancer and is considered the most aggressive form of breast
malignancies. It is often mistaken for a breast infection because it has a
thickened appearance like an orange peel (peau d'orange), causing the
breast to become swollen and tender.
A client has taken steroids for 12 years to help manage chronic obstructive pulmonary
disease (COPD). When making a home visit, which nursing function is of greatest
importance to this client? Assess the client's
A. pulse rate, both apically and radially.
B. blood pressure, both standing and sitting.
C. Temperature
D. skin color and turgor.
Give this one a try later!
, C. Temperature
Rationale
It is very important to check the client's temperature. Long term use of
steroids use COPD clients is effective in suppressing inflammation in their
airways making it easier for them to breath, but at the same time suppresses
the immune system, placing the client at risk for infection.
A 58-year-old client who has been post-menopausal for five years is concerned
about the risk for osteoporosis because her mother has the condition. Which
information should the nurse offer?
A. Osteoporosis is a progressive genetic disease with no effective treatment.
B. Calcium loss from bones can be slowed by increasing calcium intake and exercise.
C. Estrogen replacement therapy should be started to prevent the progression
osteoporosis.
D. Low-dose corticosteroid treatment effectively halts the course of osteoporosis.
Give this one a try later!
B. Calcium loss from bones can be slowed by increasing calcium intake and
exercise.
Rationale
Post-menopausal females are at risk for osteoporosis due to the cessation
of estrogen secretion, but a regimen including calcium, vitamin D, and
weight-bearing exercise can help prevent further bone loss.
The nurse is planning care for a client with newly diagnosed diabetes mellitus that
requires insulin. Which assessment should the nurse identify before beginning the
teaching session?
A. Present knowledge related to the skill of injection.
B. Intelligence and developmental level of the client.
C. Willingness of the client to learn the injection sites.
D. Financial resources available for the equipment.
, Give this one a try later!
C. Willingness of the client to learn the injection sites.
Rationale
If a client is incapable or does not want to learn, it is unlikely that learning
will occur, so motivation is the first factor the nurse should assess before
teaching.
The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic
encephalopathy. Which finding would the nurse consider an indication of progressive
hepatic encephalopathy?
A. An increase in abdominal girth.
B. Hypertension and a bounding pulse.
C. Decreased bowel sounds.
D. Difficulty in handwriting.
Give this one a try later!
D. Difficulty in handwriting.
Rationale
A daily record in handwriting may provide evidence of progression or
reversal of hepatic encephalopathy leading to coma (D). (A) is a sign of
ascites. (B) are not seen with hepatic encephalopathy. (C) does not indicate
an increase in serum ammonia level which is the primary cause of hepatic
encephalopathy.
A 58-year-old client, who has no health problems, asks the nurse about the
Pneumovax vaccine. The nurse's response to the client should be based on which
information?
A. The vaccine is given annually before the flu season to those over 50 years of age.
B. The immunization is administered once to older adults or persons with a history of
chronic illness.
C. The vaccine is for all ages and is given primarily to those persons traveling overseas
to areas of infection.
should the nurse do first?
A. Place a chair at a right angle to the bedside.
B. Encourage deep breathing prior to standing.
C. Help the client to sit and dangle legs on the side of the bed.
D. Allow the client to sit with the bed in a high Fowler's position.
Give this one a try later!
, D. Allow the client to sit with the bed in a high Fowler's position.
Rationale
The first step is to raise the head of the bed to a high Fowler's position,
which allow venous return to compensate from lying flat and the
vasodilation effects of perioperative drugs. This helps prevent the client
from becoming light-headed and decreases the chance of a client fall.
A client has a staging procedure for cancer of the breast and ask the nurse which
type of breast cancer has the poorest prognosis. Which information should the nurse
offer the client?
A. Stage II.
B. Invasive infiltrating ductal carcinoma.
C. T1N0M0.
D. Inflammatory with peau d'orange.
Give this one a try later!
D. Inflammatory with peau d'orange.
Rationale
Inflammatory breast cancer onset is very rapid and a very rare form of
breast cancer and is considered the most aggressive form of breast
malignancies. It is often mistaken for a breast infection because it has a
thickened appearance like an orange peel (peau d'orange), causing the
breast to become swollen and tender.
A client has taken steroids for 12 years to help manage chronic obstructive pulmonary
disease (COPD). When making a home visit, which nursing function is of greatest
importance to this client? Assess the client's
A. pulse rate, both apically and radially.
B. blood pressure, both standing and sitting.
C. Temperature
D. skin color and turgor.
Give this one a try later!
, C. Temperature
Rationale
It is very important to check the client's temperature. Long term use of
steroids use COPD clients is effective in suppressing inflammation in their
airways making it easier for them to breath, but at the same time suppresses
the immune system, placing the client at risk for infection.
A 58-year-old client who has been post-menopausal for five years is concerned
about the risk for osteoporosis because her mother has the condition. Which
information should the nurse offer?
A. Osteoporosis is a progressive genetic disease with no effective treatment.
B. Calcium loss from bones can be slowed by increasing calcium intake and exercise.
C. Estrogen replacement therapy should be started to prevent the progression
osteoporosis.
D. Low-dose corticosteroid treatment effectively halts the course of osteoporosis.
Give this one a try later!
B. Calcium loss from bones can be slowed by increasing calcium intake and
exercise.
Rationale
Post-menopausal females are at risk for osteoporosis due to the cessation
of estrogen secretion, but a regimen including calcium, vitamin D, and
weight-bearing exercise can help prevent further bone loss.
The nurse is planning care for a client with newly diagnosed diabetes mellitus that
requires insulin. Which assessment should the nurse identify before beginning the
teaching session?
A. Present knowledge related to the skill of injection.
B. Intelligence and developmental level of the client.
C. Willingness of the client to learn the injection sites.
D. Financial resources available for the equipment.
, Give this one a try later!
C. Willingness of the client to learn the injection sites.
Rationale
If a client is incapable or does not want to learn, it is unlikely that learning
will occur, so motivation is the first factor the nurse should assess before
teaching.
The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic
encephalopathy. Which finding would the nurse consider an indication of progressive
hepatic encephalopathy?
A. An increase in abdominal girth.
B. Hypertension and a bounding pulse.
C. Decreased bowel sounds.
D. Difficulty in handwriting.
Give this one a try later!
D. Difficulty in handwriting.
Rationale
A daily record in handwriting may provide evidence of progression or
reversal of hepatic encephalopathy leading to coma (D). (A) is a sign of
ascites. (B) are not seen with hepatic encephalopathy. (C) does not indicate
an increase in serum ammonia level which is the primary cause of hepatic
encephalopathy.
A 58-year-old client, who has no health problems, asks the nurse about the
Pneumovax vaccine. The nurse's response to the client should be based on which
information?
A. The vaccine is given annually before the flu season to those over 50 years of age.
B. The immunization is administered once to older adults or persons with a history of
chronic illness.
C. The vaccine is for all ages and is given primarily to those persons traveling overseas
to areas of infection.
