Capstone Exam 3 Questions and Answers

Capstone Exam 3 Questions and Answers The nurse is discharging a client who was prescribed prednisone. The nurse tells the client that one of the side effects may be impaired sleep. The client says, "I already have a hard time sleeping. What can I do to help with that?" Which recommendations should the nurse make? Select all that apply. A. avoid alcohol late in the evening B. keep the bedroom dark and quiet C. maintain the same consistent sleep schedule D. eat a large, heavy meal at dinner to help promote sleep E. read or do another quiet, noncomputer activity before bed F. do a vigorous exercise routine after work to help him become tired a. avoid alcohol late in the evening b. keep the bedroom dark and quiet c. maintain the same consistent sleep schedule e. read or do another quiet, noncomputer activity from bed The nurse is preparing to discharge a client who was treated for tuberculosis. Which guidelines for home management should the nurse include in his discharge teaching? Select all that apply. A. The client may resume his normal activities. B. The family should maintain respiratory isolation at home. C. The medication regimen should be followed diligently as prescribed. D. The client may return to work when three sputum cultures are negative. E. The nurse should educate the client about the medication and possible side effects and their management. b. the family should maintain respiratory isolation at home c. the medication regimen should be followed diligently as prescribed d. the client may return to work when three sputum cultures are negative The nurse is caring for a client who has a nasogastric tube for medication administration and tube feedings. How should the nurse care for the tube during her shift? Select all that apply. A. flush tube every 4 hours with hot water to maintain patency B. allow the feeding and tubing to hang until empty, up to 48 hours C. maintain the head of bed in a high-Fowler's position during feedings D. check residuals and replace them unless the amount is greater than 300 mL E. check under the adhesive tape on the nose daily to assess for skin breakdown F. assess the bowel sounds before feeding, and feed at half the rate if bowel sounds are absent c. maintain the head of bed in a high-Fowler's position during feedings e. check under the adhesive tape on the nose daily to assess for skin breakdown The nurse is teaching a group of nursing students about proper client positioning. Which statement by a student nurse indicates an understanding of proper positioning? A. A client receiving an enema should be placed on the right side in the Sims' position. B. A client with a below-the-knee amputation should be positioned with the affected limb elevated at a 45-degree angle. C. Clients with pulmonary edema should be positioned upright with the legs dangling over the side of the bed. D. Clients with a craniotomy should be positioned with the head of bed at a 20-degree angle with the head in a neutral, midline position. c. clients with pulmonary edema should be positioned upright with the legs dangling over the side of the bed The nurse is caring for a client with deep vein thrombosis (DVT). Which should be included in the plan of care? A. bed rest with the affected extremity elevated B. bed rest with the bed in reverse Trendelenburg C. walking slowly in the hall with assistance to prevent pneumonia D. sitting up in the chair for all meals and during visitation time a. bed rest with the affected extremity elevated The nurse is assessing a six-month-old infant at the clinic. When the nurse strokes from the heel of the foot upward toward the ball, the infant exhibits no movement. Which action is the priority for the nurse? A. take the infant's vital signs B. order a neurology consult C. examine the infant's nose and ears D. ask how much formula the infant consumes daily b. order a neurology consult The nurse is caring for a client with COPD who complains of poor quality of sleep. Which question should the nurse ask next? A. "Does your partner snore heavily?" B. "Do you get exercise during the day?" C. "How many pillows do you sleep on?" D. "Do you eat large meals right before bed?" c. "How many pillows do you sleep on?" The nurse is teaching infant CPR to a group of newly graduated nurses hired to work in the labor and delivery unit. The nurse understands that proper technique with infants includes which action? Select all that apply. A. The femoral artery is checked for a pulse following each cycle of CPR. B. Chest compression depth should be approximately 1.5 inches, or 4 cm. C. A single rescuer should use three fingers on the dominant hand to do compressions. D. Rest the infant facedown on the forearm with the hand supporting the head and jaw. E. If arrest is witnessed the emergency response system should be activated before beginning CPR b. Chest compression depth should be approximately 1.5 inches, or 4 cm e. If arrest is witnessed the emergency