RN Medical Surgical 2024 Exam New Latest Version Best Studying Material, Exams of Nursing

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A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report? a) Alkaline phosphate 125 units/L b) Clay-colored stools c) Platelets 70,000/mm d) Distended abdomen ---------- Correct Answer ---------- c) Platelets 70,000/mm A home health nurse is providing nutrition education for a client who has trigeminal neuralgia. Which of the following foods should the nurse recommend? a) Graham crackers b) Iced coffee c) Vanilla pudding d) Vegetable soup ---------- Correct Answer ---------- c) Vanilla pudding A nurse is caring for a client who is 6 hours postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? a) Adjust the clamps on the fixator frame b) Maintain the affected extremity in a dependent position c) Palpate the dorsalis pedis d) Wrap gauze on the sharp point of the pins ---------- Correct Answer ---------- c) Palpate the dorsalis pedis A nurse is caring for a client in the emergency department who experienced a full- thickness burn injury to the lower torso 1 hour ago. Which of the following findings should the nurse expect? a) Hypotension b) Bradycardia c) Decreased respiratory rate d) Urinary diuresis ---------- Correct Answer ---------- a) Hypotension A nurse is planning care for an older adult client who has Meniere's disease. Which of the following interventions should the nurse include in the plan of care? a) Perform range of motion exercises to the client's neck every 4 hours b) Limit the client's fluid intake to 1500 ml/day c) Administer aspirin if the client reports a headache d) Encourage the client to change positions slowly ---------- Correct Answer ---------- d) Encourage the client to change positions slowly

A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake. Which of the following choices would the nurse recommend as containing the least potassium? a) Half cup non-fat yogurt b) Two tablespoons of peanut butter c) 1 cup white rice d) One medium baked potato with skin ---------- Correct Answer ---------- c A nurse is assessing a client following the insertion of a central venous catheter. Which if the following findings indicates a pneumothorax? a) Diminished breath sounds b) Itching over the incision c) Distended neck veins d) Irregular heart rate ---------- Correct Answer ---------- a) Diminished breath sounds A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take when performing a closed intermittent irrigation? a) Use a 3 mL syringe to perform the irrigation b) Clamp the catheter above the specimen port c) Place the client in trendelenburg position d) Inject the irrigation solution slowly into the catheter ---------- Correct Answer ---------- d) Inject the irrigation solution slowly into the catheter A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching? a) I will need to take my clothes to the dry cleaners to sterilize them b) I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash c) I will be sure to wear gloves and wash my hands when I change my cat's litter box d) I will increase the amount of fresh fruits and vegetables I consume ---------- Correct Answer ---------- c) I will be sure to wear gloves and wash my hands when I change my cat's litter box A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority? a) Level of pain b) Gag reflex c) Warmth of extremities d) Temperature ---------- Correct Answer ---------- b) Gag reflex A nurse is caring for an older adult who is suspected of having septicemia. Which of the following actions is the nurse's priority? a) Obtain a history to determine recent injuries b) Obtain a broad spectrum antibiotic for rapid administration c) Obtain an WBC count with differential

d) Obtain a blood specimen for culture and sensitivity testing ---------- Correct Answer --- ------- d) Obtain a blood specimen for culture and sensitivity testing A nurse is caring for a client who has just undergone a total laryngectomy. Which of the following findings is the nurse's priority for immediate intervention? a) Blood-tinged secretions b) Tachypnea c) Fever d) IV infiltration ---------- Correct Answer ---------- d) IV infiltration A nurse is admitting a client to the emergency department after a GSW to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? a) Administer IV fluids to the client b) Insert a urinary catheter c) Initiate beta-blocker therapy d) Prepare the client for an intravenous pyelogram ---------- Correct Answer ---------- a) Administer IV fluids to the client A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings require immediate intervention by the nurse? a) A client has 100 mL blood in the closed suction drain b) The clients capillary refill in the left toe is 6 seconds c) the client has an oral temperature of 38.3 C (100.9 F) d) The client reports a pain level 7 on a scale for 0 to 10 at the operation site ---------- Correct Answer ---------- b) The clients capillary refill in the left toe is 6 seconds A nurse in an emergency department is reviewing a client's ECG reading. Which of the following findings should the nurse identify as an indication that the client has a first degree heart block? a) More P waves than QRS complexes b) Prolonged PR intervals c) non discernible P waves d) No correlation between P and QRS waves ---------- Correct Answer ---------- b) Prolonged PR intervals A nurse is reviewing the medication list of a client who is being admitted with diabetes insipidius. Which of the following medications places the client at an increased risk for developing diabetes insipidius? a) Flanitidine b) Atorvastatin c)Propranolol d) Lithium (answer is d) ---------- Correct Answer ----------

