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Terms in this set (82)
1. A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the
following instructions should the nurse in the teaching?
a) "Place throw rugs on wooden floors at home. "
b) "Supplement your diet with vitamin E."
c) "Swim laps for 20 minutes twice per week."
d) "Take calcium supplements with meals."
d) "Take calcium supplements with meals." (The nurse should instruct the client to take calcium
carbonate supplements with or following meals to increase absorption and effectiveness.)
2. A nurse is reviewing the medication record of a client who is taking digoxin. Which of the
following medications should the nurse identify as increasing the risk for the client to develop
digoxin toxicity?
a) Potassium chloride
b) Famotidine
c) Levothyroxine
d) Furosemide
d) Furosemide (The nurse should identify that loop diuretics, such as furosemide, increase the
urinary excretion of potassium, which can lead to hypokalemia. Hypokalemia increases the risk
for the development of digoxin toxicity.)
,3. A nurse is reinforcing teaching about insulin injections with an adult client who weighs 45.4
kg (100 lb.). Which of the following statements by the client indicates an understanding of the
teaching?
a) "I should insert the needle at a 90-degree angle."
b) "I should give my shot in my belly tissue."
c) "I will pull back on the syringe plunger to look for blood before I push the medication in."
d) "I will use the side of my hand to pull my skin to the side prior to administering the insulin."
b) "I should give my shot in my belly tissue."
4. A nurse is reinforcing discharge teaching for a client who had a mechanical mitral valve
replacement. Which of the following statements by the client indicates an understanding of the
teaching?
a) "I will notify my dentist about this procedure."
b) "I will take an enteric-coated aspirin daily."
c) "I will use a firm-bristled toothbrush."
d) "I will weigh myself once a week."
a) "I will notify my dentist about this procedure." (The nurse should instruct the client to notify
his dentist about the mechanical mitral valve replacement before any procedures so antibiotic
therapy can be initiated to reduce the risk of endocardial infection.)
5. A nurse is reviewing the medical record for an older adult client who is experiencing nausea
and vomiting. Based on the client data, which of the following actions should the nurse take?
(Click on the "Exhibit" button for additional client information. There are three tabs that contain
separate categories of data.) View the Exhibit Exhibit 1 Exhibit 2 Exhibit 3 Diagnosis Results
Sodium 142 mEq/ Potassium 4.2 mEq/L BUN 36 mg/dL Creatinine 1.4 mg/dL Nurses' Notes
1200: Alert and oriented x3 Lungs clear to auscultation Decreased skin turgor Dry mucous
membranes Graphic Record Temperature 0800: 37.7° C (99.9° F) 1200: 37.2° C (99.0° F)
Pulse 0800: 96/min 1200:105/min Respiratory rate 0800: 18/min 1200: 20/min Blood pressure
0800; 118/62 mmHg 1200: 104/65 mm Hg
a) Encourage the client to ambulate.
b) Administer an antipyretic medication.
c) Notify the charge nurse of the client's BUN level
d) Keep the temperature in the client's room warm.
c) Notify the charge nurse of the client's BUN level (The client's BUN level is above the
expected reference range of 10 to 20 mg/dL, which indicates dehydration and impaired renal
function. The nurse should notify the charge nurse of this finding and anticipate interventions to
restore the client's fluid volume.)
, 6. A nurse is providing information regarding transmission-based precautions for a client who
has Clostridium difficile to assistive personnel (AP). Which of the following instructions should
the nurse include? (Select all that apply).
a) "Provide the client with disposable utensils and dishes for meals."
b) "Leave blood pressure equipment in the client's room."
c) "Clean contaminated surfaces with a bleach solution."
d) "Use an alcohol-based hand sanitizer after client care."
e) "Wear a face mask when in the client's room."
a) "Provide the client with disposable utensils and dishes for meals." (Clients who have C.
difficile require contact precautions, which include using disposable utensils and dishes during
meals to prevent exposure to contaminants by others.)
b) "Leave blood pressure equipment in the client's room." (When using contact precautions, the
health care staff should dedicate equipment to single-client use to prevent transmission of the
pathogen.)
c) "Clean contaminated surfaces with a bleach solution." (The health care staff should use a
bleach solution to clean equipment to prevent transmission of the pathogen.)
7. A nurse is admitting a client who is suspected having active tuberculosis (TB). Which of the
following actions should the nurse take first? (chap. 20)
a) Administer antituberculosis medication.
b) Institute airborne precautions.
c) Obtain sputum cultures.
d) Auscultate breath sounds.
b) Institute airborne precautions. (The greatest risk from this client is transmitting TB to staff
and other clients. Therefore, the first action the nurse should take is to implement airborne
precautions.)
8. A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain. Which of
the following actions should the nurse take?
a) Fill the bulb reservoir with 0.9% sodium chloride.
b) Allow the Jackson-Pratt drain to hang freely.
c) Cut a slit in a gauze sponge and apply it around the tubing insertion site.
d) Compress the bulb reservoir and then close the drainage valve.
d) Compress the bulb reservoir and then close the drainage valve. (The nurse should fully
compress the bulb reservoir and then replace the valve plug using aseptic technique to
establish suction after emptying or activating a Jackson-Pratt drain.)