response system should be activated before beginning CPR The nurse is caring for a comatose client with a Salem sump tube. Which action by the nurse is correct regarding care of this client? A. clamp the air vent during tube feedings B. place the client on the left side in a high-Fowler's position C. assess the position of the Salem sump before each feeding D. infuse bolus feedings with a pump or by gently plunging into the stomach c. assess the position of the salem sump before each feeding The nurse is teaching a client diagnosed with gastroesophageal reflux disease (GERD) about dietary measures to manage symptoms. Which food does the nurse advise the client to avoid? a. bananas b. tomatoes c. white bread d. grilled salmon e. steel-cut oatmeal b. tomatoes The nurse is caring for a client with sternal wires following a coronary artery bypass graft (CABG). The client complains of severe pain when coughing and deep breathing. What nonpharmacological measures can the nurse take to increase client comfort? Select all that apply. a. apply hot packs to the sternum b. give morphine PRN for pain before client coughs c. suggest using audio books or relaxing music as a distraction d. teach the client how to use a pillow to splint the chest when coughing e. encourage the client to engage in prayer, meditation, or other activities f. properly position the head of the bed to minimize pressure on the sternum c. suggest using audio books or relaxing music as a distraction d. teach the client how to use a pillow to splint the chest when coughing e. encourage the client to engage in prayer, meditation, or other activities f. properly position the head of the bed to minimize pressure on the sternum The nurse is caring for a client who is sedated and on the ventilator in ICU. The family expresses concern about controlling the client's pain when he cannot speak. The nurse explains that assessing pain in a nonverbal client involves watching for which of the following signs? Select all that apply. a. grabbing at the bed rails b. biting the ventilator tubing c. facial grimacing d. stiffness or rigidity of the body d. decreased urinary output f. increased blood pressure and heart rate as shown on the cardiac monitor a. grabbing at the bed rails b. biting the ventilator tubing c. facial grimacing d. stiffness or rigidity of the body f. increased blood pressure and heart rate as shown on the cardiac monitor The clinic nurse is seeing a pregnant client who is expecting her first child. She complains of morning sickness and nasal stuffiness. The nurse recommends interventions to minimize discomfort from her symptoms. Which should the nurse recommend? Select all that apply. a. take ginger pills to alleviate nausea b. drink a full glass of water at each meal c. use a humidifier to help with congestion d. eat dry crackers before getting out of bed in the morning e. eat three regular meals each day to provide needed nutrients f. use an over-the-counter nasal spray such as a saline-based spray c. use a humidifier to help with congestion d. eat dry crackers before getting out of bed in the morning The nurse is caring for a client who refuses to get out of bed. He tells the nurse, "I'm too tired to get up. I'm sick. I'm supposed to rest in the hospital." For which complications of immobility does the nurse understand that the client is at risk? Select all that apply. a. decreased appetite b. urinary tract infection c. orthostatic hypotension d. muscular atrophy and foot drop e. boredom, frustration, and anxiety f. increased length of hospitalization b. urinary tract infection c. orthostatic hypotension d. muscular atrophy and foot drop e. boredom, frustration, and anxiety f. increased length of hospitalization The nurse is caring for a group of clients in a medical/ surgical unit. Which client does the nurse understand to be at highest risk for developing decubitus ulcers? a. a 27-year-old client who fractured her arm playing volleyball b. a 6-year-old client on pelvic skin traction for muscle spasms c. a 42-year-old obese client with controlled atrial fibrillation who uses a wheelchair d. a 70-year-old client with heart failure who uses a cane for ambulation in the room and hall b. a 6 year old client on pelvic skin traction for muscle spasms The nurse is caring for a client receiving total parenteral nutrition (TPN). During the assessment, the nurse notes absence of breath sounds on the right side, where the central catheter is placed. Which of the following does the nurse suspect is responsible for this abnormal assessment finding? a. air embolism b. fluid overload c. pneumothorax d. refeeding syndrome c. pneumothorax The nurse is reviewing a client's morning medication orders. Which of the following orders would prompt the nurse to call the health care provider for order clarification? a. famotidine 20 mg PO BID b. haloperidol 15 mg IM q4h prn c. lithium carbonate 300 mg PO TID d. amoxicillin 500 mg PO q12h × 7 days b. haloperidol 15 mg IM a4h prn A