PN Medical-Surgical Exam 2020 – Latest 2024-2025 Version Update with Best Study Material, Exams of Nursing

Download PN Medical-Surgical Exam 2020 – Latest 2024-2025 Version Update with Best Study Material and more Exams Nursing in PDF only on Docsity! PN MEDICAL SERGICAL EXAM 2020 LATEST VERSION UPDATE 2024-2025 BEST STUDYING MATERIAL ACCURATE QUESTIONS AND VERIFIED ANSWERS GUARANTEED PASS GRADED A. A nurse is assisting with the admission assessment of a client who has late-stage emphysema. The nurse should recognize which of the following as an expected finding? A. Slow, deep respirations B. Flushed facial skin C. Elevated body mass index D. Clubbing of the fingernails - Ans - D. Clubbing of the fingernails Rationale: Emphysema is a lung disease that causes shortness of breath due to damage to the air sacs in the lungs. Stage 4 emphysema is the most severe stage, in which a person has an FEV1 score below 30% of the expected value. Some of the symptoms of stage 4 emphysema are: Severe shortness of breath, even at rest Chest tightness and pain Fatigue and weakness Loss of appetite and weight loss Bluish lips or fingernails due to low oxygen levels Based on these symptoms, the expected finding for a client who has late-stage emphysema is clubbing of the fingernails. Clubbing is a condition in which the fingernails become curved and enlarged due to chronic low oxygen levels in the blood A nurse is caring for an older adult client who has hypothyroidism. Which of the following findings should the nurse expect? A. weight loss B. Bradycardia C. Restlessness D. Increased temperature - Ans - B. Bradycardia A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for 2 days. Which of the following laboratory values should the nurse report to the provider? a) Potassium 4.0 mEq/L b) Lithium 0.9 mEq/L c) BUN 12 mg/dL d) Sodium 132 mEq/L - Ans - D. Sodium 132 mEq/L Rationale: The nurse should identify that a sodium level of 132 mEq/L is not within the expected reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can lead to lithium accumulation and places the client at risk for lithium toxicity. The nurse should report this finding to the provider. A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3. Which of the following actions should the nurse take? a) Cleanse the client's toothbrush with hydrogen peroxide. b) Instruct the client to use a disposable razor to shave. c) Decrease the client's protein intake. d) Encourage the client to eat unpasteurized dairy products. - Ans - A. Cleanse the client's toothbrush with hydrogen peroxide. Rationale: A WBC count of 4,000/mm3 is considered low and is known as leukopenia. A low WBC count can be caused by cancer or cancer treatment. The nurse should instruct the client to cleanse their toothbrush with hydrogen peroxide. People with leukemia or leukopenia should avoid using disposable razors, which can cause cuts and bleeding that can lead to infections. Instead, they recommend using an electric razor to reduce the risk of injury. Encouraging the client to eat unpasteurized dairy products is not recommended as they can contain harmful bacteria that can cause infections. Decreasing the client's protein intake is not recommended as protein is important for wound healing and immune function TEST A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first? a) Activate the fire alarm system. b) Use a fire extinguisher at the source of the smoke. c) Assist the client to a nearby common area. d) Close the doors to the room and to the bathroom. - Ans - C. Assist the client to a nearby common area. Rationale: use Rescue The nurse should not apply the first drop of blood to the test strip since the alcohol could cause false reading. Hexachlorophene is not recommended for cleaning the client's finger as it can cause tissue damage. TEST A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching? a) "It is common for one breast to be larger than the other." b) "It is common for the skin on my breasts to dimple." c) "I will perform breast exams the day my period begins." d) "I will perform breast exams every other month." - Ans - A. "It is common for one breast to be larger than the other." Rationale: It is normal to have asymmetrical breasts, usually, the left breast is bigger than the right. This is because of the difference in the percentage of breast tissues and fatty tissues, that's why they react differently to hormonal changes. "Dimpling on the skin on breasts is NOT common" Physician consultation should be taken regarding this as it can be a sign of breast cancer. "Self-breast exams are recommended to be performed after a week when the period starts." The rest of the month breasts reamain tender due to hormone fluctuation. "Self-Breast exams should be performed every month." For women in reproductive age usually after a week when the period starts and at the same day of every month for women who have attained menopause. A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching? a) "I will need to empty the bag every 4 to 6 hours." b) "I will use moisturizing soap to clean around the stoma before applying the bag." c) "I will use a skin sealant before I apply the bag." d) "I will cut the wafer opening one-fourth of an inch larger than the stoma." - Ans - C. "I will use a skin sealant before I apply the bag." Rationale: An ileostomy is an opening in the belly that's made during surgery to allow waste to pass out of the body. It requires special care to keep the skin around it clean and prevent infection. A skin sealant can protect the skin from irritation and help the bag stick better. The other statements are incorrect because: a) You may need to empty the bag more often than every 4 to 6 hours, depending on how much waste you produce. b) You should not use moisturizing soap to clean around the stoma, as it can leave a residue that interferes with the bag's adhesion. You should use plain water or mild soap and rinse well. d) You should cut the wafer opening to fit snugly around the stoma, not larger than it. A larger opening can expose the skin to waste and cause irritation TEST A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid replacement. Which of the following interventions should the nurse contribute to the plan of care? a) Offer oral fluids every 4 hr. b) Check for neck vein distention. c) Limit oral fluids prior to bedtime. d) Monitor pulse pressure every 6 hr. - Ans - B. Check for neck vein distention. Rational: Neck vein distention might be a sign of congestion of fluid in the vascular system, which can occur when a person is receiving excessive IV fluids. Offering oral fluids every 4 hours may be appropriate for a patient who is mildly dehydrated and able to tolerate oral intake, but it is not recommended for a patient who is severely dehydrated and receiving IV fluid replacement. Limiting oral fluids prior to bedtime may be appropriate for a patient with nocturia, but it is not relevant to the care of a dehydrated patient receiving IV fluid replacement. Pulse pressure is the difference between the systolic and diastolic blood pressure readings. While monitoring vital signs, including blood pressure, is important, pulse pressure may not be the most relevant parameter to track in this context. Other vital signs like heart rate and blood pressure could be more indicative of the client's overall condition A nurse is caring for a young adult client who has testicular cancer and expresses concern about their sexual function following an orchiectomy of the involved testicle. Which of the following responses should the nurse make? a) "I'm sure any partner will understand that you have no control over this." b) "There are other ways to express intimacy besides intercourse." c) "You should focus on recovering from your cancer right now." d) "The removal of a single testicle will not prevent you from having an erection." - Ans - D. "The removal of a single testicle will not prevent you from having an erection." TEST A nurse is collecting data from a client who has hyperthyroidism and is taking propylthiouracil. Which of the following statements by the client indicates the medication is effective? a) "I no longer feel nervous." b) "I no longer take a stool softener." c) "I have less oily skin." d) "I continue to lose weight." - Ans - A. "I no longer feel nervous." Rationale: Propylthiouracil is a medication used to treat hyperthyroidism, Graves' disease, or toxic goiter (enlarged thyroid). It works by inhibiting the synthesis of thyroid hormones and thus is effective in the treatment of hyperthyroidism. The following statements by the client indicate the effectiveness of propylthiouracil: "I no longer feel nervous" - This statement is a good indicator that the medication is effective. Hyperthyroidism can cause nervousness, anxiety, and irritability. Therefore, if the client no longer feels nervous, it could be due to the medication's effectiveness. "I no longer take a stool softener" - This statement is not an indicator of propylthiouracil's effectiveness. Stool softeners are used to relieve constipation, which is not a symptom of hyperthyroidism or a side effect of propylthiouracil. "I have less oily skin" - This statement is not an indicator of propylthiouracil's effectiveness. Oily skin is not a symptom of hyperthyroidism or a side effect of propylthiouracil. "I continue to lose weight" - This statement is not necessarily an indicator of propylthiouracil's effectiveness. Weight loss can be a symptom of hyperthyroidism, but it can also be a side effect of propylthiouracil. Therefore, this statement alone cannot confirm the medication's effectiveness. a) "Encourage your partner to wake up to interact with family members." b) "Sitting quietly near the bedside can provide comfort and support." c) "I will call the provider to discuss your concerns." d) "I can ask the provider to prescribe a medication that will minimize drowsiness." - Ans - B. "Sitting quietly near the bedside can provide comfort and support." Rationale: This action shows therapeutic technique of offering self which can be verbal and non- verbal. Just being with the patient's side having your presence shows comfort and support specially as the patient is nearing its death. TEST A nurse is reinforcing teaching with a client who is postoperative following a tympanoplasty. Which of the following information should the nurse include? a) Drink fluids through a straw. b) Plan to shampoo hair in 1 week. c) Resume exercising in 10 days. d) Close mouth when sneezing. - Ans - B. Plan to shampoo hair in 1 week. Plan to shampoo hair in 1 week: The client should avoid getting water in the ear for at least one week after surgery. This includes avoiding washing hair, swimming, or taking baths. After one week, the client can resume normal hair care activities. Resume exercising in 10 days: The client should avoid strenuous exercise or heavy lifting for at least two weeks after surgery. After two weeks, the client can gradually resume normal activities. Close mouth when sneezing: The client should avoid blowing the nose or sneezing with the mouth open for at least two weeks after surgery. This can help prevent pressure changes in the ear that may interfere with healing A nurse is reinforcing discharge teaching about dietary changes with a client who has a new colostomy. Which of the following foods should the nurse recommend? a) Asparagus b) Bananas c) Grapes d) Broccoli - Ans - B. Bananas Rationale: other options are high in fiber A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory results should the nurse report to the provider? a) Glycosylated hemoglobin 5.2% b) Urine positive for ketones c) Urine negative for bilirubin d) Fasting blood glucose 70 mg/dL - Ans - b. Urine positive for ketones Rational: when there are ketones in your urine, that is the indication of DKA. Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. TEST A nurse is caring for an older adult client who has heart failure. Which of the following findings should the nurse report to the provider? a) Urinary output of 1,000 mL in 12 hr b) Potassium level 4.5 mEq/L c) PaCO2 55 mm Hg d) Chest x-ray showing cardiomegaly - Ans - C. PaCO2 55 mm Hg Rationale: Partial pressure of carbon dioxide normal range is 35 to 45 mm hg. Patients paCO2 level is 55 mm hg. So this is elevated partial pressure of carbon dioxide for this patient. Increased partial pressure of carbon dioxide indicate alveolar hypoventilation that causes respiratory acidosis. So there are more chances to develop respiratory acidosis. Respiratory acidosis should be treated immediately. Health care provider should be reported by nurse for elevated partial pressure of carbon dioxide. Potassium level 4.5 meq/L is a normal value. Normal value of serum potassium is 3.6 to 5.1 meq/L. Chest X ray showing cardiomegaly so in heart failure this a general sign. 1000 ml of urine output in 12 hour is low output but this is necessary to report about elevated partial pressure of carbon dioxide. TEST A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads, "Apply to the left foot for 20 min." Which of the following actions should the nurse take? a) Complete Semmes-Weinstein monofilament testing following treatment. b) Apply the heating pad as prescribed by the provider. c) Clarify the prescription with the provider. d) Observe the skin 10 min after the start of treatment. - Ans - C. Clarify the prescription with the provider. Rationale: diabetic neuropathy of lower extremities increasing chances of impaired perceptual sensation to heat -> increasing risk for burns -> IF test is done, the patient will be assessed how much they can sense pain from heat -> preventing burns to skin -> making letter C the correct answer. A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements by the client indicates an understanding of the teaching? a) "I should clean around the stoma with moisturizing soap." b) "I should avoid broccoli and chewing gum." c) "I should decrease the amount of fresh fruit in my diet." d) "I should place an aspirin in the pouch to eliminate odor." - Ans - B. "I should avoid broccoli and chewing gum." TEST A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image? a) Denies feelings of sadness about the ostomy b) Prefers not to look at the stoma site c) Accepts that seual activity will decrease d) Participates in performing ostomy care - Ans - D. Participates in performing ostomy care TEST A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider? a) Ammonia 55 mcg/dL b) Bilirubin 1.0 mg/dL c) Platelets 60,000/mm3 A TENS unit is a device that delivers mild electrical current to the affected area of the back using small transcutaneous electrode pads. It can be used to relieve lower back pain and improve posture in those with herniated discs and lower back conditions. It can also help to reduce swelling and stiffness in the lower back. This can help to improve your mobility and overall range of motion. TEST The nurse is reinforcing teaching about a Transcutaneous Electrical Nerve Stimulation (TENS). Which of the following statements by the nurse is accurate? a) "This form of pain management involves tiny needles inserted into the skin and subcutaneous tissues." b) "This form of pain management focused on a pleasant thought to divert focus." c) "This form of pain management involves meditation, yoga, and progressive muscle relaxation." d) "This form of pain management involves mild electrical stimulus applied to the area of pain." - Ans - D. This form of pain management involves mild electrical stimulus applied to the area of pain. Rationale: This nonpharmacological technique is known as TENS. Option A this nonpharmacological technique is known as acupuncture. Option B this nonpharmacological technique is known as Imagery. Option C this nonpharmacological technique is known as Relaxation. TEST A nurse is reviewing a client's medical record. Which of the following findings is the priority for the nurse to report? a) Urine output 200 mL/8 hrs b) A client's rating of ear pain as 5 on a scale from 0 to 10 c) Potassium level 6.2 mEq/L d) Abnormal hepatoiminodiacetic acid (HIDA) scan - Ans - C. Potassium level 6.2 mEq/L Rational: Among the options, the elevated potassium level of 6.2 mEq/L is the most critical finding that should be reported to the provider. Hyperkalemia can lead to serious cardiac complications and requires immediate attention. The other options, including an abnormal hepatoiminodiacetic acid (HIDA) scan, a client's rating of ear pain, and urine output of 200 mL/8 hr, are important but not as high a priority as the elevated potassium level. A nurse is reinforcing teaching about decreasing the risk of osteoporosis to a client who is postmenopausal. Which of the following instructions should the nurse include? a) Limit vitamin D intake. b) Increase daily intake of vitamin E. c) Add a weight-bearing exercise regimen. d) Take calcium carbonate supplements once a day with breakfast. - Ans - C. Add a weight-bearing exercise regimen. Rationale: Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes. This can lead to a decrease in bone strength that can increase the risk of broken bones (fractures). Pregnancy, Breastfeeding, and Bone Health. Numerous studies have shown that weight-bearing exercise can help to slow bone loss, and several show it can even build bone. A nurse is caring for a client who has COPD with copious secretions. Which of the following actions should the nurse take? a) Place the client in prone position. b) Administer high-flow oxygen. c) Limit fluid intake. d) Perform postural drainage. - Ans - D. Perform postural drainage. Rationale: COPD (Chronic Obstructive Pulmonary Disease) is a chronic lung disease that causes breathing difficulties. It is characterized by the production of excessive mucus and secretions in the airways, which can lead to airway obstruction and difficulty breathing. In the case of a client with COPD and copious secretions, the nurse should perform postural drainage. Postural drainage is a technique that involves positioning the patient so that gravity can help drain secretions from the lungs. This technique is effective in clearing mucus from the lungs and improving breathing. Administering high-flow oxygen or limiting fluid intake are not appropriate interventions for a client with COPD and copious secretions. High-flow oxygen can lead to oxygen toxicity, while limiting fluid intake can cause dehydration and thickening of mucus, making it harder to clear. Placing the client in prone position is not recommended for clients with COPD and copious secretions. This position can cause increased pressure on the diaphragm, leading to difficulty breathing. A nurse is reinforcing teaching with a client who has COPD and reports shortness of breath and little appetite. Which of the following instructions should the nurse include in the teaching? a. Eat lighter, low -calorie foods first. b. Eliminate dairy products. c. Consume three regular meals daily. d. Limit fluid intake during meals - Ans - D. Limit fluid intake during meals Rationale: They tend to make breathing more difficult. Eat 4 to 6 small meals a day. This enables your diaphragm to move freely and lets your lungs fill with air and empty out more easily. If drinking liquids with meals makes you feel too full to eat, limit liquids with meals or drink after meals. One way to manage your COPD symptoms is to opt for a fluid-restricted diet. A diet that restricts the number of fluids a person can take each day is called a fluid-restricted diet. Consuming too much fluid can lead to an increase in mucus formation, which can make breathing harder and also causes heart problems A nurse is collecting data from a client who had a long arm cast applied 2 hr ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately? a) The client reports increased pain at the area of the fracture. b) The client reports severe itching under the cast. c) The client's capillary refill is 3 seconds. d) The client's fingers are cool to the touch. - Ans - D. The client's fingers are cool to the touch. Rationale: fingers are cool to touch is an indicating of the cast is too tight and it is blocking circulation to the extremity. TEST Position the client upright for 30-60 minutes after eating. This will help prevent aspiration and reflux. It is important to note that sticky foods such as peanut butter should be avoided as they can be difficult to swallow and may cause choking. A nurse is reinforcing teaching with a client who has ovarian cancer and will receive chemotherapy through a peripherally inserted central catheter (PICC) line. Which of the following statements by the client indicates an understanding of the teaching? a) "I will wear an arm immobilizer to prevent dislodgement of this device." b) "I will monitor my temperature for fever while I have this device." c) "It's okay to get the device wet when I shower." d) "I should pull the dressing away from the insertion site when I change it." - Ans - B. "I will monitor my temperature for fever while I have this device." A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take? a) Replace the unit when the drainage chamber is full. b) Clamp the tube for 30 min every 8 hr. c) Pin the tubing to the client's bed sheets. d) Monitor for at least 150 mL of drainage every hour. - Ans - A. Replace the unit when the drainage chamber is full. Rationale: Pinning the tube can cause tension or pulling, which can lead to dislodgement of the tube or tension pneumothorax Clamping the tube for 30 mins every 8 hrs can lead to build up pressure in the pleural space, which can cause lung collapse or tension pneumothorax Monitor for at least 150 mL is incorrect because the nurse should monitor for the amount and character of drainage, but there is no specific amount that must be monitor hourly. A nurse is collecting data from a client who is 2 days postoperative following a colon restriction. Which of the following indicates the need for nursing intervention? a) Mild abdominal pain when coughing 30 min after receiving pain medication b) Dark brown drainage in the NG tube c) Serosanguineous