A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care? a) Place a plate guard in the client meal tray b) Position the bedside table on the client's left side c) Remind the client to use on his left side while ambulating d) Provide the client with a short handled reacher ---------- Correct Answer ---------- a) Place a plate guard in the client meal tray A nurse is administering potassium chloride via IV infusion to a client who has severe hypokalemia. Which of the following actions should the nurse take? a) Start the infusion at 30 mEq/hr b) Assess the client for a positive chvostek's sign c) Monitor the client for adequate urine output d) Check insertion site at least every 4 hours ---------- Correct Answer ---------- a) Start the infusion at 30 mEq/hr A nurse in the PACU is caring for a client. Which of the following assessment is the nurse's priority? a) Surgical site b) Level of consciousness c) Respiratory status d) Pain level ---------- Correct Answer ---------- c) Respiratory status A nurse is reviewing the medical record of a client who is scheduled for a CT scan with contrast media. Which of the following medications should the nurse instruct the client to withhold for 48 hours following the procedure? a) Carvedilol b) Furosemide c) Metformin d) Clopidrogel ---------- Correct Answer ---------- c) Metformin A nurse is caring for a client who has pancreatitis and has been receiving TPN. Which of the following laboratory tests should the nurse monitor for overall nutritional status? a) Creatinine b) Prealbumin c) Lipsae d) C-reactive protein ---------- Correct Answer ---------- b) Prealbumin A nurse is teaching a client who has endometriosis about the adverse effects of leuprolide. Which of the following manifestations should the nurse include in the teaching? a) Pallor b) Increased appetite c) Bone loss d) Hypoglycemia ---------- Correct Answer ---------- c) Bone loss

A nurse is providing teaching to a client who is receiving opioids for pain management. Which of the following information should the nurse include in the teaching? a) Monitor urinary output for retention b) Avoid taking anitemetics with the medication c) Restrict fluid intake if you are experiencing constipation d) Itching indicates you are having an allergic reaction to the medication ---------- Correct Answer ---------- a) Monitor urinary output for retention A nurse is providing discharge teaching to a client who has asthma and a new prescription for a metered dose inhaler. Which of the following client statements indicates an understanding of the teaching? a) I should clean the cap of the inhaler once a week b) I should shake the inhaler before I use it c) I should wait 15 seconds between puffs d) I should inhale the medication quickly ---------- Correct Answer ---------- b) I should shake the inhaler before I use it A nurse is assessing a client who has heart failure. Which of the following client statements should indicate to the nurse that the client needs a referral for cardiac rehabilitation? a) I hate how I feel all the time b) I am too tired to brush my teeth c) I will weigh myself daily d) I need to start eating a low sodium diet ---------- Correct Answer ---------- b) I am too tired to brush my teeth A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take? a) Remove the indwelling catheter b) Decrease transaction of the catheter c) Flush the catheter manually with 0.9% sodium chloride d) Administer ibuprofen 400 mg for pain relief ---------- Correct Answer ---------- c) Flush the catheter manually with 0.9% sodium chloride 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 an understanding of the teaching? a) "I should take calcium supplements, so the medication will work better in my system." b) "I am taking this medication to increase my energy level." c) "This medication can cause my blood pressure to drop." d) "I will need to restrict protein in my diet while taking this medication." ---------- Correct Answer ---------- b) "I am taking this medication to increase my energy level."

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 make? a) You might need to take a stool softener while taking this medication. b) You will not be able to use sildenafil if you have diabetes. c) You will need to limit your caffeine intake if you start taking sildenafil. d) You will not be able to use sildenafil if you are taking nitroglycerin. ---------- Correct Answer ---------- d) You will not be able to use sildenafil if you are taking nitroglycerin. 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? a) Restlessness b) T3 level 215 ng/dL c) Blood pressure 170/ d) Decreased weight ---------- Correct Answer ---------- c) Blood pressure 170/ A nurse on a medical-surgical unit is receiving change-of-shift report on four clients. Which of the following clients should the nurse identify as having the greatest risk for developing an infection? a) A client who has a closed fracture of the arm and is receiving an opioid pain medication b) A client who has COPD and is receiving steroid therapy c) A client who is postoperative following a laparoscopic appendectomy and is receiving an antibiotic d) A client who has a deep vein thrombosis (DVT) and is receiving anticoagulant therapy ---------- Correct Answer ---------- b) A client who has COPD and is receiving steroid therapy 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 went blurry." Which of the following actions is the nurse's priority? a) Check the client's neurological status b) Document the client's statements c) Prepare the client for a CT scan d) Teach the client about using safety precautions for falls ---------- Correct Answer ------- --- a) Check the client's neurological status 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? a) Teach the importance of a clear liquid diet after discharge b) Tell the client to remove incisional adhesive strips 3 days after discharge c) Demonstrate ways to deep breath and cough d) Instruct the client to maintain bedrest for 48 hours ---------- Correct Answer ---------- c) Demonstrate ways to deep breath and cough