client with hypertension asks the nurse to explain how amlodipine besylate (Norvasc) lowers her blood pressure. The nurse gives which explanation to the client? A. "It prevents calcium from entering the smooth muscle, which relaxes the blood vessels to lower heart rate and blood pressure." B. "It is a diuretic that works by removing extra sodium and water from the body through the kidneys, which helps lower blood pressure." C. "It causes the body to produce less angiotensin, which allows blood vessels to relax and open up, therefore reducing blood pressure." D. "It lowers blood pressure by lowering the heart rate and the workload of the heart, and decreases the amount of blood pumped out of the heart." A. "It prevents calcium from entering the smooth muscle, which relaxes the blood vessels to lower heart rate and blood pressure." The nurse is caring for a client who is taking bethanechol chloride (Urecholine) for neurogenic bladder. Which of the following does the nurse understand is correct concerning this medication? A. This is the primary treatment for clients with a urinary obstruction. B. If the client cannot swallow pills, the medication may be given by the IV or IM route. C. Urecholine should be given with food to prevent nausea and vomiting. D. Atropine sulfate should be readily available when a client receives this medication. D. Atropine sulfate should be readily available when a client receives this medication. The nurse is caring for a client taking sulfonamides to treat a urinary tract infection. Which of the following should the nurse monitor for in this client? Select all that apply. A. fever or sore throat B. reddish-pink urine C. side effects such as dyspnea, chest pains, chills, and cough D. urinary output of 1200 mL daily to minimize the risk of renal damage E. the need to decrease the dosage if the client takes warfarin sodium (Coumadin) or phenytoin (Dilantin) A. fever or sore throat D. urinary output of 1200 mL daily to minimize the risk of renal damage E. the need to decrease the dosage if the client takes warfarin sodium (Coumadin) or phenytoin (Dilantin) The nurse is caring for a client diagnosed with tuberculosis. The physician plans to treat the client with a first-line medication. Which medication should the nurse prepare to administer? A. rifampin B. ciprofloxacin C. levofloxacin D. streptomycin A. rifampin The nurse is caring for a client who complains of a headache with a pain level of 5 on a scale of 1 to 10. Which PRN pain medication order is most appropriate for the nurse to administer? A. morphine 2 mg IV q6h PRN B. aspirin 325 mg PO q6h PRN C. acetaminophen 650 mg PO q6h PRN D. nitroglycerin 0.4 mg sublingually every 5 minutes, up to 3 doses over 15 minutes C. acetaminophen 650 mg PO q6h PRN The nurse is preparing to administer 12.4 mL of liquid medication via oral syringe. Which of the following actions by the nurse indicate an understanding of how to give oral medications via syringe? A. The nurse uses either an oral or parenteral syringe to administer the medication. B. The nurse pours 10 mL of the medication into a 30 mL medicine cup, then adds 2.4 mL with a 3 mL syringe. C. The nurse pours 10 mL of the medication into a 30 mL medicine cup, then adds 2.4 mL with a 5 mL syringe. D. The nurse pours 10 mL of the medication into a 30 mL medicine cup, then slowly adds the remainder until it is almost halfway between the 10 mL mark and 15 mL mark. B. The nurse pours 10 mL of the medication into a 30 mL medicine cup, then adds 2.4 mL with a 3 mL syringe. The nurse is caring for a client with a staph infection. The client has orders for vancomycin 15 mg/ kg per 12 hours. The client weighs 136 pounds. How much of this medication will the client receive every 12 hours? 930 mg of vanco q12h The nurse is teaching a group of student nurses about drug safety. Keeping in mind Joint Commission guidelines, which of the following does the nurse teach the students? Select all that apply. A. "Do not abbreviate drug names." B. "Use daily instead of QD, Q.D., or q.d." C. "Rectum can be abbreviated PR, R, or Per Rec." D. "Use OD to indicate right eye for eye medications." E. "Use the letter u to indicate units, such as with insulin." A. "Do not abbreviate drug names." B. "Use daily instead of QD, Q.D., or q.d." The night nurse is preparing to pull night medications for a client. Levofloxacin is scheduled to be given at 0030. The nurse will give this medication at which time? A. 1: 30 a.m. B. 1: 30 p.m. C. 11: 30 p.m. D. 12: 30 a.m. E. 12: 30 p.m. D. 12: 30 a.m. The nurse has an order to administer enoxaparin (Lovenox) 40 mg subcutaneously. When the automatic medication dispenser opens, however, the nurse finds enoxaparin 80 mg in the pocket. Which is the correct action by the nurse? A. notify the pharmacy to correct the error B. skip the morning dose of the medication C. call the health care provider for order clarification D. waste half of the enoxaparin and give the remaining 40 mg A. notify the pharmacy