drainage on the wound dressing d) Oxygen saturation 95% - Ans - B. Dark brown drainage in the NG tube Rationale: Dark brown drainage in the NG tube can be an indication of old blood in the stomach or upper intestine. This tube will be set to suction and will drain out brownish colored stomach acid. When it runs from brown to light green to clear, this is an indication that things are moving through the stomach and feedings may be possible. A nurse is caring for a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report? a. Hypoactive bowel sounds in all four quadrants b. Serosanguineous drainage at the incision site c. Red streaks along the incision d. Temperature 37.2° C (99° F) - Ans - c. Red streaks along the incision Rationale: Red streaks along the incision site can be a sign of lymphangitis which is an infection and inflammation of the lymph vessels. It can result from a bacterial skin infection. A person may notice red or dark streaks extending from the site of an injury, along with swelling, pain, and warmth The different types of wound drainage are: Purulent: thick or creamy drainage that is yellow, green, or brown and indicates infection. Sanguineous: bloody drainage that is bright red and indicates active bleeding. Serosanguineous: thin or watery drainage that is clear or pink and indicates tissue injury or inflammation. (Which is normal after surgery, unless excessive bleeding) Serous: clear drainage that is thin or watery and indicates normal healing. TEST A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take? a) Provide the client with a small-handled adaptive utensil. b) Arrange for an assistive personnel to feed the client. c) Describe the food placement as though the plate were a clock. d) Discourage conversations during the client's mealtime. - Ans - C. Describe the food placement as though the plate were a clock. Rationale: Some appropriate actions by the nursing when helping a visually impaired patient with the meal tray are: Ask the patient how they prefer to receive information and mark their medications2. Read aloud what you write in the medical record and tell the patient what procedure you are about to do. Use a clock-face method to describe the location of food items on the tray1. Provide low-vision aids and adequate lighting if needed. A nurse is reinforcing teaching with a client who is starting to take metformin extended release. Which of the following instructions should the nurse include in the instructions? a) Monitor blood glucose while taking this medication. b) Chew the medication before swallowing. c) Expect muscle pain while taking this medication. d) Take the medication with breakfast. - Ans - A. Monitor blood glucose while taking this medication. Rationale: metformin is a DM medicine A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care? a) Advise the client about increased dry mouth. b) Check the client for increased hypopigmentation under the patch. c) Monitor the client for weight loss. d) Inform the client of the adverse effect of diarrhea. - Ans - a) Advise the client about increased dry mouth. Rationale: The nurse should expect absent bowel sounds in a client who has peritonitis. Other symptoms of peritonitis include abdominal pain or tenderness, bloating, fever and chills, nausea and vomiting, loss of appetite, diarrhea, increased thirst, passing significantly less urine, inability to pass stool or gas, fatigue A nurse is reinforcing teaching with a client about menopause. Which of the following statements by the client indicates an understanding of the teaching? a) "I will need hormone replacement therapy for the rest of my life." b) "I should expect to have an increased risk for breast cancer." c) "The use of black cohosh will decrease vaginal bleeding." d) "I should use a vaginal douche to prevent dryness." - Ans - B. "I should expect to have an increased risk for breast cancer." A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease. Which of the following dietary instructions should the nurse include? a) Chew food thoroughly. b) Use a straw when drinking liquids. c) Drink carbonated beverages with meals. d) Limit meals to three per day with no snacking in between. - Ans - A. Chew food thoroughly TEST A nurse is preparing a client for a colposcopy following an abnormal Papanicolaous (Pap) test. Which of the following actions should the nurse take? a) Place the client in the Sims' position. b) Reinforce teaching that the procedure involves dilation of the cervix. c) Insert a tampon following the procedure. d) Instruct the client to avoid sexual intercourse until the cervix is healed. - Ans - D. Instruct the client to avoid sexual intercourse until the cervix is healed. Rationale: A colposcopy is a procedure to examine your cervix, vagina and vulva for signs of disease using a special instrument called a colposcope. For this procedure, you will be asked to lie on your back, legs in stirrups, and buttocks at the lower edge of the table (a position known as the dorsal lithotomy position). A speculum will be placed in your vagina to open it and allow the colposcope to get close to your cervix. The other options are incorrect because: The procedure does not involve dilation of the cervix. A tampon should not be used after the procedure because it can cause infection or bleeding. A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou test. Which of the following actions should the nurse take? Instruct the client to avoid using tampons following the procedure. Instill a vaginal cream prior to the procedure. Place the client in the Sims' position. Reinforce teaching that the procedure involves dilation of the cervix. - Ans - Instruct the client to avoid using tampons following the procedure. Rationale: A colposcopy is a procedure to examine your cervix, vagina and vulva for signs of disease. It is often done after an abnormal Pap test. To prepare for a colposcopy, you should: Avoid scheduling your colposcopy during your period. Don't have vaginal intercourse or use tampons, medication or douches for two days before the procedure. Take an over-the-counter pain reliever before your appointment. The procedure involves placing a speculum in your vagina and looking at your cervix through a magnifying instrument called a colposcope. Your doctor may apply a vinegar solution to highlight any abnormal areas and take tissue samples if needed. The correct answer to the question is: instruct the client to avoid using tampons following the procedure. The other options are incorrect or unnecessary. Instilling a vaginal cream prior to the procedure may interfere with the examination. Placing the client in the Sims' position is not required for a colposcopy. The procedure does not involve dilation of the cervix. A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the following interventions should the nurse include? a) Encourage the client to eat a low-protein diet. b) Prohibit fresh flowers in the client's room. c) Obtain the client's rectal temperature every 4 hr. d) Initiate airborne precautions for the client. - Ans - B. Prohibit fresh flowers in the client's room. Rationale: The nurse should include the following interventions in the plan of care for a client who has a low WBC count: Encourage the client to eat a nutritious diet that is rich in protein and vitamins. Prohibit fresh flowers in the client's room as they can harbor bacteria and fungi that can cause infections2. Obtain the client's rectal temperature could accidently introduce bacteria to the patient. Initiate standard precautions for the client, which include wearing gloves and a gown when entering the room. A nurse is reinforcing teaching with a female client who has a history of urinary tract infections. Which of the following instructions should the nurse include? a) Use a vaginal douche once a week. b) Empty the bladder at least every 6 hr. c) Increase milk consumption to make the urine more alkaline. d) Urinate before and after sexual intercourse. - Ans - D. Urinate before and after sexual intercourse. Rationale: Urinating before and after sex promotes flushing of possible pathogenic bacteria that may have invaded the urinary tract -> decreasing the chances of UTI. Option A vaginal douching is associated with an increased incidence of infection. Option B it should be done as often as needed. If possible as frequent as possible. If only emptied every 6 hours, it increases the risk for infection. Option C does not make urine more alkaline as milk is digested in gastric acid -> thus does not help alkalinize urine A nurse is caring for a client who has a prescription for a sequential compression device (SCD). Which of the following actions should the nurse take when applying the SCD? a) Ensure two fingers fit between the leg and the sleeve. b) Wrap excess tubing to the side of each leg. c) Current medication prescriptions d) Number of family members who have visited e) Admission vital signs from 1 week ago - Ans - A. Primary health problem B. Scheduled times for dressing changes C. Current medication prescriptions TEST A nurse is collecting data from a client prior to administering hydrochlorothiazide for mild hypertension. Which of the following findings should the nurse identify as a contraindication to administering the medication? a) 2+ pedal edema b) Potassium 2.8 mEq/L c) Allergy to shellfish d) History of GERD - Ans - B. Potassium 2.8 mEq/L Rationale: HCTZ or hydrochlorothiazide is a diuretic medication also used in treating high blood pressure. It is non-selective diuretic therefore it also flushes out electrolytes such as potassium. Normal potassium range is 3.5-5.0mEq/L, therefore a value of 2.8mEq/L is contraindicated because it can lead further to hypokalemia. A nurse is caring for a client who has a terminal illness and is in the active phase of dying. The client refuses further hydration and nourishment. Which of the following actions should the nurse take? a) Request a prescription for IV fluids. b) Ask the client's health care surrogate for permission to withhold nourishment. c) Provide regular oral care for the client with a moist swab. d) Explain the importance of oral hydration to the chest. - Ans - C. Provide regular oral care for the client with a moist swab. A nurse is caring for a client who has returned to the unit following a cardiac catheterization using a femoral approach. Which of the following methods should the nurse use to monitor for complications? a) Check the client's blood pressure while the client lies supine, sits, and stands. b) Palpate the client's brachial pulses and compare bilaterally. c) Check for jugular vein distention while the client is supine. d) Palpate the client's pedal pulses and compare bilaterally. - Ans - D. Palpate the client's pedal pulses and compare bilaterally. Rationale: After a cardiac catheterization procedure using the femoral approach, it is important for the nurse to monitor the client for any complications that may arise. One such complication is impaired blood flow to the lower extremities, which can be detected by palpating