A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of his total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer? a) IV fluids b) Analgesia c) Antibiotics d) Tetanus toxoid ---------- Correct Answer ---------- a) IV fluids A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent her headaches. The nurse should identify that which of the following client medications interacts with feverfew? a) Metoprolol b) Bupropion c) Naproxen d) Atorvastatin ---------- Correct Answer ---------- c) Naproxen A nurse is providing discharge teaching to a client who has laryngeal cancer and is receiving radiation treatment. Which of the following statements made by the client indicates an understanding of the teaching? a) I will wear a badge to measure how much radiation I am receiving b) I will remove the markings on the skin after each radiation treatment c) I will avoid direct exposure to the sun d) I will rinse my mouth with a commercial mouthwash ---------- Correct Answer ---------- c) I will avoid direct exposure to the sun 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? a) Obtain the client's vital signs b) Describe the blood transfusion procedure to the client c) Check for the type and number of units of blood to administer d) Initiate a peripheral IV ---------- Correct Answer ---------- c) Check for the type and number of units of blood to administer 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? a) Bradycardia b) Tremors c) Orthostatic hypotension d) Drowsiness ---------- Correct Answer ---------- c) Orthostatic hypotension A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? a) Bounding pedal pulse b) Capillary refill less than 2 seconds

c) Pain that increases with passive movement d) Areas of warmth on the cast ---------- Correct Answer ---------- c) Pain that increases with passive movement A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include? a) Limit visitation time for the client's children to 40 minutes per day b) Clean the equipment in the client's room once per week c) Provide a diet of fresh fruits and vegetables for the client d) Apply new gloves when alternating between wound care sites ---------- Correct Answer ---------- d) Apply new gloves when alternating between wound care sites A nurse is caring for client who has cancer. The client tells the nurse, "I would prefer to try vitamins and minerals instead of chemotherapy". Which of the following responses should the nurse make? a) I have never heard of any holistic treatment that is effective b) You should ask your provider about your plan c) The best way to treat your cancer is chemotherapy d) Tell me what you know about chemotherapy ---------- Correct Answer ---------- d) Tell me what you know about chemotherapy A nurse is planning to teach a client whose provider has prescribed a low purine diet. The nurse should plan to instruct the client that he can include which of the following foods in his diet? (select all that apply) a) Sardines b) Nuts c) Apricots d) liver e) Scallops ---------- Correct Answer ---------- b) Nuts c) Apricots A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse take? a) Place pillows under the clients knee b) Gently massage the area around the clients incision c) Apply an ice pack to the clients knee d) Perform range of motion exercises to the clients knee ---------- Correct Answer ---------

• c) Apply an ice pack to the clients knee A nurse is caring for client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change? a) I will need to have my partner take over shopping for groceries and cooking the meals for us

b) It's going to be difficult to tell my parents I can't take them to their appointments anymore c) I feel bad that I have to ask my partner to keep the house clean d) These crutches will make it impossible to care for my child ---------- Correct Answer --- ------- a) I will need to have my partner take over shopping for groceries and cooking the meals for us. A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances? a) Adhesive tape b) Latex c) Anesthetics d) Povidone iodine ---------- Correct Answer ---------- b) Latex A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first? a) A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% b) A client who has left-sided paralysis an slurred speech from a prior stroke c) A client who has thrombocytopenia and reports a nosebleed d) A client who has multiple sclerosis and reports ataxia and vertigo ---------- Correct Answer ---------- c) A client who has thrombocytopenia and reports a nosebleed A nurse is monitoring a client who is receiving two units packed PBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? a) back pain b) Hypertension c) Chills d) Bradycardia ---------- Correct Answer ---------- a) back pain A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include? a) Use a heating pad to keep your feet warm at night b) Wear loos-fitting slippers around the house c) Wear cotton rather than nylon socks d) Wash your feet twice per day with antimicrobial soap and hot water ---------- Correct Answer ---------- c) Wear cotton rather than nylon socks A nurse is providing teaching to a client who has a deep vein thrombosis (DVT). Which of the following findings should the nurse identify as a risk factor for the development of the DVTs? a) NSAID use b) Hypertension c) Oral contraceptives d) Cirrhosis ---------- Correct Answer ---------- c) Oral contraceptives