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Terms in this set (82)
1. A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the
following instructions should the nurse in the teaching?
a) "Place throw rugs on wooden floors at home. "
b) "Supplement your diet with vitamin E."
c) "Swim laps for 20 minutes twice per week."
d) "Take calcium supplements with meals."
d) "Take calcium supplements with meals." (The nurse should instruct the client to take calcium
carbonate supplements with or following meals to increase absorption and effectiveness.)
2. A nurse is reviewing the medication record of a client who is taking digoxin. Which of the
following medications should the nurse identify as increasing the risk for the client to develop
digoxin toxicity?
a) Potassium chloride
b) Famotidine
c) Levothyroxine
d) Furosemide
d) Furosemide (The nurse should identify that loop diuretics, such as furosemide, increase the
urinary excretion of potassium, which can lead to hypokalemia. Hypokalemia increases the risk
for the development of digoxin toxicity.)
,3. A nurse is reinforcing teaching about insulin injections with an adult client who weighs 45.4
kg (100 lb.). Which of the following statements by the client indicates an understanding of the
teaching?
a) "I should insert the needle at a 90-degree angle."
b) "I should give my shot in my belly tissue."
c) "I will pull back on the syringe plunger to look for blood before I push the medication in."
d) "I will use the side of my hand to pull my skin to the side prior to administering the insulin."
b) "I should give my shot in my belly tissue."
4. A nurse is reinforcing discharge teaching for a client who had a mechanical mitral valve
replacement. Which of the following statements by the client indicates an understanding of the
teaching?
a) "I will notify my dentist about this procedure."
b) "I will take an enteric-coated aspirin daily."
c) "I will use a firm-bristled toothbrush."
d) "I will weigh myself once a week."
a) "I will notify my dentist about this procedure." (The nurse should instruct the client to notify
his dentist about the mechanical mitral valve replacement before any procedures so antibiotic
therapy can be initiated to reduce the risk of endocardial infection.)
5. A nurse is reviewing the medical record for an older adult client who is experiencing nausea
and vomiting. Based on the client data, which of the following actions should the nurse take?
(Click on the "Exhibit" button for additional client information. There are three tabs that contain
separate categories of data.) View the Exhibit Exhibit 1 Exhibit 2 Exhibit 3 Diagnosis Results
Sodium 142 mEq/ Potassium 4.2 mEq/L BUN 36 mg/dL Creatinine 1.4 mg/dL Nurses' Notes
1200: Alert and oriented x3 Lungs clear to auscultation Decreased skin turgor Dry mucous
membranes Graphic Record Temperature 0800: 37.7° C (99.9° F) 1200: 37.2° C (99.0° F)
Pulse 0800: 96/min 1200:105/min Respiratory rate 0800: 18/min 1200: 20/min Blood pressure
0800; 118/62 mmHg 1200: 104/65 mm Hg
a) Encourage the client to ambulate.
b) Administer an antipyretic medication.
c) Notify the charge nurse of the client's BUN level
d) Keep the temperature in the client's room warm.
c) Notify the charge nurse of the client's BUN level (The client's BUN level is above the
expected reference range of 10 to 20 mg/dL, which indicates dehydration and impaired renal
function. The nurse should notify the charge nurse of this finding and anticipate interventions to
restore the client's fluid volume.)
, 6. A nurse is providing information regarding transmission-based precautions for a client who
has Clostridium difficile to assistive personnel (AP). Which of the following instructions should
the nurse include? (Select all that apply).
a) "Provide the client with disposable utensils and dishes for meals."
b) "Leave blood pressure equipment in the client's room."
c) "Clean contaminated surfaces with a bleach solution."
d) "Use an alcohol-based hand sanitizer after client care."
e) "Wear a face mask when in the client's room."
a) "Provide the client with disposable utensils and dishes for meals." (Clients who have C.
difficile require contact precautions, which include using disposable utensils and dishes during
meals to prevent exposure to contaminants by others.)
b) "Leave blood pressure equipment in the client's room." (When using contact precautions, the
health care staff should dedicate equipment to single-client use to prevent transmission of the
pathogen.)
c) "Clean contaminated surfaces with a bleach solution." (The health care staff should use a
bleach solution to clean equipment to prevent transmission of the pathogen.)
7. A nurse is admitting a client who is suspected having active tuberculosis (TB). Which of the
following actions should the nurse take first? (chap. 20)
a) Administer antituberculosis medication.
b) Institute airborne precautions.
c) Obtain sputum cultures.
d) Auscultate breath sounds.
b) Institute airborne precautions. (The greatest risk from this client is transmitting TB to staff
and other clients. Therefore, the first action the nurse should take is to implement airborne
precautions.)
8. A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain. Which of
the following actions should the nurse take?
a) Fill the bulb reservoir with 0.9% sodium chloride.
b) Allow the Jackson-Pratt drain to hang freely.
c) Cut a slit in a gauze sponge and apply it around the tubing insertion site.
d) Compress the bulb reservoir and then close the drainage valve.
d) Compress the bulb reservoir and then close the drainage valve. (The nurse should fully
compress the bulb reservoir and then replace the valve plug using aseptic technique to
establish suction after emptying or activating a Jackson-Pratt drain.)