the client's pedal pulses and comparing them bilaterally. Palpating the pedal pulses involves gently pressing the fingertips against the dorsalis pedis and posterior tibial arteries on both feet to assess the presence, strength, and symmetry of the pulses. The dorsalis pedis artery is located on the top of the foot, just lateral to the extensor hallucis longus tendon, while the posterior tibial artery is located behind the medial malleolus, slightly inferior to the ankle bone. TEST A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following client statements indicates understanding of the teaching? a) "I should put lotion between my toes every day to prevent dryness and cracking." b) "I should apply a heating pad to my feet every night to help with circulation." c) "I should use my wrist to test the temperature of the water before bathing." d) "I should round the corners of my toenails with a nail file to prevent ingrown nails." - Ans - C. "I should use my wrist to test the temperature of the water before bathing." Rationale: When taking care of their feet, people with diabetes should check their feet daily for signs of swelling, redness, or heat, which may be signs of infection. They should also wash their feet daily and dry well between the toes. If there is a lot of moisture between the toes, they can use methylated spirits. They should moisturize dry skin, especially cracked heels (for example, with sorbolene cream) but not between the toes It's important to avoid hot water and harsh soaps that can damage the skin. People with diabetes should also avoid using a heating pad, hot water bottle, or electric blanket on their feet and avoid walking barefoot. They should protect their feet from heat and cold and never attempt to remove corns, calluses, warts, or other foot lesions themselves. They should see their doctor or podiatrist for these issues. TEST The nurse is reinforcing teaching about foot care to the diabetic client. Which of the following statements should the nurse make? A. "Remove any calluses or corns when they develop." B. "Do not use any foot powder as a remedy for sweating feet." C. "Apply lotion to feet and in between toes to keep skin soft." D. "The best time to perform nail care is after a bath or shower." - Ans - D. "The best time to perform nail care is after a bath or shower." Rationale: Toenails are soft and easier to trim after a bath or shower.(Medical Surgical RM Chp. 72) A nurse is contributing to the plan of care for a client who has disuse syndrome following cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care? a) Dietitian b) Herbalist c) Occupational therapist d) Social worker - Ans - C. Occupational Therapist Rationale: Occupational therapist helps patient to recover, improve, as well as maintain the skills needed for activities of daily living coming from injuries and disabilities. In this case coming from disuse syndrome. A nurse is collecting data from a client who had a left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately? a) Difficulty speaking b) A change in pupil size c) Right-sided weakness d) Inability to follow direction - Ans - B. A change in pupil size Rationale: A change in the pupil specially when dilation is noted can be indicative of neurologic emergency. Anisocoria is a significant neurologic finding that needs further evaluation. TEST A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take? A nurse is preparing to assist with the administration of peritoneal dialysis to a client. In which order should the nurse take the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) a) Record the client's vital signs. b) Measure the client's abdominal girth. c) Prime the client's catheter tubing with dialysate solution. d) Infuse dialysate solution into the client's peritoneal cavity. e) Open the client's drainage tubing after 10 min of dwell time. - Ans - A. Record the client's vital signs. B. Measure the client's abdominal girth. C. Prime the client's catheter tubing with dialysate solution. D. Infuse dialysate solution into the client's peritoneal cavity. E. Open the client's drainage tubing after 10 min of dwell time. A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first? a) Administer a glycerin suppository. b) Ambulate the client in the hallway. c) Offer an analgesic medication. d) Request the client to be NPO. - Ans - B. Ambulate the client in the hallway Rationale: Cramping and hypoactive bowel sound is common post operative for patient having abdominal surgery that can last until 5 days. This can be due to the gas introduced in the abdomen during surgery. Walking can encourage peristaltic bowel movement relieving gas and constipation. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? a) Empty urine from the drainage bag every 12 hrs. b) Secure the catheter tubing to the client's thigh. c) Apply topical antimicrobial ointment to the client's urinary meatus following catheter care. d) Use clean technique to collect urine specimens from the drainage system. - Ans - B. Secure the catheter tubing to the client's thigh. Rationale: When caring for a client with an indwelling urinary catheter, the nurse should take the following actions: Empty urine from the drainage bag every 8 hours or when it is half full. This helps prevent the urine from flowing back into the bladder and causing an infection. Secure the catheter tubing to the client's abdomen or thigh. This helps prevent accidental dislodgement of the catheter and reduces tension on the catheter. Cleanse the meatus with soap and water during daily hygiene. The nurse should avoid using topical antimicrobial ointment unless there is a specific indication for its use. Use sterile technique to collect urine specimens from the drainage system. This helps prevent contamination of the specimen and ensures accurate test results. TEST A nurse is caring for a client who is 8 hr postoperative following a left hip arthroplasty. Which of the following laboratory values indicates the nurse should notify the provider? a) BUN 18 mg/dL b) Potassium 2.6 mEq/L c) Blood glucose 98 mg/dL d) Hemoglobin 8.6 g/dL - Ans - D. Hemoglobin 8.6 g/dL Rationale: (Range of Hgb: Male - 14 to 18 Female - 12 to 16 - trick to remember 2-4-6-8) Below range is indicated of anemia. Post operative anemia is not a good sign because it can be interpreted as there is a presence of bleeding. TEST A nurse is caring for a client who has been admitted with Addison's disease. For which of the following laboratory findings should the nurse plan to monitor and report to the provider? a) Glucose 55 mg/dL b) Potassium 3.8 mEq/L c) Sodium 140 mEq/L d) BUN 15 mg/dL - Ans - A. Glucose 55 mg/dL TEST A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema? a) Keep both arms below the level of the client's heart. b) Limit range-of-motion exercises with the affected arm. c) Obtain blood pressure readings using the client's right arm. d) Use the client's left arm to obtain blood samples. - Ans - D. Use the client's left arm to obtain blood sample Rational: To prevent the development of lymphedema after mastectomy, the nurse should avoid constriction of the affected area, like blood pressure cuffs. The nurse should also obtain blood pressure readings using the client's left arm and use the client's left arm to obtain blood samples. The nurse should encourage range-of-motion exercises with the affected arm. A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in order of performance. Use all stamps.) a) Check the medication administration record to verify the client's allergies. b) Ensure an air bubble is present in the prefilled enoxaparin syringe. c) Locate the injection site 5 cm (2 in) to the right or left of the umbilicus. d) Pinch clean skin at the injection site and dart the needle into the skinfold at a 90 degree angle e) Slowly inject the medication into the site without aspirating. - Ans - A. Check the medication administration record to verify the client's allergies. B. Ensure an air bubble is present in the prefilled enoxaparin syringe. C. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus. D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90 degree angle E. Slowly inject the medication into the site without aspirating. A nurse is collecting data from a client who is African-American. Which of the following areas should the nurse check to determine the presence of pallor? a) Apply restraints to the client. b) Insert a tongue blade into the client's mouth. c) Administer an IV bolus of lorazepam. d) Place the client in the prone position. - Ans - c) Administer an IV bolus of lorazepam Rationale: Administering an IV bolus of lorazepam is the appropriate action for a patient who is expecting a generalized tonic-clonic seizure, as it can help prevent or reduce the severity of the seizure. TEST A nurse is prioritizing care for four clients following a change-of-shift report. Which of the following clients should the nurse attend to first? a) A client who has diverticulitis and a temperature of 38.3C (100.9F) b) A client who has a prescription for a sputum specimen to be obtained before breakfast c) A client who sustained a head injury 2 days ago and has a decreased level of consciousness d) A client who has Alzheimer's disease and requires assistance to the bathroom - Ans - C. A client who sustained a head injury 2 days ago and has a decreased level of consciousness. Rationale: The decrease level of consciousness needs immediate action and monitoring. This could lead to deficit level of brain functioning that may lead to shock thus needing intensive care. Having a febrile client as what option 1 presents also needs attention however fever is also included in the symptoms of infected/inflamed diverticula. Though significant but the value given is manageable range. A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of the following actions should the nurse take? A. Alternate the client's daily routine B. Keep the lights dimmed. C. Raise the four side rails on the client's bed. D. Participate in reminiscence therapy with the client. - Ans - D. Participate in reminiscence therapy with the client. TEST A nurse is reinforcing teaching with a client who is taking oxybutynin. The nurse should tell the client that the medication will have which of the following effects? a) Relaxes the muscles of the bladder b) Increases venous return to the heart c) Relaxes the muscles of the colon d) Increases tissue perfusion in the lungs - Ans - A. Relaxes the muscles of the bladder. Rationale: Oxybutynin relaxes the bladder muscles to decrease the urge of constant urination. Option B does not increase or promote venous return. Option C the bladder is the target organ not the colon. Option D not associated with increased blood flow and perfusion to lungs. TEST A nurse is reviewing the laboratory report of a client who has cancer and is experiencing anorexia. Which of the following laboratory values should indicate to the nurse that the client is experiencing malnutrition? a) Prealbumin 10.5 mg/dL b) Hematocrit 45% c) WBC count 6,000/mm3 