to correct the error The nurse is caring for a client who has an order for ceftriaxone IV. The client is awake and alert and has been taking PO medications and eating. The IV ceftriaxone is not available in the automatic medication dispenser. What should the nurse do next? A. hold the medication since the client is afebrile B. call the pharmacy to send up the missing IV medication C. obtain the PO ceftriaxone from the medication dispenser and administer it D. call the health care provider and see if the client can be switched over to oral ceftriaxone D. call the health care provider and see if the client can be switched over to oral ceftriaxone The nurse is preparing to administer furosemide IM to a 6-month-old client with edema. Which location is the preferred injection site for this client? A. the gluteus medius B. the vastus lateralis C. the dorsogluteal site D. the ventrogluteal muscle B. the vastus lateralis The nurse is caring for a client with breast cancer who has an order for doxorubicin IV. The nurse anticipates which common side effect of this medication? A. permanent hair loss B. halos around objects and blurred vision C. red urine for 1 - 2 days after administration D. facial flushing and red streaking along the vein C. red urine for 1 - 2 days after administration A young child with a rash that's raised and has circumscribed areas filled with fluid comes to the school nurse. What type of rash should the nurse document? A. maculopapular rash B. heat rash C. vesicular rash D. pustular rash C. vesicular rash A 10-year-old is sent home from school with a report of having lice. The nurse should instruct the parent on which intervention? A. wash the hair for three continuous days with dandruff shampoo B. isolate all clothing of the child for one week C. treat with an approved pediculicide agent according to directions D. shave the child's head, then cleanse with herbal shampoo C. treat with an approved pediculicide agent according to directions A nurse in intensive coronary care is caring for a client with an endotracheal tube who underwent coronary bypass surgery. The client awakens and attempts to communicate. Which nursing interventions should the nurse perform? Select all that apply. A. offer a communication board B. ask simple yes/ no questions C. ask open-ended questions D. offer an electrolarynx A. offer a communication board B. ask simple yes/ no questions A nurse is teaching a client with left-sided hemiparesis to walk with a cane. The nurse should include which points about safe cane use when teaching the client? Select all that apply. A. hold the cane in the right hand B. hold the cane in the left hand C. move the cane and step forward with the right leg D. move the cane and step forward with the left leg A. hold the cane in the right hand D. move the cane and step forward with the left leg The nurse is assessing a client with Addison's disease. The nurse expects to note which of the following? A. craving of salty foods B. weight gain C. craving of sweet foods D. hyperactivity A. craving of salty foods An elderly man is admitted to the ED during the night shift. He reports slipping and hitting his forehead on the bathtub several hours earlier. The nurse is assessing the client's frontal lobe function. Which of the following questions/ statements should the nurse ask the client? A. "Tell me when you feel me touch your arm." B. "Tell me when you stop hearing the tuning fork sound." C. "Do you have problems with balance?" D. "How much is two plus four plus seven?" D. "How much is two plus four plus seven?" A client is admitted to the ED after complaining of acute chest pain radiating down the left arm. The client is diaphoretic and anxious, and has difficulty breathing. Which laboratory studies would the nurse anticipate? A. blood urea nitrogen (BUN) B. white blood cell count C. LDH D. myoglobin D. myoglobin A nurse is monitoring a client's intracranial pressure (ICP) after a motor vehicle accident. Upon checking the ICP, the nurse knows to contact the physician. What reading would warrant this action? A. 8 mm Hg B. 14 mm Hg C. 18 mm Hg D. 22 mm Hg D. 22 mm Hg A nurse is caring for a client, diagnosed with Parkinson's disease, who scored as a high-risk fall candidate on the St. Thomas Risk Assessment Tool in Falling Elderly Inpatients. Which nursing interventions should the nurse implement? Select all that apply. A. provide the client with a call-light device B. keep the bed in the lowest position C. use a beveled floor mat at bedside D. implement a bed alarm B. keep the bed in the lowest position C. use a beveled floor mat at bedside D. implement a bed alarm While preparing a client for a colonoscopy, the nurse would be correct to implement which interventions? Select all that apply. A. instruction on high fiber diet the day before the procedure B. instruction that a sedative will be administered before the procedure C. instruction not to eat or drink 6 - 12 hours before the procedure D. instruction not