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RN Adult Medical Surgical Online Practice Exam 2019 A: Questions and Answers, Exams of Nursing

A collection of practice questions and answers for an rn adult medical surgical online exam. It covers various topics related to nursing care, including heart failure, hypertension, cirrhosis, supraventricular tachycardia, stress incontinence, graves' disease, chronic glomerulonephritis, burns, seizures, cardiac catheterization, esophageal cancer, radiation therapy, dysphagia, hepatic encephalopathy, emphysema, mechanical ventilation, colorectal cancer, stroke, pneumonia, and dehydration. The questions are designed to assess the knowledge and understanding of nursing principles and practices.

Typology: Exams

2024/2025

Available from 11/12/2024

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RN ADULT MEDICAL SURGICAL ONLINE

PRACTICE 2019 A ACTUAL EXAM WITH

COMPLETE QUESTIONS AND

ANSWERS/GRADED A+

The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider. - ANSWER a nurse in a provider's office assessing a client who has hypertension and takes propranolol. which of the following findings should indicate to the nurse that a client is experiencing an adverse reaction to this medication? elevated bilirubin level Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice. - ANSWER a nurse is reviewing the laboratory results of a client who has cirrhosis. which of the following laboratory values should the nurse expect? Digoxin Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion. - ANSWER a nurse is preparing a client who has supra ventricular tachycardia for elective cardioversion. which of the following prescribed

medications should the nurse instruct the client to withhold for 48hr prior to cardioversion? "I am dieting to lose weight." Excess weight creates increased abdominal pressure that can result in stress incontinence. - ANSWER A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of

  1. which of the following statements by the client indicates and understanding of the teaching? wide eyes The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve. - ANSWER 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? 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. - ANSWER 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?

IV fluids After establishing that the client's airway is secure and administering oxygen, evidence-based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support. - ANSWER 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 a patent airways and administering oxygen, which of the following items should the nurse prepare to administer first? turn the client to the side. The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration. - ANSWER a nurse is caring for a client who is having a seizure. which of the following interventions is the nurse's priority? 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. - ANSWER a nurse is caring for a client 1 hr following a cardiac catheterization. the nurse notes the formation of a hematoma at the insertion side and a decreased pulse rate in the affected extremity. which of the following interventions is the nurse's priority? "I will use my hands rather than a washcloth to clean the radiation area." The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further

irritation. - ANSWER a nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. which of the following statements should the nurse identify as an indication that the client understands the teaching? suction machine The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client's airway as needed and reduce the risk for aspiration. - ANSWER a nurse is preparing to admit a client who has dysphagia. the nurse should plan to place which of the following items at the client's bedside? a client should sign an informed consent before receiving a placebo during a research trial. A nurse should ensure a client has provided informed consent before administering a placebo. The nurse should not administer a placebo to a client who thinks it is an active medication, because this action is a violation of client rights. - ANSWER a nurse is teaching a class about client rights. which of the following instructions should the nurse include? hypokalemia Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration. - ANSWER a nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. the client is experiencing excessive stools. which of the following findings is an adverse effect of the medication?

instruct the client to allow the machine to breathe for them. When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator." - ANSWER a nurse is caring for a client who has emphysema and is receiving mechanical ventilation. the client appears anxious and restless, and the high-pressure alarm is sounding. which of the following actions should the nurse take first? add cabbage to the diet. To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber. - ANSWER 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? visual spatial deficits left hemianopsia one-sided neglect - ANSWER a home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. which of the following neurological deficits should the nurse expect to find when assessing the client? nonrebreather mask

The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask.

  • ANSWER a nurse is caring for a client who has viral pneumonia. the client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? place the client in high-fowler's position. The greatest risk to this client is injury from airway obstruction. Therefore, the priority intervention the nurse should take is to move the client into high-Fowler's position. High-Fowler's position facilitates lung expansion and improves ventilation and gas exchange. - ANSWER a nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. the client has dyspnea with a productive cough and is using accessory muscles to breathe. which of the following actions should the nurse take first? avoid placing plants or flowers in the client's room. Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room. - ANSWER a nurse is planning care for a client who has extensive burn injuries and is immunocompromised. which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection. Urine specific gravity of 1. A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a

manifestation of hypertonic dehydration. - ANSWER an older adult client is brought to an emergency department by a family member. which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? administer an opioid analgesic to the client. The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite. - ANSWER a nurse in an emergency department is reviewing the providers prescriptions for a client who sustained a rattlesnake bite to the lower leg. which of the following prescriptions should the nurse expect? 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. - ANSWER a nurse is assessing a client who has had a suspected stroke. the nurse should place the priority on which of the following findings? roll each testicle between the thumb and fingers. The nurse should instruct the client to roll each testicle horizontally between the thumbs and fingers to feel for any lumps deep in the center of the testicle. - ANSWER a nurse is teaching a young adult client how to perform testicular self-examination. which of the following instructions should the nurse include? "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. - ANSWER 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? "I will wear clean graduated compression stockings every day." The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand. - ANSWER a nurse is teaching a client who has venous insufficiency about self-care. which of the following statements should the nurse identify as an indication that the client understands the teaching? tachycardia When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately to the provider. - ANSWER a nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse's priority? current medications The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing. - ANSWER a nurse is reviewing the health record of a client who is scheduled for allergy skin testing.