A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take? a) Remove soiled items from the room after each change b) Give the dosimeter badge to the oncoming nurse at the end of the shift c) Apply a second pair of gloves before touching the client's implant is it dislodges d) Limit family member visits to 30 minutes per day ---------- Correct Answer ---------- d) Limit family member visits to 30 minutes per day A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? a) Generalized abdominal pain b) Cloudy effluent c) Increased heart rate d) Fever ---------- Correct Answer ---------- d) Fever A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications? a) Pantoprazole b) Acetaminophen c) Furosemide d) Diphenhydramine ---------- Correct Answer ---------- c) Furosemide A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer. Which of the following actions should the nurse plan to take? a) Provide ketorolac for abdominal pain b) Administer nitroprusside IV based on the client's weight c) Insert a large bore nasogastric tube d) Ensure that the client has a 22-gauge IV line in place ---------- Correct Answer ---------- c) Insert a large bore nasogastric tube A nurse is caring for a client who has bladder cancer and a WBC of 900/mm3. Which of the following actions should the nurse take? a) Instruct the client to avoid eating raw fruit b) Move the client to a negative pressure room c) Use contact isolation while providing care d) Apply pressure to venipuncture sites for 10 minutes ---------- Correct Answer ---------- a) Instruct the client to avoid eating raw fruit A nurse is caring for patient who has hypotension, cool and clammy skin, tachycardia and tachypnea. Which of the following positions should the nurse place the client? a) Reverse trendelenburg b) Feet elevated

c) Side lying d) High-fowler's ---------- Correct Answer ---------- a) Reverse trendelenburg A nurse is caring for a client who weighs 190 lb and is receiving total parenteral nutrition. If the RDA protein is 0.8 g/kg of body weight, how many grams of protein should the client receive daily? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero) ---------- Correct Answer ---------- 69 grams A nurse is planning care for a client what has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care? a) Flush a catheter using a 10 mL syringe b) Use clean technique when changing the dressing c) Cleanse the site with provodine iodine d) Change the dressing every 24 hours ---------- Correct Answer ---------- a) Flush a catheter using a 10 mL syringe A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin? a) Thalassemia b) Rheumatoid arthritis c) COPD d) Thrombocytopenia ---------- Correct Answer ---------- d) Thrombocytopenia A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's abstract thinking? a) What is meant by saying "don't beat around the bush?" b) What do you understand about your condition? c) Can you count backwards form 100 in intervals of 7? d) Can you state where you were born? ---------- Correct Answer ---------- a) What is meant by saying "don't beat around the bush?" A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include int he plan of care? a) Apply an occlusive dressing b) Turn and reposition the client every 4 hours c) Support bony prominences with pillows d) Massage reddened areas three times daily ---------- Correct Answer ---------- c) Support bony prominences with pillows A nurse is reviewing a cardiac rhythm strip of a client who has atrial flutter. Which of the following findings should the nurse expect? a) Progressively longer PR durations

b) Undetectable P waves c) Absent PR intervals with ventricular rate of 40 to 60/ minute d) Sawtooth pattern with arterial rate of 252-400/ minute ---------- Correct Answer ---------

• d) Sawtooth pattern with arterial rate of 252-400/ minute A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse should plan to take which of the following actions? a) Administer a stool softener following the procedure b) Ask the client to empty his bladder prior to the procedure c) Instruct the client to take deep breaths and hold them during the procedure d) Assist the client into the left lateral position during the procedure ---------- Correct Answer ---------- b) Ask the client to empty his bladder prior to the procedure A nurse is planning a staff education session about hepatitis A. Which of the following information should the nurse include? a) Immunization for Hepatitis A is recommended prior to travel to high-risk areas b) The incubation of Hepatitis A is 5 to 10 days c) Hepatitis A is transmitted through blood exposure d) Clients who have Hepatitis A require broad-spectrum antibiotics ---------- Correct Answer ---------- a) Immunization for Hepatitis A is recommended prior to travel to high- risk areas A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing this client? a) Phosphate level b) Glucose level c) Serum troponin d) Serum ammonia ---------- Correct Answer ---------- d) Serum ammonia A nurse is planning care for a client who is status epilepticus. Which of the following interventions is the nurses priority to include? a) Administer phenytoin IV bolus to the client b) Provide the client oxygen at 6 L/min using a nasal cannula c) Turn the client to the lateral position during seizure activity d) Administer diazepam intravenously to the client ---------- Correct Answer ---------- c) Turn the client to the lateral position during seizure activity A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation? a) Elevate the knees higher than the hips when sitting b) Remove the wedge device when turning c) Encourage the client to lean forward when attempting to stand d) Place two bed pillows between the legs when in bed ---------- Correct Answer ---------- d) Place two bed pillows between the legs when in bed

