RN Adult Medical Surgical Online Practice A 2024 Newly updated, Exams of Health sciences

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RN Adult Medical Surgical Online Practice A

2024 Newly updated

A nurse is caring for a client who is receiving dialysis treatment. For each potential nursing intervention, click to specify if the intervention is indicated or not indicated. - well answered Perform a 12-lead ECG is not indicated. The client is not reporting chest pain; therefore, a 12-lead ECG is not indicated at this time. Place the client in Trendelenburg position is indicated. The client should be placed in the Trendelenburg position to increase blood flow to the heart, improving cardiac output and organ perfusion. Administer a 0.9% sodium chloride 200 mL IV bolus is indicated. The nurse should administer 200 mL of 0.9% sodium chloride IV bolus to increase fluid volume and the client's blood pressure. Apply oxygen at 2 L/min via nasal cannula is indicated. The nurse should administer oxygen at 2 L/min via nasal cannula to increase the amount of oxygen carried in the blood. Notify the provider immediately is indicated. The nurse should notify the provider immediately as part of the nurse's role to provide an update on the client's condition. Obtain the client's blood glucose level is not indicated. There is no indication that the client is experiencing hypoglycemia; therefore, obtaining a blood glucose level is not indicated. A nurse is caring for a client who is postoperative following abdominal surgery. A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take?

• well answered Apply oxygen via a face mask is incorrect. It is not necessary to place a face mask on the client because their SaO2 is within the expected reference range of 95% to 100%. Instruct the client to splint the abdomen with a pillow for coughing is correct. It is important for the client to turn, cough, and deep breathe to reduce the risk for respiratory complications. The nurse should instruct the client to splint the incision while performing these actions to reduce the risk of complications to the surgical incision.

Plan to ambulate the client as soon as possible is correct. The nurse should plan to ambulate the client as soon as possible to promote ventilation and decrease the risk of thrombosis. Report urinary output to the provider is correct. The client should produce at least 30 mL of urine per hour. Therefore, the nurse should report this finding to the provider. Ask the client to rate their pain on a 0 to 10 pain scale is correct. The nurse should have the client rate their pain prior to and following the administration of pain medication to evaluate its effectiveness. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. which actions should the nurse take? Keep the line open with 0.9% sodium chloride until the new bag arrives. Administer dextrose 10% in water until the new bag arrives. Flush the line and cap the port until the new bag arrives. Decrease the infusion rate until the new bag arrives. - well answered Administer dextrose 10% in water until the new bag arrives A nurse is caring for a client who had a nephrostomy tube inserted 12 hr. ago. Which of the following findings should the nurse report to the provider? The client's urinary output has increased. The client reports back pain. The client's urine color is red tinged. The client's tube requires irrigation. - well answered The client reports back pain The nurse should notify the provider if the client reports back pain, which can indicate that the nephrostomy tube is dislodged or clogged. A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority? - well answered Turn the client to the side.

A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication? - well answered Report of a night cough. (the nurse should recognize that this is an early indication of heart failure and report this adverse reaction to the provider) A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take? - well answered Use a 30-mL syringe. (Nurse should use a 30-60 mL syringe with an 18 or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound.) A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to the nurse that the client has exophthalmos? - well answered Last picture or the picture with wide- opened, bulging eyes. A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving? - well answered glucose 272 mg/dL A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect? - well answered Constipation (due to client's decrease in metabolism, resulting in slow motility of the gastrointestinal tract.) A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first? - well answered Check for the type and number of units of blood to administer. A nurse is caring for a client who has a leg cast and is returning to demonstrate the proper use of crutches while climbing stairs. Place boxes in order. - well answered 1. Places body weight on the crutches.