the nurse should postpone the testing and report to the provider with if the following findings? a client who is receiving preoperative teaching for a right knee arthroplasty The nurse should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions. - ANSWER a nurse is caring for a group of clients. the nurse should plan to make a referral to physical therapy for which of the following clients? BUN 32 mg/dl DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine. - ANSWER a nurse is caring for a client who has DKA. which of the following laboratory findings should the nurse expect? "you should cut the opening of the skin barrier one-eighth inch wider than the stoma." The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine. - ANSWER a nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. which of the following statements should the nurse include in the teaching 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. - ANSWER a nurse is providing teaching for a female client who has recurrent urinary tract infections. which fo the following information should the nurse include in the teaching? wear a mask. Bacterial meningitis requires droplet precautions; therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy. - ANSWER a nurse and an assistive personnel are caring for a client who has bacterial meningitis. the nurse should give the AP which of the following instructions? place a pillow between the client's legs. The nurse should place a pillow between the client's legs to prevent hip dislocation. - ANSWER 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? naproxen Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding. - ANSWER a nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. the nurse should identify that which of the following client medications interact with feverfew calcium

A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis. - ANSWER a nurse is caring for a client who has pancreatitis. the nurse should expect which of the following laboratory results to be below the expected reference range? 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. - ANSWER a nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contract. which of the following information should the nurse provide? 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. - ANSWER a nurse is assessing a client who had extracorporeal shock wake lithotripsy (ESWL) 6 hr ago. which of the following findings should the nurse expect? 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. - ANSWER 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?

blood pressure 170/80 mm Hg Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm. - ANSWER a nurse is caring for a client who has a new diagnosis of hyperthyroidism. which of the following is the priority assessment finding that the nurse should report to the provider? wrap fingers with individual dressings. The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand. - ANSWER a nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. which of the following instructions should the nurse include? I will monitor my blood pressure while taking this medication - ANSWER 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? try to walk at least three times per week for exercise. The development of a regular exercise routine can improve outcomes in clients who have heart failure. - ANSWER a nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. which of the following information should the nurse include in the teaching?

decreased viral load Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment. - ANSWER a nurse is caring for a client who has HIV. which of the following findings indicates a positive response to the prescribed HIV treatment? Hgb 8 g/dL The nurse should report an Hgb level of 8 g/dL, which is below the expected reference range and is an indicator of postoperative hemorrhage or anemia. - ANSWER a nurse is caring for a client who is postoperative following a total hip arthroplasty. which of the following laboratory values should the nurse report to the provider? check that one finger fits between the cast and the leg. To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application. - ANSWER a nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. which of the following actions should the nurse take? "I am taking this medication to increase my energy level." The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance. - ANSWER a nurse is providing teaching to a client who has chronic kidney disease and a new

prescription for erythropoietin. which of the following statements by the client indicates and understanding of the teaching? calcium carbonate Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to administer a calcium supplement, such as calcium carbonate, as a calcium replacement. - ANSWER a nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). the client reports muscle cramps and a tingling sensation in their hands. which of the following medications should the nurse plan to administer? aged cheese Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches. - ANSWER a nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. to help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid? take daily cranberry supplements. The client should take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI. - ANSWER a nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). which of the following information should the nurse include in the teaching?

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. - ANSWER 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 first take? remain with the client for the first 15 min of the infusion. The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood. - ANSWER a nurse is preparing to administer a unit of packed RBCs to a client. which of the following actions should the nurse take? "I used to never worry about my feet. now, I inspect my feet every day with a mirror." This statement indicates that the client is successfully coping with the change because the client is performing preventive foot care to reduce the risk for complications. - ANSWER a nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. which of the following client statements indicates the client is successfully coping with the change? sleepiness exhibited by the client widening pulse pressure decerebrate posturing - ANSWER a nurse is caring for a client who has a closed head injury and has an intravascular catheter placed.

which of the following findings indicate that the client is experiencing increased intracranial pressure (ICP)? remind the client to scan their complete range of vision during ambulation. The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls. - ANSWER a nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. which of the following instructions should the nurse include? heart rate 110/min A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate. - ANSWER a nurse in an emergency department is caring for a client who reports visiting 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? inject the medication into the anterolateral abdominal wall. The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation. - ANSWER a nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. which of the following actions should the nurse take? "you will not be able to use sildenafil if you are taking nitroglycerin."