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The current infusion is almost complete and the new solution os not available. Which of the following actions should the nurse take? a) Infuse dextrose 10% in water b) Decrease the rate of the infusion c) Disconnect and flush the IV access line d) Administer lactated ringers through the peripheral IV site ---------- Correct Answer ----- ----- a) Infuse dextrose 10% in water A nurse is assessing a client who has a diagnosis of colon cancer. Which of the following should the nurse expect? a) Steatorrhea (fatty stools) b) Elevated hemoglobin c) Hematochezia (rectal bleeding) d) Weight gain ---------- Correct Answer ---------- c) Hematochezia (rectal bleeding) A nurse is assessing a client admitted with peripheral vascular disease. Which of the following finding indicates a venous vascular disorder? a) An ulcer at the tip of the toe b) Hair loss distal to the clients calves c) Leg pain at rest d) Edema on the ankle ---------- Correct Answer ---------- d) Edema on the ankle A nurse is caring for client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse? a) Pulse pressure changes from 30 to 20 mmHg b) Bilateral pupil diameter changes from 4 to 2 mm c) WBC changes form 9,000 to 16,000 mm d) Glasgow Coma Scale score changes from 14 to 9 ---------- Correct Answer ---------- d) Glasgow Coma Scale score changes from 14 to 9 A nurse is administering furosemide 80mg PO twice-daily to a client who has pulmonary edea. Which of the following assessment findings indicates to the nurse that the medication is effective? a) Respiratory rate of 24 b) Adventitious breath sounds c) Weight loss of 1.8 kg (4 lb) in the past 24 hours d) Elevation in blood pressure ---------- Correct Answer ---------- c) Weight loss of 1.8 kg (4 lb) in the past 24 hours A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contraindication for receiving the medication? a) Creatinine 0.8 mg/dL b) Sodium 136 mEq/L c) Potassium 3.2 mEq/L

d) Bun 18 mg/dL ---------- Correct Answer ---------- c) Potassium 3.2 mEq/L A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following action should the nurse take? a) Place the dosimeter film badge on the client's door b) Wear a lead apron when providing care c) Leave the door to the client's room open d) Allow visitors to hold the client's hand ---------- Correct Answer ---------- b) Wear a lead apron when providing care A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following results should the monitor to determine long term glucose control? a) Glycosylated hemoglobin level (A1C) b) Fasting blood glucose level c) Oral glucose tolerance test results d) Post-prandial glucose level ---------- Correct Answer ---------- a) Glycosylated hemoglobin level (A1C) A nurse is provide preoperative teaching for a client who is having left-sided cardiac catheterization. Which of the following information should the nurse include in the teaching? a) You should plan to remain in bed 18 hours after the procedure b) You will have blood pressure measurements every 5 minutes for the first 2 hours after the procedure c) You will receive a general anesthetic during the procedure d) You should expect a warm sensation after the injection of the contrast dye during the procedure ---------- Correct Answer ---------- d) You should expect a warm sensation after the injection of the contrast dye during the procedure A nurse is caring for a client who has anemia. Which of the following assessment findings should the nurse anticipate with the client's condition? a) Bradycardia b) Headache c) Heat intolerance d) Flushed skin color ---------- Correct Answer ---------- d) Flushed skin color A nurse is teaching a client who has a new prescription for Warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interact with this medication? a) Kale b) Beef stew c) Yogurt d) Orange juice ---------- Correct Answer ---------- a) Kale

A nurse is monitoring an older adult client who has an extrapolation of chronic lymphocytic leukemia. The nurse note petechiae on the client's skin, which of the following actions should the nurse take? a) Determine the client's blood type b) Avoid administering IV pain medications c) Implement airborne precautions d) Institute bleeding precautions ---------- Correct Answer ---------- d) Institute bleeding precautions A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching? a) I should expect to take my medication for 3 weeks b) I should apply antibiotic ointment for the lesions c) I should expect my lesions to resolve in 6 weeks d) I should use natural skin condoms during sexual intercourse ---------- Correct Answer ---------- b) I should apply antibiotic ointment for the lesions A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg/dL, which of the following actions is the nurse's priority? a) Insert an NG tube b) Obtain consent for the surgery c) Apply anti embolytic stockings d) Insert an indwelling urinary catheter ---------- Correct Answer ---------- a) Insert an NG tube A nurse is preparing to administer two units of packed RBCs to a client. Which of the following actions should the nurse take? a) Transfuse each unit of blood over five hours b) Change the IV tubing after each unit of blood is transfused c) Administer the blood through a 22 gauge intravenous catheter d) Prime the tubing with 0.9% sodium chloride ---------- Correct Answer ---------- d) Prime the tubing with 0.9% sodium chloride A nurse is caring for a client who has chronic renal failure. The client displays the following ABG results: pH: 7.24 paCO2: 44 mmHg paO2: 84 mmHg HCO3: 18 mEq/L base excess- 2 and O2 saturation 95%. The nurse should include that the client has which of the following acid-base balances? a) Metabolic alkalosis b) Respiratory acidosis c) Respiratory alkalosis d) Metabolic acidosis ---------- Correct Answer ---------- d) Metabolic acidosis A nurse in a provider's office is teaching a client about the self management of GERD which of the following instructions should the nurse include?