2. Advances the unaffected leg onto the stair.

3. Shift their weight from the crutches to the unaffected leg.
4. Brings the crutches and the affected leg up the stair A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following instructions should the nurse include? - well answered Ibuprofen can cause gastrointestinal bleeding in older adult clients. A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? - well answered Add cabbage to the diet A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring patent airway and giving oxygen, which should the nurse administer first? - well answered IV fluids A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which statement should the nurse make? - well answered "Discontinuing with the treatments is your choice if it is your wish to do so." A nurse is providing teaching to a client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching? - well answered "You should void every 4 hours to decrease the risk of urinary retention." A nurse is teaching a class about client rights. Which of the following instructions should the nurse include? - well answered A client should sign an informed consent before receiving a placebo during a research trial. A nurse is reviewing the ABG results of a client who has advanced COPD. which of the following results should the nurse expect? - well answered PaCO2 56 mm Hg A client who has COPD retains PaCO2 due to the weakening and the collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange and causes the PaCO2 to increase above the expected reference range.

A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? - well answered HR 110 A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? - well answered Loosen restrictive clothing. (The nurse should loosen tight, restrictive clothing to prevent injury and suffocation) A nurse is planning care for a client who is postoperative following a laparotomy and has a closed- suction drain. Which of the following actions should the nurse take to manage the drain? - well answered Compress the drain reservoir after emptying. Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the drain, and into the reservoir. A nurse is providing preoperative teaching for a client scheduled for an open cholecystectomy. Which of the following actions should the nurse take? - well answered Demonstrate ways to deep breathe and cough. The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications. A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching? - well answered Void before and after intercourse. The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and prevents the occurrence of infection. A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? - well answered Place a pressure bag around the flush solution. The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line.

A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan? - well answered Tell the client that it is possible to return to similar previous levels of activity. The nurse should help the client develop realistic goals and activities to have a productive life. A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan? - well answered Monitor the client's temperature every 4 hours The nurse should monitor the temperature of a client who has neutropenia every 4 hr because the client's reduced amount of leukocytes greatly increases the client's risk for infection. A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? - well answered Flex the foot every hour when awake. The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return. A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions? - well answered Suppressing gastric acid production Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? - well answered Place a pillow between the client's legs. The nurse should place a pillow between the client's legs to prevent hip dislocation.

A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis? - well answered Hyperkalemia The nurse should identify that a client who has chronic glomerulonephritis can experience hyperkalemia as a result of kidney failure. Kidney failure results in decreased excretion of potassium. A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? - well answered Extremity cool upon palpation The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome. A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? - well answered "It's like a curtain closed over my eye." A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field. A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? - well answered "Ginkgo biloba can cause an increased risk for bleeding." Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with peripheral artery disease. The supplement also decreases platelet aggregation, which in turn increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba without first speaking with their provider. A nurse is caring for a client in the Emergency department. Select 4 findings that require follow-up by the nurse. - well answered Visual disturbances Tingling of the lips

Hand grasps Expressive aphasia A nurse is caring for a client in the Emergency department. For each finding below, click to specify if the finding is consistent with migraine, stroke, or meningitis. - well answered Hand grasps is consistent with migraine, stroke, and meningitis. Numbness is consistent with migraine and stroke Aphasia is consistent with migraine and stroke Visual changes are consistent with migraine, stroke, and meningitis. Family history is consistent with migraine and stroke. A nurse is caring for a client in the Emergency department. Complete the following sentence by using the list of options. - well answered The nurse should identify that the client is most likely experiencing a migraine and the nurse should address the client's pain. A nurse is caring for a client in the Emergency department. A nurse is caring for a client who has a migraine. Which of the following interventions should the nurse anticipate? - well answered Administer sumatriptan Dim the lights in the client's room A nurse is caring for a client in the Emergency department. Drag one condition and one client finding to fill in each blank in the following sentence. - well answered Following the administration of sumatriptan, the nurse should monitor for CHEST PAIN due to the risk of MYOCARDIAL ISCHEMIA. A nurse is caring for a client in the Emergency department. The nurse is evaluating the client's understanding of discharge instructions. Which of the following client statements indicates an understanding of the teaching? - well answered "Foods that contain tyramine might trigger my headaches" is correct. I will keep a food and headache diary" is correct. I will place a cool cloth on my forehead when I experience a migraine" is correct. A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect? - well answered Hypoactive bowel sounds

Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to decreased peristalsis. A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? - well answered "I will avoid direct exposure to the sun." The client should avoid exposure of irradiated skin areas to the sun for at least 1 year after completing radiation therapy. Skin in the radiation path is especially sensitive to sun damage. A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect? - well answered Stone fragments in the urine ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones. A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority? - well answered Temperature 38.9° C (102° F) When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is an elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to the provider because it can lead to seizures and coma. A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide? - well answered Increase fluid intake. Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test. A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? - well answered A client who is

postoperative following abdominal surgery and reports feeling that something "popped" when they coughed. A feeling of something popping or loosening with coughing might indicate a wound dehiscence. This client will need to have revisions to the plan of care, which can include management of the dehiscence, prevention of evisceration, or possible surgical repair of an evisceration if one occurs. A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? - well answered Slow the infusion rate. Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breathe, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload. A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.) - well answered Follow a smoking cessation program Maintain an appropriate weight Eat a low-fat diet A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? - well answered The client's heart rate increases. Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia. A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? - well answered I will monitor my blood pressure while taking this medication.

The client should monitor their blood pressure while taking this medication because hypertension is a common adverse effect and can lead to hypertensive encephalopathy. A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse right in the affected extremity. Which of the following interventions is the nurse's priority? - well answered Apply firm pressure to the insertion site. The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding. A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following lab values is a manifestation of osteomyelitis and should be reported to the provider? - well answered Sedimentation rate An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis. A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings? - well answered Dysphagia Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding. A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include? - well answered Numbness can occur along the inside of the affected arm. The nurse should instruct the client that numbness can occur near the incision and along the inside of the affected arm due to nerve injury. A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider? - well answered Restlessness

Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is restlessness, which can be an indication the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue, and headache. A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication? - well answered Crackles heard on auscultation Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestations of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation. A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thorancentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer? - well answered Dyspnea Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing and improve comfort. A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. to reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client?

• well answered Scan the environment by turning your head from side to side." Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head from side to side helps enlarge a client's visual field. This technique is also useful for the client during mealtimes. A nurse has received report on a client who is being admitted to the emergency department. Select the 3 findings that require follow-up by the nurse. - well answered Oxygen saturation is correct Pain level is correct Wound drainage is correct.

The nurse is caring for the client. Complete the following sentence by using the list of options. - well answered The client is most likely experiencing a HEMOTHORAX as evidenced by the client's RESPIRATORY FINDINGS The nurse is caring for the client. Drag words from the choices below to fill in each blank in the following sentence. 2330: Report received from ambulance crew: Client has a penetrating wound to the anterior upper right chest. Client is alert and oriented with a Glasgow Coma Scale (GCS) score of 15. Client's shirt covered with bright red blood. Client reports pain as 6 on a scale of 0 to 10. Shortness of breath noted.2345: Client is alert and oriented with a GCS score of 15. Client has a penetrating wound to the anterior right upper chest measuring 2.5 cm (1 in). No other wounds or injuries found. Bilateral radial and pedal pulses are +1. Left lung sounds are clear, right upper lung sounds diminished. Client still reports pain as 6 on a scale of 0 to 10 over anterior chest. Bowel sounds are present in all 4 quadrants. - well answered The nurse should first address the client's OXYGENATION followed by the client's blood pressure The nurse is caring for the client. For each potential provider's prescription, to specify if the potential prescription is anticipated or contraindicated for the client. - well answered Transfuse packed RBCs is anticipated Place the client in Trendelenburg position is contraindicated Prepare the client for chest tube insertion is anticipated. Cover the client with a cooling blanket is contraindicated. Initiate NPO status is anticipated The nurse is caring for the client. The nurse is caring for the client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? - well answered Place the client in high-Fowler's position is correct Place two rubber-tipped hemostats in the client's room is correct Palpate the chest tube insertion site for subcutaneous emphysema is correct. Ensure that all chest tube connections are securely attached is correct.

