Nurs 120/ Nurs120 Final Exam | 100 out of 100 | Questions and Verified Answers | Latest Update 2025/2026 | GRADED A | West Coast University

Nurs 120/ Nurs120 Final Exam | 100 out of 100 | Questions and Verified Answers | Latest Update 2025/2026 | GRADED A | West Coast University Question: A nurse answers a call light and finds the client anxious, short of breath, and reporting chest pain. The client states it's a stabbing pain". What action by the nurse takes priority? A. Take a full set of vital signs and document B. Reassure the patient that the appropriate measures will be taken C. Notify the rapid response team D. Listen to the patient's breath sounds C. Notify the rapid response team Question: The MD order states: Administer 50mg of Metoprolol PO Available: Metoprolol 100mg/tab How many tablets will the nurse administer? A. 0.5 tab B. 1 tab C. 1.5 tabs D. 2 tabs A. 0.5 tabs Question: The nurse is providing nutritional education to a client with a new diagnosis of heart failure (HF). What will the nurse be sure to include in her teaching? A. "Take a salt supplement in order to keep your sodium (N+) level normal" B. "Be sure and add any salt flavoring to food while it is cooking" C. "You will need to strictly limit your salt intake" D. "You can have all the salt you want, as long as you are voiding regularly" C. "You will need to strictly limit your salt intake" Question: The MD order states: Administer 1000ml of NS IV over 20 hours What will the nurse set as the pump infusion rate? A. 65 mL/hr B. 50 mL/hr C. 120 mL/hr D. 70 mL/hr B. 50 mL/hr Question: The nurse knows that which client is at the highest risk for developing varicose veins? A. The 30 y/o male who works in construction B. The 55 y/o retired female who is considering hormone replacement C. A 25 y/o male who works out 6 times a week D. The 42 y/o overweight female who works standing in retail sales D. The 42 y/o overweight female who works standing in retail sales Question: The nursing student is caring for a client with peripheral vascular disease (PVD). When speaking with the student, the nursing instructor asks him/her to explain the difference between arterial and venous insufficiency. The student nurse would be correct in stating that: A. Arterial insufficiency causes bounding pulses while venous insufficiency causes absent pulses B. Venous insufficiency causes congestion and blood stasis while arterial insufficiency can lead to ischemic ulcers and gangrene C. Venous insufficiency is characterized by pain with activity D. Arterial insufficiency is caused by varicose veins and blood clots B. Venous insufficiency causes congestion and blood stasis while arterial insufficiency can lead to ischemic ulcers and gangrene Question: The student nurse correctly identifies the different types of heart failure as which of the following: A. Multi-system, Hypovolemic, and Right-sided B. Left-sided, High Output, and Multi-system C. High output, Left-sided, and Right-sided D. Right-sided, Left-sided, and Hypovolemic C. High output, Left-sided, and Right-sided Question: Question: A nurse is assessing a client who has just arrived to the emergency department. During the assessment, she notes pulmonary crackles, anxiety and restlessness, and cough. Which diagnosis would she expect to see? A. Left- sided Heart Failure B. Digitalis Toxicity C. Right- sided Heart Failure D. Hypertensive Crisis A. Left- sided Heart Failure Question: A nurse is caring for a client with right-sided heart failure who is complaining about having to weigh every day. How should the nurse respond? A. "Daily weights allow us to adequately monitor edema in your extremities" B. "You will need to lose weight to decrease the incidence of heart failure" C. "Daily weights allow us to monitor whether or not you are eating properly" D. "Daily weights allow us to monitor whether or not you are gaining or losing fluid" D. "Daily weights allow us to monitor whether or not you are gaining or losing fluid" Question: The nurse is caring for a client diagnosed with primary hypertension (HTN). What risk factors contribute to primary HTN? Select all that apply A. Smoking B. Kidney Disease C. African American D. High Caffeine Consumption A. Smoking C. African American D. High Caffeine Consumption Question: What is the most common site of origin for a blood clot to occur, causing a pulmonary embolism (PE)? A. Antecubital vein in the upper extremities B. Right side of the heart C. Subclavian veins D. Deep veins of the legs and pelvis D. Deep veins of the legs and pelvis Question: The nurse is caring for four hypertensive patients. Which drug-laboratory value combination should the nurse report immediately to the health care provider? A. Hydrochlorothiazide (Hydrodiuril); Potassium: 4.2 mEq/L B. Atenolol (Tenormin); Sodium: 142 mEq/L C. Spironolactone (Aldactone); Potassium: 3.4 mEq/L D. Furosemide (Lasix); Potassium: 2.1 mEq/L D. Furosemide (Lasix); Potassium: 2.1 mEq/L Question: During post-op care of a client who had an arterial revascularization, the nurse assesses the client's affected extremity. The nurse notes that the affected extremity is warm to touch, has redness, and some edema. The nurse's next action should include: A. Continue to monitor the site as ordered as this is an expected finding B. Place a compression stocking on the operative leg C. Notify the doctor immediately (STAT), as this is a medical emergency D. Wrap the affected extremity with gauze A. Continue to monitor the site as ordered as this is an expected finding Question: The MD order states: Administer 250mg Ampicillin PO every 6 hours at 0600, 1200, 1800, and 2400" Available: Ampicillin 125 mg/tab How many total tablets will the patient receive over 24 hours? A. 4 tablets B. 2 tablets C. 6 tablets D. 8 tablets D. 8 tablets Question: The nurse is evaluating the blood pressure of a 75-year-old woman. Based on current research, which finding is the best indicator of heart disease risk for this client? A. Blood pressure of 138/68 mm Hg B. Diastolic of 86mm Hg C. Systolic of 160mm Hg D. Blood pressure of 110/90mm Hg C. Systolic of 160mm Hg Question: The nurse is caring for a client who developed a pulmonary embolism (PE) during their hospital stay and is currently receiving IV heparin. What lab does the nurse expect to be ordered routinely to manage IV heparin, and how would this lab be interpreted? A. PTT of 60 B. Cholesterol greater than 250 C. D-dimer of 0.4 D. INR of 3.0 A. PTT of 60 Question: The student nurse asks for clarification regarding hypertension. What is the best response by the nurse? A. "HTN is a result of vasodilation and increased cardiac output" B. "HTN is a result of vasoconstriction, increased cardiac output, and increased peripheral resistance" C. "Hypertension (HTN) is a result of vasoconstriction and decreased peripheral resistance" D. "HTN is a result of vasodilation, decreased cardiac output, and increased peripheral resistance" B. "HTN is a