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A nurse is assessing a client who has peripheral arterial disease.
Which of the following findings should the nurse expect? - CORRECT
ANSWER Hair loss on the lower legs
A nurse is reviewing the medical record of a client who is taking
warfarin for chronic atrial fibrillation. Which of the following values
should the nurse identify as a desired outcome for this therapy? -
CORRECT ANSWER INR 2.5
A nurse is reviewing the medical record of a client who has
osteomyelitis and a prescription for gentamicin. Which of the following
findings from the client's medical record should indicate to the nurse
the need to withhold the medication and notify the provider? (Click on
the "Exhibit" button for additional information about the client. There
are three tabs that contain separate categories of data.) - CORRECT
ANSWER Serum Creatinine
A nurse is providing teaching to a client who has anemia and a new
prescription for an oral iron supplement. Which of the following
statements by the client indicates an understanding of the teaching? -
CORRECT ANSWER "I will eat more high-fiber foods."
A nurse is caring for a client who has a cervical spinal cord injury
sustained 1 month ago. Which of the following manifestations
indicates that the client is experiencing autonomic dysreflexia (AD)? -
CORRECT ANSWER Heart rate 52/min
A nurse is caring for a newly admitted client who has a gastric
hemorrhage and is going into shock. Identify the sequence of actions
the nurse should take. (Move the steps into the box on the right,
,placing them in the selected order of performance. Use all the steps.) -
CORRECT ANSWER -Administer oxygen via a nonrebreather mask.
-Initiate IV therapy with a large-bore catheter.
-Insert an NG tube.
-Administer famotidine.
A nurse is planning care for a client who is scheduled for a
thoracentesis. Which of the following interventions should the nurse
include in the plan? - CORRECT ANSWER Encourage the client to
take deep breaths after the procedure.
A nurse is updating the plan of care for a client who is receiving
chemotherapy. Which of the following findings should the nurse
identify as the priority? - CORRECT ANSWER Report of sore throat
A nurse is providing follow-up care for a client who sustained a
compound fracture 3 weeks ago. The nurse should recognize that an
unexpected finding for which of the following laboratory values is a
manifestation of osteomyelitis and should be reported to the provider?
- CORRECT ANSWER Sedimentation rate
A nurse is caring for a client who had a nephrostomy tube inserted 12
hr ago. Which of the following findings should the nurse report to the
provider? - CORRECT ANSWER The client reports back pain.
A nurse is providing teaching to a client who has a recent diagnosis of
constipation-predominant irritable bowel syndrome. Which of the
following instructions should the nurse include in the teaching? -
CORRECT ANSWER Consume at least 30 g of fiber daily.
A nurse is planning care for an older adult client who has dementia.
Which of the following interventions should the nurse include in the
plan of care? - CORRECT ANSWER Place personal items, such as
pictures, at the client's bedside.
A nurse is planning care for a client who is postoperative following a
parathyroidectomy. Which of the following actions should the nurse
,identify as the priority? - CORRECT ANSWER Place a tracheostomy
tray at the bedside.
A nurse is assessing a client following the completion of hemodialysis.
Which of the following findings is the nurse's priority to report to the
provider? - CORRECT ANSWER Restlessness
A nurse is administering packed RBCs to a client. Which of the
following assessment findings indicates a hemolytic transfusion
reaction? - CORRECT ANSWER Low back pain and apprehension
A nurse is planning care for a client who is having a modified radical
mastectomy of the right breast. Which of the following interventions
should the nurse include in the plan of care? - CORRECT ANSWER
Instruct the client that the drain will be removed when there is 25 mL
of output or less over a 24-hr period.
A nurse is providing teaching to a client who has AIDS. Which of the
following statements by the client indicates an understanding of the
teaching? - CORRECT ANSWER "I will take my temperature once a
day."
A nurse is reviewing the laboratory findings of a client who developed
chest pain 6 hr ago. The nurse should identify which of the following
findings as an indication of a myocardial infarction (MI)? - CORRECT
ANSWER Troponin I 8 ng/mL
A nurse is teaching a client about osteoporosis prevention. The nurse
should instruct the client that which of the following medications can
increase their risk for developing osteoporosis? - CORRECT ANSWER
Prednisone
A nurse is preparing to administer phenytoin 600 mg PO daily to a
client. The amount available is oral solution 125 mg/5 mL. How many
mL should the nurse administer? (Round the answer to the nearest
whole number. Use a leading zero if it applies. Do not use a trailing
zero.) - CORRECT ANSWER 24 mL
, A nurse at an urgent care clinic is caring for a client who is
experiencing an anaphylactic reaction. After ensuring a patent airway,
which of the following nursing interventions is the priority? - CORRECT
ANSWER Applying oxygen via face mask
A nurse is preparing to administer a blood transfusion to a client who
has anemia. Which of the following actions should the nurse take first?
- CORRECT ANSWER Check for the type and number of units of blood
to administer.
A nurse is planning care for a client who has a sealed radiation
implant for cervical cancer. Which of the following interventions
should the nurse include in the plan of care? - CORRECT ANSWER
Keep a lead-lined container in the client's room.
A nurse is caring for a client who has breast cancer and tells the nurse
that they would like to have acupuncture because it provides greater
relief than pain medication. Which of the following statements should
the nurse make? - CORRECT ANSWER "I can speak to the provider
about incorporating acupuncture into your treatment plan."
A nurse is caring for a client who is receiving total parenteral nutrition
(TPN) and is NPO. When reviewing the chart, the nurse notes the
following prescription: capillary blood glucose AC and HS. Which of the
following actions should the nurse take? - CORRECT ANSWER
Contact the provider to clarify the prescription.
A nurse is caring for a client who has a positive culture for methicillin-
resistant Staphylococcus aureus (MRSA). Which of the following
actions should the nurse take? - CORRECT ANSWER Bathe the client
using chlorhexidine solution.
A nurse is caring for a client who has a pneumothorax and a closed-
chest drainage system. Which of the following findings is an indication
of lung re-expansion? - CORRECT ANSWER Bubbling in the water seal
chamber has ceased.