The nurse is caring for the client. The nurse is caring for the client 1 hr following chest tube insertion. - well answered Client reports pain as 3 on a scale of 0 to 10 is correct Client reports shortness of breath has decreased is correct. Wound dressing is dry and intact is correct Respiratory rate 24/min, blood pressure 108/74 mm Hg, and oxygen saturation 95% on 2 L/min via nasal cannula are correct The nurse is caring for the client 1 hr following chest tube insertion. Click to highlight the findings in the nurses* note that indicate the client's condition is improving. - well answered Client reports pain as 3 on a scale of 0 to 10 is correct. The nurse should identify that the client's pain has decreased, indicating their condition is improving. Client reports shortness of breath has decreased is correct. The nurse should identify that the client's shortness of breath has decreased, indicating their condition is improving. Wound dressing is dry and intact is correct. The nurse should identify that a dry and intact wound dressing indicates the client's wound is no longer bleeding. Respiratory rate 24/min, blood pressure 108/74 mm Hg, and oxygen saturation 95% on 2 L/min via nasal cannula are correct. The nurse should identify that the client's vital signs have improved, indicating improved hemodynamic function. A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make? - well answered I will refer you to community resources that can provide support The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body image changes. A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? - well answered This client is exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions. A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first? - well answered The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in

large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making. A nurse is reviewing the laboratory results of a client who has a history of aplastic anemia. Which of the following findings indicates that the client is experiencing pancytopenia? - well answered WBC 2000 A decreased WBC, or leukopenia, is a manifestation of pancytopenia. Pancytopenia occurs when there is a decreased RBC count, decreased WBC count, and decreased platelets. A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following findings indicates that the client is experiencing a complication? The client reports that the sequential compression devices (SCDs) are uncomfortable. The client reports pain at the surgical site as 4 on a scale of 0 to 10. The client's surgical site dressing has required changing twice in 2 hr due to drainage. The client needs assistance with a walker when ambulating in the room. - well answered The client's surgical site dressing has required changing twice in 2 hr due to drainage. Frequent dressing changing after surgery may indicate poor clotting and increased bleeding. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take? Check the client's blood glucose according to facility mealtimes. Contact the provider to clarify the prescription. Request for meals to be provided for the client. Hold the prescription until the client is no longer NPO. - well answered Contact the provider to clarify the prescription. AC means before Meal.