result of vasoconstriction, increased cardiac output, and increased peripheral resistance" Question: While discharging a client from the hospital, the nurse is discussing preventative care regarding blood clots. Which statement made by the client indicates a need for further education? A."I should be sure and move every 4-6 hours" B."I need to stop smoking ." C."changing positions during travel is important" D."Losing weight decreases the chance of getting a blood clot" A. "I should be sure and move every 4-6 hours" Question: When assessing the client for an acute arterial occlusion, the nurse knows that it is necessary to assess for the "6 Ps", which include: A. Pain, Pallor, Parasthesia, Paralysis, Poikilothermy, and Planning B. Parasthesis, Pallor, Pain, Paralysis, Poikilothermy, and Pulselessness C. Pallor, Pain, Parasthesia, Paralysis, Poikilothermy, and Pedis D. Paralysis, Pallor, Poikilothermy, Parasthesia, Planning, and PPI's B. Parasthesis, Pallor, Pain, Paralysis, Poikilothermy, and Pulselessness Question: A patient has hypertension (HTN) and several risk factors for cardiovascular disease. The patient is overwhelmed with several recommended lifestyle changes. What action by the nurse is best? A. Assist in finding one change the patient is willing to make, and that they can control B. Assess the patient's support system C. Inquire about delegating some of the patient's obligations D. Assess the patient's non-modifiable risk factors for change A. Assist in finding one change the patient is willing to make, and that they can control Question: The nurse is educating the 37 y/o client on the use of simvastatin (Zocor) for her new diagnosis of atherosclerosis. What education will the nurse include at this time? Select all that apply A. Once your symptoms disappear, you can discontinue this medication B. This medication should not be taken if you have active liver disease C. Take this medication with grapefruit juice D. Report muscle cramping to your doctor B. This medication should not be taken if you have active liver disease D. Report muscle cramping to your doctor Question: The nurse knows that the client needs further education regarding anticoagulation therapy when they state: A. "It is necessary to keep my doctor's appointments" B. "As long as I do not see any blood in my stool or urine, I do not need my bleeding time checked" C. "Stool softeners are important to prevent straining" D. "I need to use an electric razor" B. "As long as I do not see any blood in my stool or urine, I do not need my bleeding time checked" Question: During morning rounds, the nurse notices the non-verbal client grabbing her chest in pain with one hand, and a bloody tissue in the other. The client is also having shortness of breath. What STAT lab would the nurse expect the doctor to order at this time? A. VQ Scan B. D-dimer C. PTT D. INR B. D-dimer Question: The nurse is caring for a client with a five year history of hypertension (HTN) who states "I don't take my blood pressure medications because I don't feel like I have high blood pressure". What is the best response by the nurse? A. "A lot of people with HTN do not have symptoms associated with the diagnosis" B. "You are lucky, most people have severe morning headaches" C. "You need to take your medicines or you will develop kidney failure and have a stroke" D. "Do you have trouble paying for your medications?" A. "A lot of people with HTN do not have symptoms associated with the diagnosis" Question: The MD order states: Administer 75mg IV Solumedrol via IV push Available: Solumedrol 300mg/2mL How many mL's will the nurse administer? A. 1 mL B. 2 mL's C. 1.5mL's D. 0.5mL's D. 0.5mL's Question: Upon admission to the hospital, the nurse would expect which of the following interventions to be utilized for a client to prevent venous thromboembolism (VTE)? A.Bedrest for 24 Hours B.Limited Fluid Intake C.Sequential Compression Device (SCD) D. Keep legs bent at the knees as much as possible C. Sequential Compression Device (SCD) Question: The nurse is working in the CCU and has just received a client from the ER with a diagnosis of heart failure (HF) exacerbation. The plan of care includes the administration of Furosemide (Lasix). What is the expected/desired outcome of this medication administration? A. To inhibit excretion of urine B. To promote decreased urination in order to retain necessary fluid C. To promote increased urination to remove excess fluid D. To promote excretion of potassium (K+) C. To promote increased urination to remove excess fluid Question: The student nurse asks the charge nurse to explain the difference between atherosclerosis and arteriosclerosis. The charge nurse would be correct in stating that: A. "Arteriosclerosis can be prevented with a healthy lifestyle, while atherosclerosis can not be prevented" B. "Arteriosclerosis involves the formation of plaque within the arterial wall while atherosclerosis involves the hardening of the arterial wall associated with aging" C. "Atherosclerosis involves the formation of plaque within the arterial wall while arteriosclerosis involves the hardening of the arterial wall associated with aging" D. "Atherosclerosis is associated with the aging process, while arteriosclerosis is related to nutritional status" C. "Atherosclerosis involves the formation of plaque within the arterial wall while arteriosclerosis involves the hardening of the arterial wall associated with aging" Question: The nurse is caring for a patient newly diagnosed with secondary hypertension (HTN). The nurse knows the patient understands their teaching when they state: A. "I should work on my modifiable risk factors such as age and genetics" B. "This is the most common type of HTN" C. "High stress is what caused me to develop this type of HTN" D. "My kidney disease likely contributed to my developing high blood pressure" D. "My kidney disease likely contributed to my developing high blood pressure" Question: The MD order states: Administer 50mg IV Flagyl in 200mL of NS over 30 minutes The nurse will set the pump for what infusion rate? A. 200mL/hr B. 400mL/hr C. 600mL/hr D. 300mL/hr B. 400mL/hr Question: Which of the following are risk factors for hypertension (HTN)? Select all that apply. A. Physical inactivity B. Family history of hypertension (HTN) C. Excessive calorie consumption D. Bicycle racing A. Physical inactivity B. Family history of hypertension (HTN) C. Excessive calorie consumption Question: A student nurse is assessing a client with a deep vein thrombosis (DVT) in the right calf. Which of the following interventions would prompt the instructor to intervene? A. Tell the client to dorsi-flex the foot on the right extremity B. Measures the circumference of each calf C. Asks the client to uncross the legs D. Asks the client about their anticoagulation therapy A. Tell the client to dorsi-flex the foot on the right extremity Question: The nurse is caring for a client with a