a) Lie down for 30 minutes after each meal b) Sleep with the head of your bed elevated 6 inches c) Increase your caloric intake by 250 calories per day d) Eat a light meal 1 hour before bed ---------- Correct Answer ---------- b) Sleep with the head of your bed elevated 6 inches A nurse suspects that a client with diabetes mellitus is experiencing HYPOglycemia. Which of the following assessment findings supports this suspicion? a) Cool, clammy skin b) Kussmaul respirations c) Acetone breath d) Increased urinary output ---------- Correct Answer ---------- a) Cool, clammy skin A nurse is caring for a client who is receiving radiation. The client reports nausea since the therapy was initiated. Which of the following considerations should the nurse include when offering the client meals? a) Offer hot beverages with meals b) Offer a snack prior to radiation therapy c) Offer highly seasoned foods d) Offer frequent high carbohydrate meals ---------- Correct Answer ---------- d) Offer frequent high carbohydrate meals A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the information diagnosis, which of the following clients requires a private room? a) A client service port reports having fever, night sweats, and cough for 2 days b) An older adult client who was admitted with aspiration pneumonia c) a client who had diabetes mellitus and is presenting with acute ketoacidosis d) a client who has a compound fracture of the right femur ---------- Correct Answer ------ ---- a) A client service port reports having fever, night sweats, and cough for 2 days A nurse in an emergency department is assessing a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect? (select all that apply) a) Tremors b) Reports of nausea and vomiting c) Serum glucose 380 mg/dL d) Serum pH 7. e) Fruity smelling breath ---------- Correct Answer ---------- b) Reports of nausea and vomiting c) Serum glucose 380 mg/dL d) Serum pH 7. e) Fruity smelling breath

A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make? a) "This means your lung is fully expanding" b) "This indicates a possible leak" c) "Suction pressure that is too high causes this" d) "Your breathing pattern causes this" ---------- Correct Answer ---------- d) "Your breathing pattern causes this" A community health nurse is reviewing care instructions with an older adult client who has a new diagnosis of heart failure. Which of the following is the priority topic for the nurse to review with the client? a) Daily sodium restriction b) Daily exercise routine c) Changes in weight d) Fluid intake record ---------- Correct Answer ---------- c) Changes in weight A nurse is teaching a client about transcutaneous electrical nerve stimulation (TENS) unit. Which of the following statements should the nurse include? a) "Apply tester to the site prior to attaching the electrodes" b) "This device requires access to a 220 volt outlet" c) "This device delivers heat via electrodes that are attached to the affected are" d) Adjust the dial until you feel a 'pins and needles' sensation" ---------- Correct Answer - --------- d) Adjust the dial until you feel a 'pins and needles' sensation" A nurse is providing teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse include? a) "Used a raised toilet seat to maintain your hips above the knees" b) "Twist at the waist when standing from a seated position" c) "Move your stronger leg first when using a walker" d " Apply a heating pad to the affected hip to decrease pain" ---------- Correct Answer ---- ------ a) "Used a raised toilet seat to maintain your hips above the knees" A nurse finds a client in bed, unresponsive and breathing. Which of the following actions should the nurse take first? a) Establish IV access b) Apply blood pressure cuff c) Palpate for the client's carotid pulse d) Initiate cardiac monitoring for the client ---------- Correct Answer ---------- c) Palpate for the client's carotid pulse A nurse is caring for a client who is experiencing a hypertensive crisis. Which of the following actions should the nurse take? a) Initiate IV dopamine infusion b) Perform a neurological assessment c) Place the client supine

d) Begin an IV bolus of lactated ringers ---------- Correct Answer ---------- b) Perform a neurological assessment A nurse is providing discharge teaching about blood sugar monitoring for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should instruct the client to obtain which of the following supplies? a) Sterile lancets b) Compression stockings c) Hand mirror d) Toenail clippers ---------- Correct Answer ---------- c) Hand mirror A nurse is completing discharge teaching for a client who has a peripherally inserted central catheter (PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching? a) Change the dressing daily b) Do not elevate the arm above the level of the heart c) Use a 10 mL syringe to flush the line d) Clean the insertion site using 20 mL of hydrogen peroxide ---------- Correct Answer --- ------- b) Do not elevate the arm above the level of the heart A nurse is preparing naloxone 10 mcg/kg via IV bolus to a client who weights 220 lbs. The amount available is 0.4 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth) ---------- Correct Answer ---------- 2.5 mL A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy? a) Opioid analgesic b) Anticonvulsant c) Anti-thrombotic d) Diruetic ---------- Correct Answer ---------- c) Anti-thrombotic A nurse is caring for client who has a new colostomy, the nurse notes that the client appears withdrawn and looks away during ostomy care. Which of the following actions should the nurse take? a) Ask the client how they feel about the stoma b) Make a referral for the client to see an ostomy nurse c) Include the client's partner in stoma care education d) Educate the client about expected stoma apperance ---------- Correct Answer ---------- a) Ask the client how they feel about the stoma A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first? a) Administer proparacaine eye drops into the affected eye b) Place strips of pH paper on to the cul-de-sac of the affect eye c) Collect information about the irritant that caused the injury