Mealtimes do not pertain to this client due to the NPO status. The nurse should monitor the client's glucose levels on a set schedule, either every 6 hr or per facility protocol. Thus, the prescription requires clarification. A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the following information should the nurse include in the teaching? - well answered Family members in the household should undergo TB testing. Family members who live in the same household with the client have been exposed to TB. Therefore, the nurse should recommend TB screening to foster early detection and treatment of TB. A nurse is providing teaching to a female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching? "Taking my daily progesterone should improve my symptoms." "A risk factor for my condition is obesity." "I should limit my daily fluid intake." "I will switch my morning cup of coffee to hot tea." - well answered "A risk factor for my condition is obesity." Excess weight creates increased abdominal pressure that can result in stress incontinence. A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement? Place a padded tongue blade at the client's bedside. Keep the side rails lowered on the client's bed. Maintain the client's bed at hip level or above. Ensure that the client has a patent IV. - well answered Ensure that the client has a patent IV. The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? Encourage the client to take deep breaths after the procedure. Assist the client to hold their arms up during the procedure. Instruct the client to remain NPO after midnight prior to the procedure. Keep the client on bed rest for 8 hr following the procedure. - well answered After a thoracentesis, the client should deep breathe to re-expand the lung. A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change? A client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose. A client who had a cholecystectomy and is starting on a modified-fat diet. A client who has Crohn's disease and is experiencing diarrhea three times a day. A client who has multiple sclerosis and is experiencing progressive difficulty ambulating. - well answered A client who has multiple sclerosis and is experiencing progressive difficulty ambulating. The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change as the client becomes less independent. A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? Anorexia and jaundice Bronchospasm and urticaria Hypertension and bounding pulse Low back pain and apprehension - well answered Low back pain and apprehension Hemolytic transfusion reactions result from the infusion of incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority? Obtaining vital signs Placing the client in Fowler's position Administering epinephrine Initiating an IV infusion of 0.9% sodium chloride - well answered Administering epinephrine Evidence-based practice indicates that the priority intervention is for the nurse to administer epinephrine quickly to dilate the bronchioles and prevent circulatory shock. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? Increase intake of foods containing calcium. Alternate application of heat and cold to the affected joints. Keep the affected extremities elevated. Limit movement of the affected joints. - well answered Alternate application of heat and cold to the affected joints. The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and pain. The application of cold can relieve joint swelling and the application of heat can decrease joint stiffness and pain. A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care? Collect and place the client's urine or feces in a biohazard bag. Limit the client's ambulation to their own room. Wear a lead apron while providing care to the client.

Limit each visitor to 1 hr per day. - well answered Wear a lead apron while providing care to the client. The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure A nurse is caring for a client. Exhibit 1 Nurses' Notes 1000: Client is alert and oriented and reports not feeling well for a few days. Client is on continuous ambulatory peritoneal dialysis (CAPD) and reports dialysate appeared cloudy this morning. Reports abdominal pain as 4 on a scale of 0 to 10. Bowel sounds active in all quadrants. Peritoneal dialysis access site red, warm to touch, with a small amount of purulent drainage noted on dressing. 1300: Client is lying in bed with the knees flexed, guarding the abdomen. Abdomen is slightly distended, hypoactive bowel sounds. Client reports nausea. Reports pain as 6 on a scale of 0 to 10. Provider notified and updated with client condition and diagnostic results. - well answered Drag 1 condition and 1 client finding to fill in each blank in the following sentence The client is experiencing manifestations of PERITONITIS due to X-RAY RESULTS. A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first? - well answered call for help

Evidence-based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock. Therefore, the nurse should obtain immediate assistance. A nurse is caring for a client who is postoperative. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress. - well answered - Hypovolemia- Initiate fluid challenge and insert a large-gauge IV.- Monitor blood pressure and urine output. The nurse should insert a large-gauge IV and initiate a fluid challenge because the client is most likely experiencing hypovolemia as evidenced by the client's restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine output. The nurse should monitor the client's urine output and blood pressure to evaluate the effectiveness of treatment. A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?

• well answered "I should take this medication with a meal." The client should take metformin with or immediately following meals to improve absorption and to minimize gastrointestinal distress. A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires re-evaluation of the IV therapy prescription? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) - well answered BUN The client's Hct and BUN levels indicate dehydration and require an increase in the IV fluid infusion rate. A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority? - well answered Increased respiratory secretions

Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. Clients who have ALS may experience respiratory muscle weakness and dysphagia, and excessive respiratory secretions can impair the ability to clear the airway, which increases the client's risk for aspiration. A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority? - well answered Check the client's neurologic status. The first action the nurse should take using the nursing process is to assess the client. Therefore, the nurse should first check the neurologic status of the client. A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include? - well answered "You will need to stay still in the bed during each treatment session." A nurse is caring for a client who is brought to the emergency department following an oil fire. Drag words from the choices below to fill in each blank in the following sentence. - well answered During the emergent phase of burn care, the client is at risk for developing HYPOVOLEMIA and RESPIRATORY FAILURE. A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate? - well answered Airborne