suspected diagnosis of heart failure. Which diagnostic tests does the nurse anticipate an order for? Select all that apply A. Brain Natriuretic Peptide (BNP) B. Echocardiagram C. MRI D. Chest X-Ray A. Brain Natriuretic Peptide (BNP) B. Echocardiagram D. Chest X-Ray The nurse is educating a 65 y/o client on their new diagnosis of hypertension (HTN). The nurse knows the client understands the diagnosis when the client makes which of the following statements: A. "I will cut down on my alcohol intake and eat a moderately high-salt diet" B. "I might start drug therapy if my blood pressure is consistently greater than170/90 mmHg" C. "Decreasing my stress level will not affect my blood pressure" D. "I should work on my modifiable risk factors which include my activity level, diet, and age" B. "I might start drug therapy if my blood pressure is consistently greater than170/90 mmHg" The nurse is assessing a client post-op for an arterial revascularization and has reason to suspect a graft occlusion has occurred. The nurse knows that a graft occlusion in any client is which of the following: Select all that apply A. Characterized by Severe, Continuous, Aching Pain B. A Medical Emergency C. Characterized by Throbbing Pain D. Characterized by Decreased or Absent Pulses in the Operative Leg A. Characterized by Severe, Continuous, Aching Pain B. A Medical Emergency D. Characterized by Decreased or Absent Pulses in the Operative Leg The nurse is completing the pre-op assessment for a client about to undergo arterial revascularization of the right leg. What priority assessment must be competed during the pre-op assessment? A. Assess the clientt's weight in kg. B. Assess dorsalis pedis and posterior tibial pulses bilaterally C. Assess the capillary refill on the feet bilaterally D. Assess the strength of the lower extremities bilaterally B. Assess dorsalis pedis and posterior tibial pulses bilaterally The nurse is educating a client on non-surgical interventions for peripheral arterial disease (PAD). This education will include A. Positioning: raising the legs above the heart B. Do not exercise C. Applying direct heat to promote vasodilation D. Limiting caffeine, stress, and nicotine intake D. Limiting caffeine, stress, and nicotine intake While assessing a client with peripheral arterial disease (PAD), the nurse is told that the patient is able to walk four blocks without pain. What question should the nurse ask next? A. "Do you walk mostly uphill, downhill, or on flat surfaces?" B. "Could you walk further than that a few months ago?" C. "How far would you like to be able to walk?" D. "Have you considered swimming instead of walking?" B. "Could you walk further than that a few months ago?" A nurse is assessing a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? A. "I think my belly is swollen" B. "When I urinate at night it is a large amount and looks like water" C. "I have to stop half way up the stairs to catch my breath" D. "I can't wear my wedding rings anymore because they are too tight" C. "I have to stop half way up the stairs to catch my breath" The nurse suspects the client has a pulmonary embolism (PE) and notifies the provider, who orders an arterial blood gas (ABG). and D-dimer. The health care provider is on the way to the facility. The nurse anticipates and prepares the patient for which additional diagnostic test? A. Ultrasound B. Venous Doppler Studies C. Pulmonary angiography D. 12-Lead ECG C. Pulmonary angiography The nurse is assessing a client who has just been admitted to the cardiac unit. While obtaining the client's history, the client states "I've noticed that my shoes have been really tight lately". Which pathology does the nurse suspect, based on this statement? A. Right-sided Heart Failure B. Emphysema C. Left-sided Heart Failure D. High Output Heart Failure A. Right-sided Heart Failure The nurse is assessing a client with a long history of heart failure (HF). The patient comes in with complaints of nausea, vomiting, diarrhea, and blurred vision. After obtaining serum lab results, the nurse notes that the patient has a potassium (K+) level of 5.9. What does the nurse suspect is wrong with the patient? A. Digitalis Toxicity B. Anemia C. Hyperthyroidism D. Hyponatremia A. Digitalis Toxicity The nurse is working in the clinic and assessing a client with a history of heart failure (HF). The client asks why he is taking the medication Metaprolol (Toprol). The best explanation of the medication's benefit is: A. "This is a beta-blocker and works by increasing the heart rate and preventing the right ventricle from filling" B. "This is an ace-inhibitor and works as a vasodilator" C. "This is the best medication for acute heart failure" D. "This is a beta-blocker and works by decreasing the heart rate, allowing the right ventricle to fill" D. "This is a beta-blocker and works by decreasing the heart rate, allowing the right ventricle to fill" The nurse is educating a patient with a new diagnosis of heart failure (HF) on the goal of medical treatment. What is the most appropriate statement by the nurse? A. "The goal of care is to decrease the efficiency of myocardial contraction" B. "The goal of care is to increase the workload of the heart" C. "The goal of care is to decrease the workload of the heart" D. "The goal of care is to increase the heart rate" C. "The goal of care is to decrease the workload of the heart" The nurse is caring for a client with a history of hypertension (HTN) who currently has a blood pressure of 190/125, a severe headache, and shortness of breath. What diagnosis does the nurse expect? What treatment does the nurse expect to administer? A. Hypertensive crisis; IV vasodilators B. Stage I hypertension; PO antihypertensive C. Malignant HTN; bolus of IV fluids D. Stage II hypertension; IV anti-hypertensive A. Hypertensive crisis; IV vasodilators The nurse arrives at work and receives the following patient information during shift report. Which of the following takes priority and will be seen immediately? A. The 56 y/o with left-sided heart failure with a respiratory rate of 23 breaths per minute B. The 63 y/o with left-sided heart failure complaining of a sleepless night C. The 60 y/o with right-sided heart failure who needs to use the bathroom for the second time in an hour. D. The 59 y/o with left-sided heart failure with frothy, pink-tinged sputum D. The 59 y/o with left-sided heart failure with frothy, pink-tinged sputum The nurse is caring for a client that has been diagnosed with high-output heart failure. The nurse understands that the main cause for this pathology is: A. A decrease in metabolic needs B. An increase in RBC's C. Hypothyroidism D. An increase in metabolic needs D. An increase in metabolic needs The nurse is caring for a client who presents with symptoms consistent with a pulmonary embolism (PE). The provider orders a pulmonary angiography. Which of the following patient findings should the nurse report immediately? A. Client's allergy to contrast dye B. Client's report of anxiety regarding confined spaces C. Client's allergy to eggs D. client's report of chest pain A. Client's allergy to contrast dye The nurse is prepared for complications related to administering warfarin (Coumadin) by having which of the following readily available? A. Vitamin K B. Protamine Sulfate C. Platelets D. Charcoal A. Vitamin K The nurse is caring for a client with hypertension (HTN) who was recently prescribed Lisinopril (Zestril). What medication education will the nurse provide at this time? A. "You need to decrease your potassium intake because this is a potassium-sparing diuretic" B. "Report a nagging cough to your doctor" C. "Hold this medication if your heart rate is less than 70" D. "You do not need to take your blood pressure prior to taking this medication" B. "Report a nagging cough to your doctor" A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How would the nurse respond? A. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." B. "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock." C. "A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates." D. "You need to start with multiple injections until you become more proficient at self-injection." A. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet would the nurse decrease? A. Carbohydrates B. Fats C. Proteins D. Total calories C. Proteins The nurse is caring for a diabetic client whose finger stick blood sugar was 216 at 12:00pm. The nurse has the following two orders:1.) Give subcutaneous Novolog 10 units before meals at 0800, 1200, and 1600.2.) Give subcutaneous Novolog per sliding scale before meals at 0800, 1200, and 1600: blood sugar 150 - 199: give 3 units, 200 - 249: give 6 units, 250 - 299: give 9 units, 300 or greater: give 12 units How many total units of insulin will the nurse administer to this client? A. 16 units of Novolog B. 19 units of Novolog C. 10 units of Novolog D. 22 units of Novolog A. 16 units of Novolog A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations would the nurse monitor the client? Select all that apply. A. Tachycardia B. Dependent pulmonary crackles C. Deep and fast respirations D. Orthostatic hypotension E. Decreased urine output A. Tachycardia C. Deep and fast respirations D. Orthostatic hypotension The client is prescribed metformin (Glucophage) 600 mg daily. The dose is divided into three equal doses and taken 30 minutes before meals, for the last 2 weeks. The patient's blood glucose levels remain too high, so the doctor adjusted the dose to a total of 900 mg daily, divided into three equal doses and taken 30 minutes before meals. The client has a supply of 150mg tablets that she wants to complete prior to filling the new prescription. How many tablets will the client take for each dose? 2 tablets A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would the nurse include in this client's teaching to prevent injury? A. "Examine your feet using a mirror every day." B. "Rotate your insulin injection sites every week." C. "Check your blood glucose level before each meal." D. "Use a bath thermometer to test the water temperature." A. "Examine your feet using a mirror every day." We have an expert-written solution to this problem! The doctor's orders state: "Infuse .9% NS at 150mL/hr for 8 hours, then decrease fluids to 100mL/hr for 10 hours, then decrease fluids to 75mL/hr for 7 hours." Based on this order, how much fluid will the client have received after 13 hours? (give an answer in Liters) 1.7 L The nurse understands the importance of distinguishing diabetic ketoacidosis (DKA) and hyperglycemic-hyperosmolar syndrome (HHS). Which fluid should be administered in early treatment intravenously for both conditions? A. Potassium B. Bicarbonate C. Glucagon D. Normal Saline D. Normal Saline The nurse is reviewing labs on a 40-year-old newly admitted client. The labs are as follows: A1C 5.3%, fasting glucose 98, and WBCs 6500. What can the nurse conclude from these findings? A. The client has diabetes B. The client is pre-diabetic C. The client's labs are within normal limits D. The client has type 2 diabetes C. The client's labs are within normal limits A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take first? A. Document the finding in the client's chart. B. Examine the client's feet for signs of injury. C. Assess tactile sensation in the client's hands. D. Notify the healthcare provider. B. Examine the client's feet for signs of injury. A nurse provides diabetic education at a public health fair. Which disorders would the nurse include as complications of diabetes mellitus? Select all that apply. A. Blindness B. Respiratory failure C. Cirrhosis D. Stroke E. Kidney failure A. Blindness D. Stroke E. Kidney failure We have an expert-written solution to this problem! A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen:• Fasting blood glucose: 75 mg/dL (4.2 mmol/L)• Postprandial blood glucose: 200 mg/dL (11.1 mmol/L)• Hemoglobin A1c level: 5.5%.How would the nurse interpret these laboratory findings? A. Increased risk for developing hyperglycemia B. Good control of blood glucose C. Increased risk for developing ketoacidosis D. Signs of insulin resistance B. Good control of blood glucose A nurse assesses a client who has diabetes mellitus and notes that the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the client's clinical manifestations have not changed. What action would the nurse take next? A. Administer 1 mg of glucagon intramuscularly. B. Administer 10 units of regular insulin subcutaneously. C. Administer another half-cup (120 mL) of orange juice. D. Administer a half-ampule of dextrose 50% intravenously. C. Administer another half-cup (120 mL) of orange juice. We have an expert-written solution to this problem! A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications? A. "Maintain tight glycemic control and prevent hyperglycemia." B. "Limit your intake of protein to prevent ketoacidosis." C. "Prevent hypoglycemia by eating a bedtime snack." D. "Restrict your fluid intake to no more than 2 L a day." A. "Maintain tight glycemic control and prevent hyperglycemia." We have an expert-written solution to this problem! When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, "I will never be able to stick myself with a needle." How would the nurse respond? A. "Your disease will not be managed properly if you refuse to administer the shots." B. "I can give your injections to you while you are here in the hospital." C. "Everyone gets used to giving themselves injections. It really does not hurt." D. "Tell me what it is about the injections that are concerning you." D. "Tell me what it is about the injections that are concerning you." We have an expert-written solution to this problem! The nurse is educating the nursing student on the importance of insulin in blood glucose regulation. Which statement by the nurse is correct