d) BUN 15 mg/dL - Ans - A. Prealbumin 10.5 mg/dL Rationale: Prealbumin normal range is 15-36mg/dL. Prealbumin helps in the thyroid hormone and Vitamin A circulation in our bloodstream. It also helps in regulation of how the body uses energy. Below normal prealbumin is indicative of malnutrition. A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factor for falls? a) Instructs the client to wear their own socks to the bathroom b) Keeps the client's bed in the low position c) Positions the bedside table close to the client d) Attaches the call light to the side rail of the client's bed - Ans - A. Instructs the client to wear their own socks to the bathroom Rationale: Bathroom floor can be slippery -> If wearing socks -> patient might slip (increased risk for falls) Option B patient will not likely be injured if fall occurs since bed is close to floor due to its low position and patient does not have to step far off from bed to stand up -> decreasing risk for falls. Option C patient does not need to get up to get things from bedside table, decreasing risk for falls. Option D since call light is close to patient, little mobility is needed, decreasing risk for falls. A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement? a) Encourage the client to ambulate with a staff member. b) Isolate the client in their room. c) Apply bilateral wrist restraints to the client. d) Administer a prescribed oral dose of trazodone to the client. - Ans - A. Encourage the client to ambulate with a staff member. A nurse is reinforcing teaching with a client who is to begin taking lansoprazole. Which of the following statements by the client indicates an understanding of the teaching? a) "I should chew the capsule thoroughly." b) "I should report episodes of diarrhea." c) "I should take the medication following a meal." d) "I should expect the medication to cause indigestion." - Ans - B. "I should report episodes of diarrhea." An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hrs ago. Which of the following clients should the nurse identify as having a positive test result? a) A client whose injection site has an elevated area measuring 15 mm (0.6 in) b) A client who injection site is scabbed c) A client whose injection site is firm and measures 3 mm (0.1 in) d) A client whose injection site is ecchymotic - Ans - A. A client whose injection site has an elevated area measuring 15 mm (0.6 in) Rationale: b) Occupational therapist c) Physical therapist d) Speech therapist - Ans - B. Occupational therapist TEST A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr to an older adult client who has rhinitis. The amount available is diphenhydramine syrup 12.5 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.) - Ans - 10 mL TEST A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion? a) Hypertension b) Vomiting c) Distended neck veins d) Polyuria - Ans - B. Vomiting Rationale: A septic reaction to a blood transfusion is a rare but serious complication that occurs when the donor blood is contaminated with bacteria. The symptoms may include vomiting, fever, chills, and hypotension. A nurse is reinforcing teaching about environmental modifications in the home with a family member of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching? a) Leave the television on. b) Install locks at the top of doors. c) Schedule alternate caregivers. d) Place throw rugs on the floor. - Ans - B. Install locks at top of doors. Rationale: Putting locks on top of the doors which is out of reach by the patient prevents everyone from being lock out as the patient tends to forget as they wander which is typical in its condition. Option A keeping the television ON will attract attention of the patient however excessive noise and exceedingly brightly lights could disturb the patient. Option C will make the patient confused. In assigning a care giver to patient with this condition, consistency and familiarity is essential eliminating confusion. Option D puts patients at risk for fall and injury. Remember patient with Alzheimer tends to wander around. A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newly licensed nurse. Which of the following should the nurse include in the teaching? a) Avoid direct contact. b) Administer a broad-spectrum antibiotic. c) Place an airborne precautions. d) Isolate for 24 hr after lesions appear. - Ans - A. Avoid direct contact A nurse is reinforcing teaching with a client and her partner about performing chest physiotherapy at home. Which of the following statements by the client indicates an understanding of the teaching? a. "I should take a prescribed bronchodilator following the procedure." b. "I will wear a sweatshirt during the procedure" c. "I will need to change my position multiple times during the procedure." d. "I should eat a small meal prior to the procedure." - Ans - C. "I will need to change my position multiple times during the procedure." Rational: Changing positions multiple times during chest physiotherapy helps to facilitate airway clearance and prevent complications. Taking a prescribed bronchodilator following the procedure may be necessary but is not directly related to performing chest physiotherapy. Wearing a sweatshirt during the procedure and eating a small meal prior to the procedure are not specific instructions related to chest physiotherapy. A nurse is reinforcing teaching with a client who has gestational hypertension about collecting a 24-hr urine specimen for protein. Which of the following statements should the nurse include in the teaching? a) You should start the 24-hour collection with your first urination. b) Do not add a urine specimen to the collection container if it contains stool. c) Cleanse your perineum with povidone-iodine prior to collecting each urine specimen - > wrong; not necessary as it is not used for urine culture, thus, a sterile specimen is not necessary d) You should record the time on the collection container of any missed urine specimens - Ans - B. Do not add a urine specimen to the collection container if it contains stool. if specimen is contaminated with stool, specimen collection must be restarted, thus, it is important for patients to be educated about this. Rationale: a. first urine must be discarded. c. not necessary as it is not used for urine culture, thus, a sterile specimen is not necessary. d. you should not miss any urine specimens. Otherwise, it wouldn't be a complete 24H urine specimen collection. A nurse is caring for a client who has cardiomyopathy and is experiencing sensory overload. Which of the following actions should the nurse take? A. Break up nursing care into small, frequent sessions. B. Ensure the blinds in the client's room remain open. C. Place the client in a room near the nurses' station. D. Play quiet music in the clients' room. - Ans - A. Break up nursing care into small, frequent sessions. Rationale: The nurse should break up nursing care into small, frequent sessions to help the client with cardiomyopathy who is experiencing sensory overload. This will help the client to focus on one thing at a time and reduce the amount of stimuli that they are exposed to. Option B is not recommended as it may increase the amount of stimuli that the client is exposed to. Option C may not be helpful as it may not reduce the amount of stimuli that the client is exposed to. Option D may not be helpful as it may add more stimuli to the environment. TEST A nurse is assisting with the care of a client who is receiving penicillin via intermittent IV bolus. Which of the following should the nurse recognize as a clinical manifestation of anaphylaxis? a. Pallor b. Peripheral edema c. Pruritus d. Hypertension - Ans - C. Pruritus Rationale: Applying cold compresses to the affected extremity is not recommended as it can cause vasoconstriction and reduce blood flow. Massage is contraindicated in clients with deep vein thrombosis as it can dislodge clots and cause pulmonary embolism. TEST A nurse is contributing to the plan of care for a client who has developed an infectious wound would foul-smelling drainage. Which of the following actions should the nurse include in the plan of care? a. Minister antibiotic therapy before culturing the client's wound. b. discard soiled wound care supplies in a trash receptacle outside the client's room. c. Place the client in a private room with a private bathroom. d. Instruct visitors to perform hand hygiene four five seconds after leaving the client's room. - Ans - C. Put patient in a private room with a private bathroom Rationale: (contact precaution) TEST A nurse in a long-term care facility is reinforcing teaching about pain control with a client who has terminal cancer. Which of the following information should the nurse include? A. "We will use intramuscular medications to control your pain." B. "Pain patches are applied each morning and removed at bedtime." C. "Analgesia should be used around the clock to promote pain control." D. "A medication dose must be decreased if you develop tolerance." - Ans - C. "Analgesia should be used around the clock to promote pain control." Rationale: This is very effective in managing pain as intermittent administration of medication might not provide. Option A usually IV medications is given Option B transdermal patches could be used to manage pain in terminally ill patients, but they must be applied for 24 hours to achieve therapeutic effect and not applied in the morning and removed at night. Option D the dose must be increased to have desired therapeutic effect. TEST Manifestation of opioid toxicity? - Ans - Hypotension Rationale Opioids exhibit a myriad of cardiovascular complications including hypotension, bradycardia, peripheral vasodilatory flushing, and syncope. By contrast, opioid withdrawal triggers hypertension, tachycardia, stress cardiomyopathy, and potentially ACS. SYMPTOMS: CNS: - Coma - Convulsions CARDIAC: - Hypotension - Bradycardia - Sinus Tachycardia (uncommon) PULMONARY: - Bradypnea - Cyanosis - Pulmonary edema - Respiratory depression RENAL: - Urinary Retention - Hyperkalemia (our body get rid of potassium by urine. Therefor urinary retention cause potassium to build up) EYES: - Pinpoint pupils (Miosis) TEST Patient is having dumping syndrome, what should the nurse include in teaching? - Ans - Eliminate simple sugar. Rationale: Dumping syndrome is a condition that occurs when food moves too fast from the stomach to the duodenum, usually after a surgery to the stomach. It can cause symptoms such as nausea, abdominal pain, tachycardia, hypotension, weak, dizziness, sweating and low blood sugar. The nurse should include the following points in teaching the patient: Eat small, frequent meals and avoid fluids with meals. Eat small, frequent, high-protein meals and snacks that are warm or at room temperature. Avoid liquids with meals. Avoid simple carbohydrates (cookies, candy, sweetened drinks, and ice cream). Lie down for 15-30 minutes after eating. Report any severe or persistent symptoms to your doctor. TEST Identify risk factors for osteoporosis? - Ans - Smoking cigarette Rationale: Osteoporosis is a condition that weakens the bones and makes them more likely to break. Some of the risk factors for osteoporosis are: Age: older people have lower bone density Sex: women are more prone to osteoporosis than men Family history: having a parent or sibling with osteoporosis increases your risk Menopause: lower estrogen levels in women after menopause can lead to bone loss Lifestyle: smoking, drinking too much alcohol, not getting enough calcium, vitamin D or exercise can affect your bone health TEST A nurse is reinforcing health promotion education at a community health fair. Which of the following statements by attendees indicates understanding of the teaching? *I will examine my breasts a week after each menstrual period." "I should get a hepatitis B vaccine on a yearly basis." "I do my testicular self-exam every 6 months without fail." "The flu shot I received last year will last me for 2 years." - Ans - *I will examine my breasts a week after each menstrual period." Rationale: Breast self-examination (BSE) is a way to check your breasts for any changes that may indicate breast cancer or other problems. It involves looking at and feeling your breasts in different positions and situations. Some steps to perform BSE are: TEST Pt received penicillin 30 mins ago and began to develop hives and itching. Which of the following is the nurse's highest priority question? - Ans - "Are you having any difficulty breathing?" Rationale: This question to rule out whether the patient is experiencing anaphylaxis. TEST A nurse is assisting with the care plan for a client who has osteoarthritis. The client reports knee stiffness upon ambulation. Which of the following interventions should the nurse include in the plan of care? a.) Apply moist heat prior to ambulation. b.) Rest in a soft chair. c.) Use a continuous passive motion machine. d.) Delay ambulation until the next day. - Ans - A. Apply moist heat prior to ambulation. Rationale: Heat therapy can alleviate knee osteoarthritis pain and stiffness in two ways. First, the sensation of heat provides relief by overpowering the nerves that send pain signals to your brain. This is why you'll often feel the warmth of your heating pad over the discomfort. Second, heat improves blood flow in the area. As such, moist heat is a much better choice for OA instead of ice because the warmth dilates blood vessels (larger diameter) around the knee, improves circulation, loosens up muscles and helps to alleviate joint stiffness. Applying moist heat prior to ambulation can help reduce knee stiffness and improve mobility for clients with osteoarthritis. TEST Reinforcing teaching for pt has just returned home following a total hip arthroplasty, what should the nurse include in teaching? - Ans - Place electrical cords against the wall Rationale: This action is to eliminate fall risk factors for patient with impair ambulation. TEST Pt has an order of intermittent enteral feeding through an NGT, what is the nurse priority before feeding? - Ans - Keep the head of the bed at 30-degree angle. Rationale: The nurse's priority before feeding a patient with intermittent enteral feeding through an NGT is to check the position of the tube and ensure that it is located in the stomach. This can be done by aspirating gastric contents and measuring the pH (lower than 5), or by using a chest X-ray. Checking the tube position can prevent complications such as aspiration, tube displacement, or feeding into the wrong site. placing the patient in 30-degree to prevent aspiration while feeding. TEST A nurse is reinforcing teaching with a client who is being discharged following a prostatectomy. Which of the following statements should the nurse include in the teaching? (Select all that apply.) "You may take aspirin for mild pain." "You may resume sexual intercourse after 2 weeks. "You might see blood in your urine after coughing." "You should shower instead of taking a tub bath." "You should avoid lifting objects that weigh more than 8 pounds." - Ans - - Take a shower instead of using tub bath - Pt might see blood in urine after coughing - Avoid lifting objects that weigh more than 8 lbs. Rationale: Discharge teaching following prostatectomy is important to help you recover from surgery and prevent complications. Here are some general tips: You will have a catheter (tube) to drain urine from your bladder for 1 to 3 weeks. You need to keep it clean and secure, and empty the bag when it's half full. You may also have another drain below your belly button that will be removed after 1 to 3 days. You may have pain, swelling, bleeding, or urine leakage after surgery. These should improve over time. You can take pain medicine (not aspirin since it has blood thinning factor and can increase bleeding) as prescribed and wear a support or brief underwear for comfort. You should limit physical activity for the first 2 weeks after surgery. Don't drive, lift heavy objects (object heavier than 8 lbs), or do strenuous exercise until your provider says it's OK. Take naps if you feel tired. You should eat a balanced diet with plenty of fluids, fruits, vegetables, and whole grains. This will help prevent constipation and keep your urine flow healthy. You should shower as normal and change the dressing over your surgical wound once a day or as directed by your provider. Keep the wound area clean and dry. You should follow up with your provider as scheduled and call them right away if you have any signs of infection, such as fever, chills, redness, swelling, pus, or bad smelling discharge. TEST A nurse is reinforcing discharge instructions with a client who is taking oral iron supplementation for anemia. Which of the following statements by the client demonstrates an understanding of the teaching? "I should take my supplement with an antacid to prevent an upset stomach." "I should increase my fiber intake while taking this supplement." "I should notify my doctor if my stools turn black." "I should drink my liquid iron supplement undiluted." - Ans - "I should increase my fiber intake while taking this supplement." Rationale: some key points for nursing teaching for patient taking oral iron supplements: Take iron on an empty stomach (1 hour before or 2 hours after a meal), preferably with orange juice or other forms of vitamin C. Start with only one tablet per day for a few days, then increase to two tablets per day, then three tablets per day to prevent gastrointestinal distress1. Increase the intake of vitamin C and fiber to enhance iron absorption and minimize constipation. Remember that stools will become dark in color1. Prevent staining the teeth with a liquid preparation by using a straw or placing a spoon at the back of the mouth to take the supplement. Rinse the mouth thoroughly afterward1. The recommended dose of elemental iron for adults who are not pregnant is 50-60 mg twice daily for three months. Check with your health care professional before taking iron supplements if you are breast-feeding or if you think you still need iron after taking it for 1 or 2 months. TEST Stomatitis is a common side effect of cancer treatment that causes swelling and redness of the mouth lining and painful sores. To help manage stomatitis, some possible actions the nurse can implement are: Encourage good mouth care and mouth rinses with baking soda, salt water, or saline. Use a soft toothbrush or foam swab and avoid dental floss if it causes bleeding. Avoid alcohol, tobacco, spicy, acidic, or dry foods that can irritate the mouth. Apply ice or cold foods to the mouth to reduce pain and inflammation. Give pain medicines or mouth rinses prescribed by the doctor, such as antiviral or anti- inflammatory agents. Monitor the mouth for signs of infection, such as white or yellow patches, pus, or increased pain. TEST A nurse is caring for a client who is receiving treatment for cancer and has stomatitis. Which of the following actions should the nurse take? (SATA) a.) Limit the client's fluid intake to 1,000 mL daily. b.) Rinse the client's toothbrush with hydrogen peroxide after the use. c.) Instruct the client how to use artificial saliva. d.) Give the client tooth sponges to brush her teeth. e.) Include OJ in the client's daily diet. - Ans - c.) Instruct the client how to use artificial saliva products to rinse mouth., d.) Give the client tooth sponges to brush her teeth. Rationale: Stomatitis is the inflammation of the oral mucosa, which can be caused by cancer treatment such as chemotherapy and radiation. The client with stomatitis may experience painful sores that can make it hard to eat, drink, or swallow. Here are the nursing interventions that should be taken care of: Instruct the client how to use artificial saliva. Artificial saliva can help to keep the mouth moist and relieve dryness. Give the client tooth sponges to brush her teeth. Tooth sponges are soft and gentle on the gums and teeth, which can help to prevent further irritation. DO NOT include OJ in the client's daily diet. OJ is acidic and can cause further irritation to the mouth sores. DO NOT limit the client's fluid intake to 1,000 mL daily. Adequate hydration is important for clients with stomatitis. DO NOT rinse the client's toothbrush with hydrogen peroxide after use. Hydrogen peroxide can cause further irritation to the mouth sores TEST Place in order for Z-track technique after the nurse has already performed hand hygiene and identify pt. - Ans - - Put on clean gloves and cleanse the site with alcohol - Pull the skin and the SQ away from the infection site - Insert the needle into muscle - Aspirate by pulling on the plunger and start the injection - Release and skin and withdraw the needle TEST Pt is experiencing sustained deep partial thickness burn on both legs at the backside, what should the nurse include in the care plan? - Ans - Range of motion Rationale A deep partial thickness burn is a type of burn that destroys the epidermis and dermis, leaving only the epidermal skin appendages within the hair follicles. It may require grafting or prolonged periods of recovery. Some of the things that the nurse should include in the care plan are: Improving physical mobility by providing range-of-motion exercises and splinting to prevent contractures. Improving body image and self-esteem by providing emotional support and counseling. Providing wound care and improving skin integrity by applying advanced dressings that protect the wound and promote a moist environment. Maintaining adequate nutrition by providing high-protein and high-calorie diet and supplements. Minimizing pain and providing comfort by administering analgesics and using nonpharmacologic methods such as distraction and relaxation. Preventing infection by using sterile technique and monitoring for signs of infection such as fever, increased drainage, or foul odor. TEST The nurse is assessing a patient who has just come back from a bronchoscopy. Which of the following findings should the nurse report immediately? - Ans - Facial edema Rationale: A bronchoscopy