to eat or drink 18 hours before the procedure B. instruction that a sedative will be administered before the procedure C. instruction not to eat or drink 6 - 12 hours before the procedure A nurse is preparing discharge instructions for a client with a below-the-knee amputation. Which instruction would be a priority? A. sterile wound management B. elevation of residual limb C. performing prescribed exercises D. reporting occurrence of phantom limb pain immediately C. performing prescribed exercises A nurse is following the progress of a client being treated for hypothyroidism. Which findings indicate the client is experiencing side effects of the thyroid replacement therapy? Select all that apply. A. excessive sweating B. constipation C. inability to tolerate cold D. leg cramps A. excessive sweating D. leg cramps A client is having a tonic-clonic seizure. Which of the following should the nurse do first? A. call for assistance B. restrain the client C. turn the client on her side D. provide a safe environment D. provide a safe environment The nurse is preparing to discharge a client with an ileal conduit done for treatment of bladder cancer. Which statement by the client indicates the need for further instruction? A. "I look forward to returning to my local health club to swim." B. "The local ostomy support group meets on Wednesday morning at 10 a.m." C. "My stoma should be cleaned daily with soap and water." D. "During the day I will wear a leg bag to collect my urine." A. "I look forward to returning to my local health club to swim." The nurse is caring for a client with a history of cirrhosis of the liver. Lab values reveal rising ammonia levels. Which of the following actions should the nurse anticipate performing? Select all that apply. A. replace electric razor with a straight razor B. encourage frequent periods of rest C. instruct on a potassium-restricted diet D. monitor the client's mental status B. encourage frequent periods of rest D. monitor the client's mental status The nurse is assessing a client with Graves' disease. Which assessment finding would the nurse expect in this client? A. bradycardia B. constipation C. exophthalmos D. recent weight gain C. exophthalmos The nurse is caring for a client who is HIV-positive. The nurse understands which of the following to be true regarding HIV and AIDS? A. Viral load testing monitors disease progression and evaluates effectiveness of treatment. B. The Western blot test is positive if antibodies to at least three major HIV antigens are present. C. Patients with AIDS present with a white blood cell (WBC) count between 5,000 and 10,000 cells/ mm3. D. An enzyme-linked immunosorbent assay (ELISA) test can detect the presence of antibodies within 2 weeks of exposure. A. Viral load testing monitors disease progression and evaluates effectiveness of treatment. The nurse is performing hemodialysis on a client, with the understanding that air embolus is a complication of this treatment. Which assessment findings by the nurse indicate an air embolus? A. cold intolerance B. chest pain and anxiety C. decreased respirations D. hypertension and widening pulse pressure B. chest pain and anxiety The nurse is teaching a client about peritoneal dialysis. Which complication of this treatment would the nurse instruct the client to report? A. bone pain B. confusion C. muscle cramps D. cloudy outflow D. cloudy outflow The nurse is caring for a 9-year-old boy who presented to the ED after a penetrating injury from a BB gun. The client is diagnosed with a hyphema. The nurse proceeds to place the client in which position? A. flat in bed B. semi-Fowler's C. Trendelenburg's D. lateral on the unaffected side B. semi-Fowler's The nurse is caring for a client at risk for postpartum hemorrhage. Which early sign of hemorrhage should the nurse monitor for this client? A. coma B. hypotension C. restlessness D. cool, clammy skin C. restlessness The nurse is caring for a client who presents to the ED with the following arterial blood gas (ABG) results: pH 7.32 PaCO2 47 mm Hg HCO3 24 mEq/ L PaO2 91 mm Hg Which clinical manifestation would the nurse anticipate, based on these findings? A. confusion B. nausea and vomiting C. deep, rapid respirations D. hypoventilation with hypoxia D. hypoventilation with hypoxia The nurse is caring for a client with abdominal aortic aneurysm. Which observation by the nurse indicates the need for immediate intervention? A. complaints of yellow-tinted vision B. sudden onset of frothy, pink sputum C. urinary output of 75 mL/ hr. per urinary catheter D. complaints of sudden and severe back pain and shortness of breath D. complaints of sudden and severe back pain and shortness of breath The nurse is caring for a client who has been diagnosed with pulseless electrical activity (PEA). Following effective CPR and administration of epinephrine, which is the next priority nursing action? A. check for a pulse B. insert a urinary catheter C. prepare to shock the client D. administer