regarding insulin? A. "It is a catabolic hormone that builds up glucagon reserves." B. "It is stored in muscles and converted to fat for storage." C. "It is necessary for glucose transport across cell membranes." D. "Insulin is secreted by alpha cells in the islets of Langerhans." C. "It is necessary for glucose transport across cell membranes." After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the patient's understanding. Which statement made by the client indicates a need for additional teaching? A. "I can reach my thigh the best, so I will use the different areas of my thighs." B. "Changing injection sites from the thigh to the arm will change absorption rates." C. "By rotating the sites in one area, my chance of having a reaction is decreased." D. "The lower abdomen is the best location because it is closest to the pancreas." D. "The lower abdomen is the best location because it is closest to the pancreas." A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?" How would the nurse respond? A. "Glucose is the only fuel used by the body to produce the energy that it needs." B. "Without a minimum level of glucose, your body does not make red blood cells." C. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis." D. "Your brain needs a constant supply of glucose because it cannot store it." D. "Your brain needs a constant supply of glucose because it cannot store it." We have an expert-written solution to this problem! A nurse cares for a client who has type 1 diabetes mellitus. The client asks, "Is it okay for me to have an occasional glass of wine?" How would the nurse respond? A. "Because of poor kidney function, people with diabetes should avoid alcohol." B. "Drinking any wine or alcohol will increase your insulin requirements." C. "You should not drink alcohol because it will make you hungry and overeat." D. "One glass of wine is okay with a meal." D. "One glass of wine is okay with a meal." A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes that the client's breath has a "fruity" odor. What action would the nurse take? A. Consult the provider to test for ketoacidosis. B. Encourage the patient to use an incentive spirometer. C. Increase the patient's intravenous fluid flow rate. D. Perform meticulous pulmonary hygiene care. A. Consult the provider to test for ketoacidosis. We have an expert-written solution to this problem! A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement would the nurse include in this client's teaching? A. "Change positions slowly when you get out of bed." B. "If you miss a dose of this drug, you can double the next dose." C. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." D. "Discontinue the medication if you develop a urinary infection." C. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." The nurse is educating the client who was just diagnosed with type 2 diabetes mellitus. What education will the nurse give in regard to disease management? A. "You will not need to check your own blood sugar levels at this time." B. "A low-carb diet is ideal for most diabetics." C. "We should focus on your diet and exercise and see what modifiable risk factors we can change." D. "It is important that I teach you how to self-administer insulin." C. "We should focus on your diet and exercise and see what modifiable risk factors we can change." The nursing student asks the nurse, "What is the goal in treating a patient with diabetes?" What is the nurse's best response? A. The goal is to prevent blindness B. The goal is to lower their A1C by 3% C. The goal is for the client to lose 10% of their body fat D. The goal is to maintain optimal blood sugar levels D. The goal is to maintain optimal blood sugar levels A nurse teaches a client with diabetes mellitus about sick-day management. Which statement would the nurse include in this client's teaching? A. "If vomiting, do not use insulin or take your oral antidiabetic agent." B. "Monitor your blood glucose levels at least every 4 hours while sick." C. "When ill, avoid eating or drinking to reduce vomiting and diarrhea." D. "Try to continue your prescribed exercise regimen even if you are sick." B. "Monitor your blood glucose levels at least every 4 hours while sick. We have an expert-written solution to this problem! The client is to receive 20 mEq of KCL p.o. every morning. The pharmacy sends a bottle labeled 30 mEq/15 mL. How many mL will the nurse administer? 10 A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse include in this client's teaching to decrease the client's insulin needs? A. "Limit your fluid intake to 2 L a day." B. "Animal organ meat is high in insulin." C. "Limit your carbohydrate intake to 80 g a day." D. "Walk at a moderate pace for 1 mile daily." D. "Walk at a moderate pace for 1 mile daily." We have an expert-written solution to this problem! A nurse teaches a client who is prescribed an insulin pump. Which statement would the nurse include in this client's discharge education? A. "Use only buffered insulin in your pump." B. "Test your urine daily for ketones." C. "Store the insulin in the freezer until you need it." D. "Change the needle every 3 days." D. "Change the needle every 3 days." After teaching a young adult client newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? A. "Diabetes can cause blindness, so I should see the ophthalmologist yearly and when I have vision changes." B. "I will see the eye doctor when I have a vision problem and yearly after age 40." C. "I should continue seeing the ophthalmologist as I usually do." D. "My vision will change quickly. I should see the ophthalmologist twice a year." A. "Diabetes can cause blindness, so I should see the ophthalmologist yearly and when I have vision changes." We have an expert-written solution to this problem! A nurse teaches a client with diabetes mellitus about foot care. Which statements would the nurse include in this client's teaching? Select all that apply. A. "Trim toenails straight across with a nail clipper." B. "Wash your feet every other day." C. "Treat any blisters or sores with Epsom salts." D. "Do not walk around barefoot." E. "Soak your feet in a tub each evening." A. "Trim toenails straight across with a nail clipper." D. "Do not walk around barefoot." The nurse is caring for the diabetic client who complains of sweating at night and who has hyperglycemic episodes in the morning. The nurse suspects that the client is experiencing the Somogyi effect. What interventions would the nurse potentially implement? Select all that apply A. Provide an evening snack B. Increase the client's protein intake C. Decrease nighttime insulin doses D. Provide an evening snack and check blood sugars every 2 hours E. Monitor insulin regimens A. Provide an evening snack C. Decrease nighttime insulin doses E. Monitor insulin regimens A nurse prepares to administer prescribed regular and NPH insulin. Place the nurse's actions in the correct order to administer these