is a procedure to look at the airways in the lungs using a thin, lighted tube. It can be used to diagnose and treat lung problems. It can cause facial edema (swelling) in rare cases, usually due to complications such as bleeding, infection, or injury to the airways or lungs. Some possible complications after a bronchoscopy are: Bleeding. This is more likely if a biopsy was taken. Usually, bleeding is minor and stops without treatment. Infection. This can cause fever, chills, cough, or chest pain. Antibiotics may be needed to treat it. Collapsed lung. This can happen if the lung is punctured during the procedure. Air can collect in the space around the lung, which can cause the lung to collapse. This may need a chest tube to remove the air and reinflate the lung. TEST A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following findings should the nurse report to the provider? - Ans - Diminished breath sounds Rationale: Diminished breath sounds might indicate a pneumothorax or laryngeal edema. The nurse should report this finding to the provider for further evaluation of the client. TEST A nurse is reinforcing teaching about food care for a client who has diabetes. Which of the following statements indicates an understanding of the teaching? a.) "I should round the corners of my toenails when trimming them." b.) "I can apply lotion between my toes after shower". c.) "I can wear open-toe shoes." d.) "I should wear cotton socks". - Ans - "I should wear cotton shock." Rationale: cotton sock help with absorption moist on your foot TEST Nurse is collecting data on a patient who is 1 day post-op following hysterectomy, which of the findings should be reported immediately? - Ans - Creatinine 2.3 (range is 0.5 to 1.1) TEST A nurse in a long-term care facility is collecting data from an older adult client. Which of the following findings indicates that the client might be dehydrated? Phototherapy, specifically ultraviolet (UV) light therapy, is a common treatment option for psoriasis. It helps to slow down the rapid skin cell growth and reduce inflammation. Dermabrasion is a procedure used for scar revision, oil-based ointments are not typically recommended for psoriasis, and benzoyl peroxide is used for acne treatment. TEST Alendronate teaching - Ans - Sit upright 30 to 60 mins after taking medication Rationale: Alendronate is a medication used to prevent and treat bone loss (osteoporosis) in adults. It belongs to a class of drugs called bisphosphonates. It works by slowing down the breakdown of bone and increasing bone density. Here are some important points to remember when taking alendronate: Take it on an empty stomach, as soon as you get up in the morning, and at least 30 minutes before any food, drink, or other medication. Swallow the tablet whole with a full glass of plain water. Do not chew, suck, or crush it. Stay upright (sitting, standing, or walking) for at least 30 minutes after taking it. Do not lie down until after your first food of the day. Avoid taking calcium, iron, antacids, vitamins, or other supplements within 30 minutes of taking alendronate. They can interfere with its absorption. Tell your doctor and dentist that you are taking alendronate. You may need to stop it before certain dental procedures or surgeries. Report any side effects to your doctor, such as heartburn, chest pain, difficulty swallowing, jaw pain, muscle or joint pain, or signs of low calcium levels. TEST Pt has peripheral IV infusion, the nurse notes edematous, cool, and tender at the injection site. What should the nurse expect? - Ans - Infiltration Rationale: The nurse should expect that the patient has an infiltration or extravasation of the IV fluid or medication into the surrounding tissue. This can cause inflammation, pain, and possible tissue damage. The nurse should stop the infusion, remove the IV, and notify the doctor. The nurse should also mark and photograph the affected area TEST Pt is 8 hr abdominal post-op, BP is 94/56, which action should the nurse take first? - Ans - Compare the reading to the preoperative value. TEST A nurse is preparing to perform a sterile dressing change for a client who has a stage III pressure ulcer. Which of the following actions should the nurse plan to take? A. Prepare the sterile dressing supplies 30 min before the dressing change B. offer the client pain medication before the procedure C. Disinfect the wound bed with alcohol before applying tape D. Don sterile gloves before removing the dressing - Ans - B. Offer the client pain medication before the procedure Rationale: Pressure ulcers can be very painful, and premedication can help reduce discomfort and anxiety during the dressing change. The other options are incorrect because: A. Preparing the sterile dressing supplies 30 min before the dressing change is unnecessary and may increase the risk of contamination. C. Disinfecting the wound bed with alcohol before applying tape is not recommended as alcohol can damage healthy tissue and delay healing. D. Donning sterile gloves before removing the dressing is not required as only post- surgical wounds need a sterile dressing applied in the operating room. TEST A nurse is reinforcing teaching about meal planning with a client who has hypertension. Which of the following statements by the client indicates an understanding of the teaching? A. "I can have canned soup." B. "I can season food with vinegar." C. "I can season food with ketchup." D. "I can have a bologna sandwich." - Ans - B. "I can season food with vinegar." Rationale: The client should avoid canned soup, ketchup, and bologna sandwich as they are high in sodium and saturated fats which can increase the amount of fluid in the blood, raise blood pressure temporarily or permanently, and damage the blood vessels. Instead, they should choose foods that are rich in polyunsaturated fats, such as fish, walnuts, flaxseeds, and sunflower seeds, which can help prevent blood pressure elevation. - No canned soup (It has high salt + preservatives therefore it is wrong) - No sardines (it has high salt) - No ketchup (high in sodium) - No bologna sandwiches (Bologna is a saturated fat, and high in salt) TEST The nurse is reinforcing teaching with a group of clients who are at risk for coronary heart disease due to hypercholesterolemia. Which of the following information should the nurse include in the teaching? a. Increase intake of dairy products b. limit servings of meat per meal to 113 to 170 g ( 4 to 6 oz ) c. cook with coconut oil d. include fish in the diet two times per week - Ans - D. Include fish in the diet two times per week. Rationale: When teaching clients at risk for coronary heart disease due to hypercholesterolemia, it is important to include fish in the diet two times per week. Fish, particularly fatty fish such as salmon, is a good source of omega-3 fatty acids, which have been shown to have cardiovascular benefits. Increasing intake of dairy products, limiting meat servings, and cooking with coconut oil are not specifically recommended for reducing hypercholesterolemia. TEST Math. Order 15000 units every 12 hours for a patient weighing 80 kg, available is 10000 units / mL. How many mL should be administered per dose? - Ans - 1.5 mL (80 kg is just a distraction) 15000 / 10000 = 1.5 TEST Client positioning for Thoracentesis position? - Ans - Leaning forward Rationale: The best position is sitting upright and leaning slightly forward with arms and head resting supported on a table in front of you. This position allows the provider to access your back and makes it easier for you to hold still. If you can't sit, you can lay on your side instead. Pain on L calf is an indication of manifestation of DVT and tachypnea is an indication of pulmonary embolism which caused by the dislodged blood clog traveled to the lungs. TEST Which of the following solutions can be infused together with pack of RBCs - Ans - 0.9% normal saline Rationale: this solution will not cause clump or clothing of the RBCs TEST A nurse is caring for a client who has a closed head injury. In which of the following positions should the nurse place the client? A. Modified Trendelenburg B. Sims C. Semi-Fowler's D. Prone - Ans - C. Semi-Fowler position Rationale: To decrease intracranial pressure TEST The nurse is reviewing the change-of-shift report, which of the following pt should the nurse see first? - Ans - Pt with an indwelling catheter and has urine output 80 mL over the past 8h Rationale: normal urine output should be 30 mL/hr TEST The nurse is teaching about saturated fat, which of the following cooking oil should the nurse recommend? a. Coconut oil b. Vegetable shortening c. Palm oil d. canola oil - Ans - D. Canola oil Rationale: The nurse should recommend canola oil as it is low in saturated fat and high in unsaturated fat. Coconut oil, vegetable shortening, and palm oil are high in saturated fat which can increase the risk of heart disease TEST The nurse is collecting data following thoracentesis procedure, what should the nurse report - Ans - RR of 26/min Rational: normal should be 10 - 20 TEST Pt is stung by a wasp. Which of the following manifestations indicate pt is experiencing anaphylaxis? - Ans - Swelling Rationale: common symptoms include pruritus, urticaria (hives), angioedema (swelling), bronchospasm, hypotension, and tachycardia. Pallor, peripheral edema, and hypertension are not specific clinical manifestations of anaphylaxis. TEST Pt is 3 days post-op with a new ileostomy, which of the following findings should the nurse report? a. Stool contains scant red b. Stool is a dark green color c. Stoma retracts into the abdominal ball - Ans - Stoma retracts into the abdominal ball Rationale: An ileostomy is a surgical procedure that creates an opening in the abdomen to divert digestive waste. It may be temporary or permanent depending on the condition. There are different types of ileostomy and they have different risks and complications. According to one source2, some of the early complications of an ileostomy that may occur within three months of surgery are: Stomal necrosis (tissue death). Stomal bleeding. Stomal retraction (sinking into the abdomen). Mucocutaneous separation (skin around the stoma pulling away). Stool containing scant red blood (option a) may be normal in the first few days after surgery. Stool being a dark green color (option b) may also be normal as the ileostomy starts to function. TEST Pt experienced ischemic stroke, which of the following findings should the nurse indicate that pt needs referral to occupational therapy? - Ans - Pt become exhausted then brushing his/her teeth TEST A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the nurse anticipate? a. Orange-colored urine. b. Referred pain in the right shoulder. c. Confusion. d. Hypothermia. - Ans - Confusion Rationale: Cystitis is a condition that causes inflammation of the bladder, usually due to an infection. It can sometimes cause confusion, especially in older adults. Confusion may indicate that the infection has spread to the kidneys or the brain, or