d( Instill 0.9% sodium chloride solution into the affected eye ---------- Correct Answer ---- ------ c) Collect information about the irritant that caused the injury A nurse is teaching a client who has AIDS and wishes to continue self care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy? a) Remind the client of the importance of the medication adherence b) Initiate a referral for the client to a home health agency c) Instruct the client to avoid eating raw vegetables d) Tell the client to avoid places where there are large crowds of people ---------- Correct Answer ---------- b) Initiate a referral for the client to a home health agency A nurse is discussing nutrition options with a client who has a new diagnosis of COPD. Which of the following statements should the nurse make? a) Plan to include high protein foods in each of your meals b) Increase your intake of vegetables such as broccoli and brussel sprouts c) Drink a glass of milk with each meal d) Consume three large meals throughout the day ---------- Correct Answer ---------- a) Plan to include high protein foods in each of your meals A nurse is teaching a client who has asthma about the use of a peak flow meter. After setting the meter to zero base line, what is the sequence of steps the nurse should instruct the client to take?

1. Stand upright
2. Fill your lungs with a deep breath
3. Seal your lips around the mouth piece
4. Exhale forcefully and quickly
5. Record the highest of three consecutive readings ---------- Correct Answer ---------- A nurse is caring for a cline with bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suction. The nurse should recognize these assessment findings indicate which of the following? a) Aspiration b) Increased cardiac output c) Plural effusion d) Fluid volume excess ---------- Correct Answer ---------- d) Fluid volume excess A nurse is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adults after the age of 60 (Select all that apply) a) Human papillomavirus b) Pnuemococcal polysaccharide c) Meningocaccal d) Influenza e) Herpes zoster ---------- Correct Answer ---------- a) Human papillomavirus e) Herpes zoster

A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless. Which of the following assessments should the nurse perform first? a) Blood pressure b) Blood glucose c) Urinary output d) motor responses ---------- Correct Answer ---------- a) Blood pressure (think increased ICP) A nurse is preparing to administer piperacillin 3.375 g by intermittent IV bolus every 6 hours. Available is piperacillin 3.375 g in dextrose 5% in water 100 mL to infuse over 30 minutes. The nurse should set the IV pump to deliver how many mL/hr ---------- Correct Answer ---------- 200 mL/hr A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find? a) Oliguria b) Poor skin turgor c) Pitting edema d) S3-S4 galloping heart sounds ---------- Correct Answer ---------- c) Pitting edema A nurse is providing discharge teaching to the partner of a client who has a linear incision sit following an open cholecystectomy. Which of the following wound care instructions should the nurse include? a) Change the dressing four times per day b) Use sterile gloves when performing the dressing change c) Clean from the incision site to the surrounding skin d) Apply tincture of benzoin prior to removing the dressing ---------- Correct Answer ------ ---- c) Clean from the incision site to the surrounding skin A nurse is preparing to administer vancomycin IV bolus to a client who has pneumonia. Which of the following clinical manifestations should the nurse instruct the client to monitor for and report? a) Pallor of the extremities b) Taste of metal in the mouth c) halo of light around objects d) Ringing in the ears ---------- Correct Answer ---------- d) Ringing in the ears A charge nurse is called into a client's room after a staff nurse reports a client has a wound evisceration. Which of the following actions should the charge nurse take? a) Attempt to reinsert the organs b) Obtain bottles of warm, sterile 0.9% sodium chloride solution c) Place the client in the left lateral recumbent position- low fowlers with knees bent d) Apply a firm pressure dressing across the clients abdomen ---------- Correct Answer -- -------- b) Obtain bottles of warm, sterile 0.9% sodium chloride solution **Possibly :)