medications.1. Inspect bottles for expiration dates.2. Gently roll the bottle of NPH between the hands.3. Wash your hands.4. Inject air into the regular insulin.5. Withdraw the NPH insulin.6. Withdraw the regular insulin.7. Inject air into the NPH bottle.8. Clean rubber stoppers with an alcohol swab. A. 1, 3, 8, 2, 4, 6, 7, 5 B. 2, 3, 1, 8, 7, 5, 4, 6 C. 3, 1, 2, 8, 7, 4, 6, 5 D. 8, 1, 3, 2, 4, 6, 7, 5 C. 3, 1, 2, 8, 7, 4, 6, 5 A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication would alert the nurse to contact the provider and withhold the prescribed dose? A. Glimepiride (Amaryl) B. Glipizide (Glucotrol) C. Pioglitazone (Actos) D. Metformin (Glucophage) D. Metformin (Glucophage) We have an expert-written solution to this problem! The diabetic client asks the nurse, "Why is exercise important for me?" What is the best response by the nurse?" A. "Exercise increases your insulin sensitivity." B. "As long as you lose weight through dieting, exercise can be limited." C. "Exercise can help decrease your blood pressure and increase your lipid levels." D. "You are a type 1 diabetic so exercising is not a priority." A. "Exercise increases your insulin sensitivity." A nurse assesses a client with diabetes mellitus and notes that the client only responds to a sternal rub by moaning, has a capillary blood glucose of 33 g/dL (1.8 mmol/L), and has an intravenous line that is infiltrated with 0.45% normal saline. What action would the nurse take first? A. Encourage the patient to drink orange juice. B. Administer 25 mL dextrose 50% (D50) IV push. C. Insert a new intravenous access line. D. Administer 1 mg of intramuscular glucagon. D. Administer 1 mg of intramuscular glucagon. A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The client's blood glucose level is 160 mg/dL (8.9 mmol/L). What action would the nurse take? A. Administer a bolus of regular insulin IV. B. Document the finding in the client's chart. C. Draw blood gases to assess the metabolic state. D. Call the surgeon to cancel the procedure. B. Document the finding in the client's chart. We have an expert-written solution to this problem! A nurse teaches a client about self-monitoring of blood glucose levels. Which statement would the nurse include in this client's teaching to prevent bloodborne infections? A. "Wash your hands after completing each test." B. "Use gloves when monitoring your blood glucose." C. "Do not share your monitoring equipment." D. "Blot excess blood from the strip with a cotton ball. C. "Do not share your monitoring equipment." The nurse is educating the diabetic client on macrovascular complications. What education will the nurse provide to the diabetic client to prevent macrovascular complications? Select all that apply A. Increase carbohydrate consumption B. Monitor for protein in the urine C. Goal BP of 155/90 or less D. Smoking cessation E. Discuss the importance of weight loss B. Monitor for protein in the urine D. Smoking cessation E. Discuss the importance of weight loss After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? A. "I will exercise more frequently because I have so many complications." B. "I should look into swimming or water aerobics to get my exercise." C. "I have so many complications; exercising is not recommended." D. "I used to run for exercise; I will start training for a marathon." B. "I should look into swimming or water aerobics to get my exercise." The client is in HHS and is receiving a bolus of 0.9% NS infusing at a rate of 1000 mL/hr. The doctor's order states: "Give a 2 Liter bolus and then decrease IV fluids to 150 mL/hr." How long will the bolus infuse for? (give the answer in hours) 2 hours The nurse is caring for a patient with type 2 diabetes. That patient has recently had insulin injections added to his medication regimen due to elevated A1C levels. Which of the following statements made by this patient indicates an understanding of teaching regarding A1C? Select all that apply A. "My A1C level should be between 7 and 8%." B. "Next time I need to remain NPO after midnight for more accurate results." C. "I will need to get my A1C checked twice a year." D. "Lowering my A1C means that I am managing my diabetes better." E. "I will need to get my A1C checked quarterly due to my medication change." D. "Lowering my A1C means that I am managing my diabetes better." E. "I will need to get my A1C checked quarterly due to my medication change." A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 07:00. At which time would the nurse assess the client for potential problems related to the NPH insulin? A. 23:00 B. 08:00 C. 20:00 D. 16:00 D. 16:00 A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: Vital Signs and AssessmentLaboratory ResultsMedicationsBlood pressure: 90/62 mm HgPulse: 120 beats/minRespiratory rate: 28 breaths/minUrine output: 20 mL/hr via catheterSerum potassium: 2.6 mEq/L (2.6 mmol/L)Potassium chloride 40 mEq/L (40 mmol/L) IV bolus STATIncrease IV fluid to 100 mL/hr What action would the nurse take? A. Increase the intravenous flow rate before administering the potassium. B. Administer the potassium and then consult with the provider about the fluid prescription. C. Administer the potassium first before increasing the infusion flow rate. D. Increase the intravenous rate and then consult with the provider about the potassium prescription. D. Increase the intravenous rate and then consult with the provider about the potassium prescription. An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation would the nurse correlate with this condition? A. Extremity tremors followed by seizure activity B. Severe orthostatic hypotension C. Oral temperature of 102° F (38.9° C) D. Increased rate and depth of respiration D. Increased rate and depth of respiration At 4:45 PM, a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: Capillary Blood Glucose Testing (AC/HS)Dietary IntakeAt 06:30—95At 11:30—70At 16:30—47Breakfast: 10% eaten—patient states that she is not hungryLunch: 5% eaten—patient is nauseous; vomits once After reviewing the client's assessment data, which action is appropriate at this time? A. Administer dextrose 50% intravenously and reassess the client. B. Provide a glass of orange juice and encourage the client to eat dinner. C. Assess the client's oxygen saturation level and administer oxygen. D. Reorient the client and apply a cool washcloth to the client's forehead. A. Administer dextrose 50% intravenously and reassess the client. The client has an order for Humalog 30 units SQ before meals. Your supply is a 3 mL prefilled cartridge, 100 units/mL. How many mLs will you administer? (Round to the tenths) 0.3 mL An adult client comes into the clinic for a fasting blood glucose test. The results of this test are 127mg/dL. Which of the following interventions would be most appropriate? A. Start the patient on metformin (Glucophage) as ordered B. Repeat another fasting blood glucose in a few weeks. C. Take a finger stick blood sugar in 1 hour for accuracy D. Send the patient home as this is a normal finding B. Repeat another fasting blood glucose in a few weeks. A nurse prepares to administer insulin to a client at 18:00. The client's medication administration record contains the following information:• Insulin glargine: 12 units daily at 18:00• Regular insulin: 6 units QID at 06:00, 12:00, 18:00, 24:00Based on the client's medication administration record, what action would the nurse take? A. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. B. Draw up and inject the insulin glargine first, wait for 20 minutes, and then draw up and inject the regular insulin. C. First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together. D. First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together. A. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. The nurse is caring for four diabetic clients. Which task would be appropriate to delegate to the PCT? A. Perform hourly blood sugar checks on a hyperglycemic client B. Monitor a client with a blood glucose of 68 mg/dl for tremors and irritability C. Check on the client complaining of anxiety and palpitations. D. Verify the infusion rate on IV insulin infusion pump A. Perform hourly blood sugar checks on a hyperglycemic client After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? A. "My intake of water is not restricted by my treatment plan or medication regimen." B. "I should increase my intake of vegetables with higher amounts of dietary fiber." C. "My intake of saturated fats should be no more than 10% of my total calorie intake." D. "I should decrease my intake of protein and eliminate carbohydrates from my diet." D. "I should decrease my intake of protein and eliminate carbohydrates from my diet." A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, "Can I ask my niece to prefill my syringes and then store them for later use when I need them?" How would the nurse respond? A. "Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes." B. "Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light." C. "No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container." D. "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." D. "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." A student is reviewing a client's chart before giving care. She/he notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis? A. Acute pain B. Both appendicitis and acute pain C. Neither appendicitis nor acute pain D. Appendicitis D. Appendicitis What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? A. Self-care Deficit B. Anxiety C. Risk for Infection D. Risk for Imbalanced Nutrition C. Risk for Infection We have an expert-written solution to this problem! A nurse is caring for a client with excessive abdominal fat. The nurse should inform the client about a risk associated with excessive abdominal fat. What is that risk? A. Cardiovascular disease B. Anorexia C. Emaciation D. Cachexia A. Cardiovascular disease A client tells the nurse, "Every time I sneeze, I wet my pants." What is this type of involuntary leakage of urine called? A. Stress incontinence B. Uncontrolled voiding C. Urinary incompetence D. Normal micturition A. Stress incontinence We have an expert-written solution to this problem! Which strategy might a nurse use to increase compliance with education? A. Maintain a clear role as the authority B. Provide verbal instruction at all times C. Use short, simple sentences for all ages D. Include the client and family as partners D. Include the client and family as partners We have an expert-written solution to this problem! When caring for a client who has just had a colonoscopy, the nurse knows to expect: Select all that apply A. The client to be sedated B. The client needs vitals taken C. The client will pass formed stool D. A bowel perforation is a possible complication A. The client to be sedated B. The client needs vitals taken D. A bowel perforation is a possible complication he nurse has assessed the client, analyzed the data, and identified constipation as a client problem. Which assessment data would support constipation? Select all that apply. A. Client reports stool is soft and has a consistency of small "marbles." B. Client reports straining when having a bowel movement. C. Client reports urgency when needing to have a bowel movement. D. Client reports frequency of bowel movements as every 3 to 4 days. E. Client reports mucous in the stool. B. Client reports straining when having a bowel movement. D. Client reports frequency of bowel movements as every 3 to 4 days. A nurse is delegating the collection of urinary output to an unlicensed assistive personnel (UAP). What should the nurse tell the UAP to do while measuring the urine? A. Tell the client to wash the urethra before voiding B. Measure the urine in a graduated cylinder C. Compare the amount of output with intake D. Use a clean measuring cup for each voiding B. Measure the urine in a graduated cylinder The doctor orders Augmentin 875 mg PO. Augmentin is available in 250 mg tablets. How many tablets will the nurse administer? A. 2 tabs B. 3.5 tabs C. 3 tabs D. 4 tabs B. 3.5 tabs The doctor has ordered Solu-Medrol 40 mg IVP every 8 hours for a patient with COPD exacerbation. The vial comes as 125 mg/2 mL. How many mLs will the nurse administer? A. 1 mL B. 0.5 mL C. 0.7 mL D. 0.6 mL D. 0.6 mL The nurse would recognize which of these devices as an open drainage system? A. Jackson-Pratt drain B. Penrose drain C. Hemovac D. Negative pressure dressing B. Penrose drain We have an expert-written solution to this problem! The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using? A. Functional Health Patterns model B. Body System model C. Human Needs (Maslow) model D. Human Response Patterns model C. Human Needs (Maslow) model Which activities does the nurse engage in during the evaluation phase? Select all that apply. A. Adjusts the time frame to achieve the desired outcomes B. Involves the client and family in formulating desired outcomes C. Initiates activities to achieve the desired outcomes D. Collects data to determine whether desired outcomes are met E. Assesses the effectiveness of planned strategies A. Adjusts the time frame to achieve the desired outcomes D. Collects data to determine whether desired outcomes are met E. Assesses the effectiveness of planned strategies The nurse notes a pressure injury on each heel of a client. The nurse knows that the client should be placed in which position to best relieve pressure off of the client's heels? A. Feet elevated, with feet/heels resting on support surface B. Feet elevated, with feet/heels extending beyond support surface C. With feet resting on top of bed cover D. Prone, so that the ankles aren't touching the bed B. Feet elevated, with feet/heels extending beyond support surface A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment? Select all that apply A. Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in frequency. B. The diminished ability of the kidneys to concentrate urine may result in urinary tract infection. C. Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. D. Alterations in the neuromuscular system may result in the client finding it difficult to access the commode. C. Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. D. Alterations in the neuromuscular system may result in the client finding it difficult to access the commode. A nurse is assessing the stoma of a client with an ostomy. What would the nurse observe in a health stoma? A. Pink and moist B. Purple-blue C. Irritation and bleeding D. Pallor A. Pink and moist A nurse educating a new mother on how to bathe her infant uses the acronym TEACH to maximize the effectiveness of the education plan. Which of the following are guidelines based on this acronym? Select all that apply A. Act on every teaching moment B. Edit client information C. Clarify often D. Always refer a client to counseling E. Tune out the individual client A. Act on every teaching moment B. Edit client information C. Clarify often An unconscious client is brought to the emergency department. Which assessment should be implemented first? A. The client's past medical history is assessed B. The client's airway should be assessed C. The nurse should determine the reason for admission D. The nurse should review the client's medications B. The client's airway should be assessed A nurse caring for older adult clients in an assisted-living facility encourages clients to eat a diet high in fiber and fluid to avoid development of which risk factor? A. Fecal incontinence B. Diarrhea C. Flatus D. Constipation D. Constipation The student nurse has just arrived for his/her first day of nursing clinical. The student knows that client care is planned according to the ordered steps of the nursing process, represented by which of the following? A. assessment, analysis, planning, implementation, and evaluation B. assessment, diagnosis, planning, implementation, and evaluation C. assessment, planning, and evaluation D. assessment, planning, implementation, and evaluation B. assessment, diagnosis, planning, implementation, and evaluation Which group of terms best describes the nursing process? A. Patient-centered, systematic, outcome-oriented B. Nurse-centered, single focus, blended skills C. Nursing goals, medical terminology, linear D. Family-centered, single point in time, intuitive A. Patient-centered, systematic, outcome-oriented The nurse is caring for a client with a new order for a nasogastric tube (NGT) to be placed. Once placed, the student nurse asks whether or not it is ok to start the ordered tube feeding at this time. What is the best response by the nurse? A. "It is not ok to start the ordered tube feeding at this time. We need to wait at least 2 hours before initiating treatment to see if the client will tolerate the tube placement." B. "We will begin the ordered tube feedings once we have a confirmation of accurate placement. C. "As soon as we receive the tube feeding from dietary, we will start the feeds." D. "It is ok to start the ordered tube feeding at this time, even though I cannot find a pH strip." B. "We will begin the ordered tube feedings once we have a confirmation of accurate placement. A client is ordered 100 mg of gentamycin by IM injection. The drug is available in 200 mg/5 mL. How many mLs will the nurse administer? 2.5 mL 2.8 mL 2.25 mL 3 mL 2.5 mL When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first? A. Assess the condition of the visible wound bed. B. Perform hand hygiene. C. Measure the width of the wound with a disposable ruler. D. Insert a swab into the wound at 90 degrees. B. Perform hand hygiene. A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean? A. The physician verbally requested specific steps of the dressing change. B. Written plans are developed that specify nursing activities for this skill. C. The client has specified how the dressing should be changed. D. The nurse is using critical thinking to implement the dressing change. B. Written plans are developed that specify nursing activities for this skill The physician orders Erythromycin 0.5 grams PO. The pharmacy sends Erythromycin 250 mg tablets. How many tablets will the nurse administer to the patient? A. 2.5 Tabs B. 1.5 Tabs C. 1.75 Tabs D. 2 Tabs D. 2 Tabs A nurse is caring for a client who is being treated for a bladder infection. The client reports to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition? A. Dysuria B. Polyuria C. Oliguria D. Anuria A. Dysuria Of the following data, what type would be collected during a physical assessment? A. Type, amount, and duration of pain B. Color, moisture, and temperature of the skin C. Specific allergies resulting in itching D. Foods eaten that cause nausea B. Color, moisture, and temperature of the skin The nurse wants to educate the client on their new diagnosis of congestive heart failure. Which one of the following factors will the nurse assess first? A. Willingness of the patient to want to learn B. Intelligence and development level of client C. Learning strengths of the client D. Financial resources available to the client A. Willingness of the patient to want to learn What are functions of the skin? Select all that apply A. Sensation B. Protection C. Temperature regulation D. Vitamin C production E. Immunologic A. Sensation B. Protection C. Temperature regulation E. Immunologic An adult male cut his leg severely with his chainsaw. His leg bled profusely until he applied pressure by tying his shirt around the wound. After a period of time, a clot formed and the wound stopped bleeding. This physiological response is part of which phase of healing? A. Inflammatory Phase B. Proliferation Phase C. Maturation Phase D. Phagocytosis A. Inflammatory Phase The nurse is doing discharge planning concerning a client's recommended diet. The nurse should include which of the following as factors that affect nutrition? A. Socioeconomic status B. All of the above C. Age D. Cultural practices B. All of the above A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? A. "I am so sick. I am about to throw up." B. "My leg hurts so bad. I can't stand it." C. "Appears anxious and frightened." D. "Unable to palpate femoral pulse in left leg." D. "Unable to palpate femoral pulse in left leg." A nurse is caring for a client with a sigmoid colostomy. What type of stools would she/he expect to find in the colostomy bag? A. Liquid B. None C. Watery D. Formed D. Formed During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnosed with benign prostatic hyperplasia. What is the name of this symptom? A. Urinary frequency B. Urinary retention C. Urinary incontinence D. Involuntary voiding B. Urinary retention A nurse is documenting the appearance of feces from a client with a permanent ileostomy. What would she/he document? A. "Colostomy