The client should not use sildenafil when taking nitroglycerin because both medications can cause vasodilation and lead to significant hypotension. - ANSWER a nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. which of the following statements should the nurse take? "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. - ANSWER 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? "you should void every 4 hours to decrease the risk of urinary retention." The nurse should instruct the client to void at least every 4 hr to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics. - ANSWER a nurse is providing teaching to an older adult 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? respiratory paralysis The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate. - ANSWER a nurse is assessing a client following the administration of

magnesium sulfate 1 g IV bolus. for which of the following adverse effects should the nurse monitor? C - ANSWER a nurse is assessing a male client for an inguinal hernia. which of the following areas should the nurse palpate to verify that the client has an inguinal hernia? "take insulin even if you are unable to eat your regular diet." The client should continue the prescribed medication regimen when ill to prevent hyperglycemia. - ANSWER a nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. which of the following statements should the nurse include when instructing the client? a client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet. When using the stable vs. unstable approach to client care, the nurse should assess this client first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual nitroglycerin tablet could be unstable. This client might be experiencing angina or could be having another MI. - ANSWER a nurse has received change-of-shift report for a group of clients. which of the following clients should the nurse assess first? 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. These secretions place the client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the ALS and the pneumonia. - ANSWER 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 in the nurse's priority? monitor the client's temperature every 4 hrs. 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. - ANSWER 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? calcium Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration. - ANSWER a nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? initiate airborne precautions. 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. - ANSWER 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?

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. - ANSWER 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? administer dextrose 10% in water until the new bag arrives. TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid a precipitous drop in the client's blood glucose level. - ANSWER 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 of the following actions should the nurse take? 12 almonds The nurse should determine that almonds are the best source of calcium to recommend because 12 almonds contain 36 mg of calcium. Removal of the parathyroid glands, which regulate calcium in the body, can result in hypocalcemia. - ANSWER a nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. the nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet? loosen restrictive clothing. The nurse should loosen tight, restrictive clothing to prevent injury and suffocation. - ANSWER a nurse is caring for a client who is

experiencing a tonic-clonic seizure. which of the following actions should the nurse take? listen with the client on their left side. When providing nursing care, the nurse should first use the least invasive intervention. Therefore, after auscultating a murmur, the first action the nurse should take is to place the client on their left side and listen to the heart again so that the murmur can be heard more clearly. - ANSWER a nurse is performing a cardiac assessment for a client who had a myocardial infraction 2 days ago. which of the following actions should the nurse take first after hearing the following sound? suppressing gastric acid production Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production. - ANSWER 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. history of asthma A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate. - ANSWER a nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. the nurse should identify that which of the following requires further assessment? obtain vital signs.

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. - ANSWER 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? 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. - ANSWER 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? hypoactive bowel sounds Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to decreased peristalsis. - ANSWER 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? bradycardia A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe

hypertension and a widened pulse pressure. - ANSWER a nurse in an ICU is assessing a client who has a traumatic brain injury. which of the following findings should the nurse identify as a component of Cushings triad? 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. - ANSWER a nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. which of the following actions should the nurse take? places body weight on the crutches. advances the unaffected leg onto the stair. shifts weight from the crutches to the unaffected leg. brings the crutches and effected leg up to the stair. - ANSWER a nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. identify the sequence the client should follow when demonstrating crutch use. fever hypertension tachycardia - ANSWER a nurse in an emergency department is caring for a client who is experiencing a thyroid storm. which of the following manifestations should the nurse expect? orthostatic hypotension The nurse should identify that dilation of arteries and veins causes orthostatic hypotension, which is an adverse effect of enalapril. - ANSWER a nurse is caring for a client who has a prescription for

enalapril. the nurse should identify which of the following findings as an adverse effect of the medication? increase fiber intake to at least 30 mg per day Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns. - ANSWER a nurse is providing teaching to a client who has irritable bowel syndrome (IBS). which of the following instructions should the nurse include in teaching? urine output 25 mL/hr Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing. - ANSWER a nurse is caring for a client who has a stage 3 pressure injury. which of the following findings contributes to delayed wound healing? perform synchronized cardioversion. The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia. - ANSWER a nurse is caring for a client who is experiencing supraventricular tachycardia. upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm Hg, and respiratory rate 30/min. which of the following actions should the nurse take? heart rate 55/min The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider. - ANSWER a nurse is caring for a client who presents to a clinic for a 1 - week follow-up visit after hospitalization for heart failure. based

on the information in the client's chart, which of the following findings should the nurse report to the provider? use a 30-mL syringe. The nurse should use a 30-mL to 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. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi. - ANSWER a nurse is planning to irrigate and dress a client, granulating wound for a client who has a pressure injury. which of the following actions should the nurse take? 167 mL/hr - ANSWER a nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). the client is to receive 2,000 kcal per day. the TPN solution has 500 kcal/L. the IV pump should be set at how many mL/hr? instruct the client on alternative therapies for pain reduction. The nurse should respect the client's concerns and offer nonpharmacologic alternatives to pain management, such as relaxing activities and distraction. - ANSWER a nurse is caring for a client who is receiving morphine for daily dressing changes. the client tells the nurse, "I don't want any more morphine because I don't want to get addicted." which of the following actions should the nurse take? 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. - ANSWER a nurse is planning care to decreased psychosocial health issues for a client who is