a bolus of sodium bicarbonate A. check for a pulse The nurse is caring for a client with cardiogenic shock. The nurse expects which signs present with this client? Select all that apply. A. hypertension; slow, labored breathing B. decreased urine output; warm, pink skin C. increased urine output; cool, clammy skin D. hypotension; weak pulse; cool, clammy skin D. hypotension; weak pulse; cool, clammy skin The nurse is caring for a client with a sacral wound. The wound is full thickness, measures 4 cm × 6 cm with irregular borders, and is covered by a layer of black collagen. Which is this wound stage? A. Stage I B. Stage II C. Stage III D. unstageable D. unstageable The nurse is caring for a client with a Braden score of 13. How does the nurse interpret this client's risk of skin breakdown? A. high risk B. mild risk C. severe risk D. moderate risk D. moderate risk The nurse is performing the Glasgow coma scale on a client. The assessment is as follows: eye opening, to pain; motor response, localizes pain; verbal response, inappropriate words. The nurse interprets which score is correct for this client? A. 9 B. 10 C. 11 D. 12 B. 10 The nurse is reviewing morning labs for a client. Which lab value requires immediate intervention by the nurse? A. calcium 9.8 mg/ dL B. sodium 137 mEq/ L C. chloride 104 mEq/ L D. potassium 3.1 mEq/ L D. potassium 3.1 mEq/ L The nurse is providing dietary instruction to a client with diabetes who has normal kidney function. Which statement by the client requires intervention by the nurse? A. "I should limit cholesterol intake to 200 mg/ day." B. "I should eat very low or no carbohydrates when possible." C. "My protein intake should be 15% to 20% of my daily calories." D. "Fiber will improve my carbohydrate metabolism and lower cholesterol." B. "I should eat very low or no carbohydrates when possible." A client with gastroesophageal reflux disease (GERD) is talking to the nurse about ways to manage her condition. Which statement reflects an understanding of management of GERD? A. "I can elevate the head of my bed 6 to 12 inches to help prevent nighttime reflux." B. "I can eat a large breakfast and smaller meals for lunch and dinner to help me feel better." C. "Lying on my left side will promote oxygenation and frequent swallowing to help clear my esophagus." D. "I should take liquid antacids to coat my esophagus and buffer acid 2 hours before I eat and 1 hour after meals." A. "I can elevate the head of my bed 6 to 12 inches to help prevent nighttime reflux." The nurse is caring for a client who adheres to a lacto-vegetarian diet. Which meal tray would the nurse deliver to the client? A. chicken sandwich, brown rice, yogurt, and milk B. steamed vegetables with rice and apple slices C. scrambled eggs, cottage cheese, dry toast, and milk D. baked zucchini, spinach salad with cheese, and yogurt D. baked zucchini, spinach salad with cheese, and yogurt The nurse is caring for a client who just returned from an above-the-knee amputation of the left leg. Which position should the nurse place the client in? A. supine, with the affected limb flat on the bed B. supine, with a wedge pillow between the thighs C. supine, with the affected limb elevated on a pillow D. on the left side with the head of the bed at 30 degrees C. supine, with the affected limb elevated on a pillow A client has orders for placing a nasogastric tube. In which position should the nurse place the client for insertion? A. low Fowler's B. high Fowler's C. reverse Trendelenburg's D. on the side opposite of the nare used for insertion B. high Fowler's The nurse is assisting the health care provider performing a liver biopsy on a client. How should the nurse position this client? Select all that apply. A. position the client supine with the left upper abdomen exposed B. position the client supine with the right upper abdomen exposed C. position the client in a low Fowler's with the right upper abdomen exposed D. raise the client's right arm and extend it behind the head, over the left shoulder E. raise the client's right arm and extend it across the front of the chest touching the left shoulder B. position the client supine with the right upper abdomen exposed D. raise the client's right arm and extend it behind the head, over the left shoulder The unit nurse is precepting a nursing student who is assisting a client with a femur fracture onto a fracture bedpan. Which action by the student nurse requires intervention by the unit nurse? Select all that apply. A. The student nurse tries to lift the client onto the bedpan. B. The student nurse positions the head of the bed between 30 and 45 degrees. C. The student nurse places the call light within reach and tells the client she will return shortly. D. The student nurse places the bedpan with the shallow end under the buttocks toward the sacrum. E. The student nurse places the bedpan with the deeper end under the buttocks toward the sacrum. A. The student nurse tries to lift the client onto