A nurse is caring for four clients. Which of the following clients is at risk for developing metabolic alkalosis? a) A client who is receiving continuous gastric suctioning b) A client who has aspiration pneumonia c) A client who is experiencing an opioid overdose d) a client who has uncontrolled diabetes mellitus ---------- Correct Answer ---------- a) A client who is receiving continuous gastric suctioning A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for developing digoxin toxicity. The nurse should monitor the client for an imbalance of which of the following electrolytes because it can increase the risk for digoxin toxicity? a) Calcium b) Potassium c) Magnesium d) Phosphatase ---------- Correct Answer ---------- b) Potassium A nurse is assessing the abdominal wound of a client who is 3 days postoperative following a colon resection. Which of the following findings should the nurse report to the provider? a) Erythema b) Ecchymotic skin c) Drainage d) Edema ---------- Correct Answer ---------- a) Erythema (redness can be indicative of infection) A nurse is completing an admission assessment for a client. The nurse should expect the provider to prescribe which of the following medications for the client? EXHIBIT VITAL SIGNS: Temp 98.3F HR 100 RR 20 BP 152/94 mmHg a) Atorvastatin b) Allopurinol c) Metoprolol d) Levothryroxine ---------- Correct Answer ---------- c) Metoprolol A nurse is assessing a client who is near the end of life following a head injury. The client has alternating periods of rapid breathing and apnea. The nurse should document these findings as which of the following respiratory patterns? a) Biot's respirations b) Hypoventilatory respirations c) Kussmaul respirations d) Cheyne-Stokes respirations ---------- Correct Answer ---------- d) Cheyne-Stokes respirations (occurs during increased intracranial pressure) A nurse is administering a unit of packed RBCs to a client and notes that there are several small clots floating in the IV bag. Which of the following actions should the nurse take?

a) Inject 5,000 units of heparin into the unit of packed RBCs b) Place the unit of packed RBCs in a warming unit for 5 minutes c) Return the unit of packed RBCs to the blood bank d) Dilute the unit using 50 mL of lactated ringers ---------- Correct Answer ---------- c) Return the unit of packed RBCs to the blood bank (take that shit back) Dark red granular tissue tells you that a pressure wound is healing ---------- Correct Answer ---------- what do to help prevent aspiration during tube feedings? a) check the amount of residual ---------- Correct Answer ---------- A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? ---------- Correct Answer ---------- Hair loss on the lower legs A nurse is 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? ---------- Correct Answer ---------- "I will use my hands rather than a washcloth to clean the radiation area. A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy. A nurse is providing teaching for the client. Which of the following instructions should the nurse include? Select all that apply. ---------- Correct Answer ---------- Avoid drinking fluids with meals Eat several small meals Consume high-protein snacks Avoid highly seasoned foods A nurse is caring for a client who is scheduled for a right knee arthroplasty. The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply. ---------- Correct Answer ---------- "I will need to do the breathing exercises every 1 to 2 hours after the surgery" "I will be sure to ask for pain medication before my knee starts to hurt too bad" "I will probably be going home with a walker" 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? ---------- Correct Answer ---------- Remind the client to scan their complete range of vision during ambulation.

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? ---------- Correct Answer ---- ------ Urine specific gravity 1.045 A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? ---------- Correct Answer -------

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A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.8° F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? ---------- Correct Answer ---------- Heart rate 110/min. A nurse is caring for a client who is 4 hr postoperative following a total vaginal hysterectomy. Click to highlight the findings the nurse should report to the provider immediately. ---------- Correct Answer ---------- Perineal pad saturated with blood, large clots present Change of blood pressure, heart rate of 102/min A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? ---------- Correct Answer ---------- Decreased viral load 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? ---------- Correct Answer - --------- Try to walk at least three times per week for exercise. 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 findings requires further assessment? ---------- Correct Answer ---------- History of asthma 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? ---------- Correct Answer ---------- "You should cut the opening of the skin barrier one-eighth inch wider than the stoma."

A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? ---------- Correct Answer ---------- Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? ---------- Correct Answer ---------- Pain that increases with passive movement A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? ---------- Correct Answer ---------- Scan the bladder with a portable ultrasound. A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ---------- "I will take my temperature once a day." A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? ---------- Correct Answer ---------- A tingling sensation replacing the pain 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 interacts with feverfew? ---------- Correct Answer ---------- Naproxen 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 Cushing's triad? ---------- Correct Answer ---------- Bradycardia 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? ---------- Correct Answer ---------- "I will wear clean graduated compression stockings every day." A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? ---------- Correct Answer ---------- Irrigate the indwelling urinary catheter.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? ---------- Correct Answer ---------- Remain with the client for the first 15 min of the infusion. 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? ---------- Correct Answer ---------- Instruct the client on alternative therapies for pain reduction. A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? ---------- Correct Answer ---------- Report of sore throat A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care? ---------- Correct Answer ------- --- Place personal items, such as pictures, at the client's bedside. A nurse is 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? ---------- Correct Answer ---------- Instruct the client to allow the machine to breathe for them. A nurse is providing teaching to a client who has a history of urinary tract infections (UTIS). Which of the following information should the nurse include in the teaching? ---------- Correct Answer ---------- Take daily cranberry supplements.. A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? ---------- Correct Answer ---------- BUN 34 mg/dL A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? ---------- Correct Answer ---------- Bubbling in the water seal chamber has ceased. A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? ---------- Correct Answer ---------- Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. A nurse is 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? ---------- Correct Answer ------ ---- Check that one finger fits between the cast and the leg.