that there is another condition involved. Some other common symptoms are: Frequent or urgent need to urinate Pain or burning sensation when urinating Blood, cloudiness or strong smell in the urine Pelvic discomfort or pressure Low-grade fever There are different types and causes of cystitis, such as bacterial, drug-induced, chemical, radiation or interstitial cystitis. TEST Pt has hemodialsis, his calcium level reads 7.2, what should the nurse monitor for? - Ans - The nurse should monitor for hyperactivity deep tendon reflexes. Rationale: Lethargy is a common finding in hemodialysis clients because they are constantly filtering the blood. necessary. The provider may remove polyps during the colonoscopy if found, but scheduling another procedure is not necessarily routine. A nurse is reinforcing teaching about foods containing potassium with a client who has a new prescription for hydrochlorothiazide, what food is the best source of potassium? a. ½ cup of cucumber slices (only 80 mg) b. 1 cup of apricot slices c. ½ cup of okra d. 1 cup of pineapple chunks (200 mg) - Ans - B. 1 cup of apricot slices. Rationale: Among the options, 1 cup of apricot slices is the best source of potassium. Apricots are rich in potassium, with approximately 450 mg per cup. Cucumber slices, okra, and pineapple chunks contain lower amounts of potassium compared to apricots. TEST The nurse is reinforcing teaching about applying antiembolic stock, which statement should be included? - Ans - Reapply before getting out of bed. Rationale: Some other possible statements to include in the teaching about applying antiembolic stockings are: Antiembolic stockings are tight fitting stockings that help prevent blood clots in your legs by promoting blood return to the heart. You should wear them as much as possible, except when you shower or clean your legs. You should make sure the stockings fit properly, are not too tight or too loose, and do not have any wrinkles or rolls. You should check your toes and feet regularly for any signs of poor circulation, such as coldness, paleness, numbness, or pain. You should follow the instructions on how to wash and dry the stockings. TEST Pt had a TB test 72 hours ago, which of the following findings indicate that pt needs further tests? - Ans - Palpable area larger than 10 mm in diameter TEST A nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hr ago. Which of the following clients should the nurse identifies as having a positive test result? A client whose injection site has an elevated area measuring 15 mm A client whose injection site is ecchymotic A client whose injection site is scabbed A client whose injection site is firm and measures 3 mm - Ans - A client whose injection site has an elevated area measuring 15 mm TEST A nurse is caring for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make? - Ans - eat soft foods. Rationale: The nurse should instruct a client who has stomatitis to eat soft, nonirritating foods to decrease irritation to the oral mucosa. ----------------- Instruct the client to avoid seasoning foods with salt or spices that can irritate the oral mucosa. Instruct the client to eat foods that are high in protein and calories to increase their caloric intake and nutrition. Instruct the client to choose foods that are a lukewarm or cool temperature to prevent irritation of the client's oral mucosa. A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? - Ans - Apply a mask on the client if transport is needed. Rationales: The nurse should apply a mask to a client who has manifestations of pertussis during transport to prevent exposure to others. (Pertussis belongs to droplet precaution) Droplet precautions require: -A private room or a room with other clients who have the same infectious disease. Ensure that clients have their own equipment. -Masks for providers and visitors. -Clients who have a droplet infection should wear a mask while outside of the room/home. A nurse is contributing to the plan of care for a client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? - Ans - Encourage weight bearing exercises Rationale: Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis. TEST A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? - Ans - Loosen clothing around the client's neck. Rationale: The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration. ---------------- The nurse should leave the bed rails up to prevent the client from falling out of bed, which can cause injury. The nurse should not apply restraints that can place the client at risk for a fracture injury. The nurse should place the client in a lateral position to allow for the drainage of oral secretions and to maintain an open airway. A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylpredniolone orally. Which of the following statements should the nurse include in the teaching? - Ans - "Limit contact with large groups of people." Rationale: Glucocorticoids cause immunosuppression and can mask infection. The client should limit contact with sources of possible infections, such as large groups of people. ------------------------ The client should take glucocorticoids with food to prevent gastrointestinal upset and bleeding. A. Store opened insulin vials at room temperature for up to 4 weeks. B. Warm the insulin vial to dissolve any crystals that develop. C. Plan to eat a snack 6 hrs after insulin administration. D. Keep unopened insulin vials in the freezer. - Ans - A. Store opened insulin vials at room temperature for up to 4 weeks. Rationale: Most insulin manufacturers recommend storing unopened insulin in the fridge. But many insulin products can be unrefrigerated for up to 28 days. There are a few exceptions. Avoid exposing your insulin to extreme hot or cold temperatures. Always read the manufacturer's instructions for storing your particular type of insulin. A nurse is preparing to enter the room of a client who has tuberculosis. Which of the following personal protective equipment should the nurse wear? A. Venturi mask B. surgical mask C. Respirator mask D. Nonrebreather mask - Ans - C. Respirator mask A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan? A. Initiate protective isolation for the client. B. Administer Ibuprofen for mild headache. C. Check the client for ecchymosis. D. Instruct the client to shave with a disposable razor. - Ans - C. Check the client for ecchymosis. Rationale: Thrombocytopenia is a medical condition characterized by low levels of platelets in the blood. It can cause nosebleeds, bleeding gums, blood in urine, heavy menstrual periods, and bruising. The priority goals of nursing care for a client with thrombocytopenia include prevention and early detection of bleeding, as well as intervening when bleeding occurs. Therefore, the nurse should include checking the client for ecchymosis in the plan of care. Ecchymosis is a medical term for a bruise, which is a common symptom of thrombocytopenia. The nurse should also instruct the client to avoid activities that may cause injury or bleeding, such as shaving with a disposable razor. Administering Ibuprofen for mild headache is not recommended as it can thin the blood and increase the risk of bleeding. Initiating protective isolation for the client is not necessary as thrombocytopenia is not contagious. A nurse is assisting with the care of a client who is postoperative and has received fentanyl for pain management. In the event the client develops respiratory depression, the nurse should make sure that which of the following medications is available to administer? A. Naloxone B. Atropine C. Fumazenit D. Acetylcysteine - Ans - Naloxone Rational: Fentanyl is a potent pain medication that can cause respiratory depression, among other side effects. In the event of respiratory depression, the nurse should have naloxone available to administer to the client. Naloxone is an opioid antagonist that can reverse the effects of fentanyl and other opioids. A nurse is reinforcing urinary bladder training for a client who has urge incontinence. Which of the following instructions should the nurseinclude? A. Restrict fluids to meal time. B. Keep a voiding diary for 3 days. C. Drink citrus juice with breakfast. D. Vold as soon as the urge occurs. - Ans - B. Keep a voiding diary for 3 days. A nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include? A. Use low-wattage light bulbs. B. Mark the edges of steps. C. Leave doors slightly ajar. D. Place throw rugs over electrical cords. - Ans - B. Mark the edges of steps. A nurse is assisting with discharge teaching for a client who requires oropharyngeal suctioning at home. The nurse should ensure that which ofthe following equipment is available for use at home? A. Yankauer catheter B. Sterile gloves C. Oropharyngeal airway D. Water-soluble lubricant - Ans - A. Yankauer catheter A nurse is caring for a client who had a colon resection 2 days ago. When entering the client's room, the nurse sees a protrusion of tissue from the incision. Which of the following is the appropriate nursing intervention? A. Cover the wound with a dry. sterile dressing. B. Cover the site with a sterile, saline-soaked dressing. C. Place the client on her left side. D. Place the client In Trendelenburg position. - Ans - B. Cover the site with a sterile, saline-soaked dressing. A nurse is reinforcing teaching with a client who has oral candidiasis and is to begin therapy with nystatin oral suspension. The nurse should tell the client to take which of the following actions? A. Gargle with a commercial mouthwash before administering the medication. B. Retain the medication in the mouth before swallowing. C. Scrape off white patches on the tongue using a swab prior to medication administration. D. Take the medication 1 hr before meals. - Ans - D. Take the medication 1 hr before meals. A nurse is reinforcing teaching with a client who is prescribed levothyroxine for a thyroid disorder. Which of the following information should the nurse include in the teaching? A. Administer the medication 1 hr before breakfast. B. Expect to discontinue the medication after 1 month. C. Take the medication with an aluminum-containing antacid. D. Notify the provider if resting pulse is less than 80/min. - Ans - A. Administer the medication 1 hr before breakfast. A nurse is caring for a client who has a prescription for a cerebral angiogram. Which of the following actions should the nurse take? A. Determine if the client has an allergy to shellfish. B. Maintain the client NPO for 2 to 3 hr. C. Inform the client she will receive sedation to prevent claustrophobia. D. Instruct the client to limit activity for 48 hrs following the procedure. - Ans - A. Determine if the client has an allergy to shellfish. ******NGN-QUESTION****** A nurse in a provider's office is reviewing the medical record of a client. Based on the information provided in the medical record, which of the following findings places the client at risk for breast cancer? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) A. Race B. Obstetric history C. Biopsy result