the bedpan. E. The student nurse places the bedpan with the deeper end under the buttocks toward the sacrum. The nurse is caring for a client who just had a laparoscopic appendectomy. The client tells the nurse that she does not want "drugs" for pain management, but prefers alternative therapy and/ or complementary therapy. Which is the best response by the nurse? A. "I know of some herbs and supplements that you can take to manage the pain." B. "Tell me what works for you, and I will see what we can provide for your comfort." C. "We use real medicine here in the hospital, so I will bring you hydrocodone for pain when you need it." D. "Yoga always relaxes me. I will get you a foam mat from physical therapy so you can practice when you want." B. "Tell me what works for you, and I will see what we can provide for your comfort." The nurse is caring for a client with fluid overload who is on strict I's and O's. The nurse understands that which is the best way to ensure accurate I's and O's? A. clear any IV pumps and reset to zero for accurate IV fluid intake B. ask the client to keep up with how many cups of fluid he drinks at meals C.ask the client to report how much urine is in the urinal each time he uses it D. tell the client not to ask for any extra water or drinks that are not on the meal tray A. clear any IV pumps and reset to zero for accurate IV fluid intake A client has just returned from a cardiac catheterization with access via the femoral artery. Which position or activity should the nurse anticipate the health care provider will order for this client? A. bed rest with bathroom privileges B. bed rest with head of bed at 45 degrees C. ambulation to prevent blood clot formation D. bed rest with head of bed at 30 degrees or less E. up to chair with assistance if the client is steady on his feet D. bed rest with head of bed at 30 degrees or less The nurse is caring for an elderly client who has been taking cimetidine (Tagamet) for a year. The nurse should monitor for which central nervous system side effects? Select all that apply. A. tetany B. agitation C. confusion D. constipation E. disorientation B. agitation C. confusion D. constipation The nurse is caring for a client scheduled to receive cyclopentolate HCl preoperatively. Which finding in the client's history would prompt the nurse to notify the health care provider? A. osteoporosis B. hypothyroidism C. renal insufficiency D. cardiac dysrhythmias D. cardiac dysrhythmias The nurse is providing discharge teaching to a client who has been prescribed prednisone. The nurse instructs the client to report which symptom to the health care provider? A. increased appetite B. anxiety or confusion C. strong, bounding pulses D. weight gain of 3 pounds B. anxiety or confusion A client with asthma has orders for terbutaline. Which finding in the medical history would the nurse be most concerned about? A. diabetes B. migraines C. osteoarthritis D. coronary artery disease D. coronary artery disease The nurse is caring for a client with multiple IV medications. Which of the following drugs are compatible? A. vancomycin and heparin B. nitroglycerin and dopamine C. sodium bicarbonate and dobutamine D. furosemide (Lasix) and ondansetron (Zofran) B. nitroglycerin and dopamine The nurse is preparing to administer pilocarpine hydrochloride eye drops to a client with glaucoma. Which is the correct technique to administer eye drops? Select all that apply. A. instruct the client to tilt the head back and look up B. pull the upper lid up and place the drops just above the pupil C. pull the lower lid down and place the drop into the conjunctival sac D. to instill multiple drops, wait 3 to 5 minutes between drops to allow maximum absorption E. instruct the client to close the eyes and gently rub the eyelids to ensure maximum absorption A. instruct the client to tilt the head back and look up C. pull the lower lid down and place the drop into the conjunctival sac D. to instill multiple drops, wait 3 to 5 minutes between drops to allow maximum absorption The nurse is teaching a client about alendronate sodium (Fosamax). Which statement by the client indicates a need for further teaching? A. "I should take this with a meal." B. "I will call my doctor if I develop a fever." C. "I should not lie down for at least 30 minutes." D. "Dairy products reduce the absorption of this medicine." A. "I should take this with a meal." The ED nurse admits a client with second-degree burns to the arms and third-degree burns to the legs. Based on the Parkland formula, which IV fluid would the nurse anticipate for this client during the first 24 hours? A. D5W B. colloid solutions C. crystalloid solutions D. 5% albumin in isotonic saline A. D5W A 12-year-old client has new orders for amphetamine and dextroamphetamine (Adderall) for attention-deficit/ hyperactivity disorder. The nurse should alert the client's caregivers about which adverse effect? A. nausea B. seizures C. weight gain D. constipation B. seizures