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A. Presence of associated symptoms
A nurse is collecting data from a client who is reporting pain. Which of the following actions should the nurse take to determine the client's pain intensity?A. Ask what precipitates the painB. Question the client about location of the painC. Offer the client a pain scale to measure his painD. Use open-ended questions to identify the sensation
C. Offer the client a pain scale to measure his pain
A nurse is obtaining a history from a client who has pain. The nurse should consider which of the following when collecting data?A. Some clients exaggerate their level of painB. The client should be able to identify the source of the pain in order to receive an opioid analgesicC. The nurse should be able to collect objective data to determine if the client is inpainD. Pain is whatever the client says it is
D. Pain is whatever the client says it is
A nurse monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (Select all that apply)A. Urinary incontinence B. DiarrheaC. BradypneaD. Orthostatic hypotensionE. Nausea
A nurse is reviewing the bowel prep using GoLYTELY with a client scheduled for a colonoscopy. Which of the following information should the nurse include?A. Check with the provider about taking current medications when consuming bowel prep. B. Consume a normal diet until starting the bowel prepC. The bowel prep will not begin acting until the day after it is consumedD. The bowel prep may be discontinued once feces start to be expelled
A. Check with the provider about taking current medications when consuming bowel prep.
A nurse is having difficulty arousing a client following an EGD. Which of the following is the priority action by the nurse?A. Check client's airwayB. Allow the client to sleepC. Increase the rate of IV fluid administrationD. Evaluate preprocedure lab findings
A nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing three specimens. Which of the following statements by the client indicates understanding of the teaching?A. "I will continue to take my Coumadin while I complete these tests."B. "I'm glad I don't have to follow any special diet at this time."C. "This test determines if I have parasites in my bowel."D. "This is an easy way to make sure I don't have colon cancer."
D. This is an easy way to make sure I don't have colon cancer
A nurse is reinforcing preprocedure teaching for a client who will undergo a sigmoidoscopy. Which of the following information should the nurse include? (Select all that apply). A. Increased flatulence can occur following the procedureB. NPO status should be maintained preprocedureC. Conscious sedation is usedD. Repositioning will occur throughout the procedureE. Fluid intake is limited the day after the procedure
A nurse is reviewing the health record of a client who is being admitted with a suspected tumor of the jejunum. The nurse should anticipate a prescription for which of the following tests?A. Serum alpha-fetoproteinB. ERCPC. GI X-ray with contrastD. Urine bilirubin
C. GI X-ray with contrast
A nurse is reviewing the lab findings of a client who has an acute exacerbation of Crohn's disease. Which of the following lab findings should the nurse expect to be increased with Crohn's disease? Select all that apply.A. HematocritB. ESRC. WBCD. Folic acidE. Serum albumin
A nurse is collecting data from a client who has been taking prednisone following an exacerbation of inflammatory bowel disease? Which of the following is priority?A. Client reports difficulty sleepingB. Blood glucose at 0800 is 140 mg/dLC. Client reports having a sore throatD. Client reports gaining 4 lbs in last 6 months
A nurse is reinforcing teaching with a client who has a prescription for sulfasalazine (Azulfidine). Whichof the following should the nurse include in the teaching?A. "Take the medication 1 or 2 hr after eating."B. "This medication may cause yellowing of the sclera."C. "Notify the provider if you experience a sore throat."D. "This medication may cause your stools to turn black."
A nurse in a clinic is reviewing self-care information with a client who has ulcerative colitis. Which ofthe following statements by the client indicates understanding of the teaching?A. "I will plan to limit fiber in my diet."B. "I will eat my meals and plan fluid intake between meals."C. "I will drink coffee with breakfast rather than citrus juice."D. "I will try to eat three moderate to large meals a day."
A nurse is reviewing discharge teaching to a client who has Crohn's disease. Which of the followingshould be included in the teaching?A. Decrease intake of calorie-dense foods.B. Drink canned protein supplements.C. Take calcium supplements daily.D. Take a bulk-forming laxative daily.
A nurse is assisting with the admission of a client who has acute pancreatitis. Which of the followingfindings is the priority to be reported to the provider?A. History of cholelithiasisB. Serum amylase levels three times greater than the expected valueC. Client report of severe pain radiating to the back that is rated at an "8"D. Hand spasms present when blood pressure is checked (adsbygoogle = window.adsbygoogle || []).push({});
A nurse is preparing to administer pancrelipase (Viokase) to a client who has pancreatitis. Which of thefollowing is an appropriate nursing action?A. Administer medication 30 min after a snack.B. Offer a glass of water following medication administration.C. Administer the medication 30 min before meals.D. Sprinkle the contents on peanut butter.
A nurse is collecting data from a client who has pancreatitis. Which of the following is an expected finding?A. Pain in right upper quadrant radiating to right shoulderB. Report of pain being worse when sitting uprightC. Pain relieved with defecationD. Epigastric pain radiating to left shoulder
A nurse is reviewing the medical record of a client who has pancreatitis. The physical exam report bythe provider indicates the presence of Cullen's sign. Which of the following is an appropriate action by thenurse to identify this finding?A. Tap lightly at the costovertebral margin on the client's back.B. Palpate the client's right lower quadrant.C. Inspect the skin around the umbilicus.D. Auscultate the area below the client's scapula
A nurse is reinforcing nutrition teaching with a client who has pancreatitis. Which of the followingstatements by the client requires further teaching?A. "I plan to eat small, frequent meals."B. "I will eat easy-to-digest foods."C. "I will use skim milk when cooking."D. "I plan to drink diet cola."
A nurse on a medical-surgical unit is helping admit a client who has hepatitis B with ascites. Which ofthe following actions should the nurse include in the plan of care?A. Follow contact precautions.B. Weigh client weekly.C. Measure abdominal girth 7.5 cm (3 in) above the umbilicus.D. Provide a high-calorie, high-carbohydrate diet.
A nurse is reinforcing teaching on prevention of transmission of hepatitis A with a recently infectedclient. Which of the following should the nurse include?A. "Don't share razors with other individuals."B. "Wash your hands after toileting."C. "Cough and sneeze into a tissue."D. "Use spermicide during intercourse."
A nurse is caring for a client who has advanced cirrhosis with worsening hepatic encephalopathy. Whichof the following is an expected assessment finding? (Select all that apply.)A. AnorexiaB. Change in orientationC. AsterixisD. AscitesE. Fetor hepaticus
A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expectto administer to this client? (Select all that apply.)A. DiureticB. Beta-blocking agentC. Opioid analgesicD. Lactulose (Cephulac)E. Sedative
A. DiureticB. Beta-blocking agentD. Lactulose (Cephulac)
A nurse is reinforcing teaching with a client who has hepatitis B about home care. Which of thefollowing should the nurse include in the teaching? (Select all that apply.)A. Limit physical activity.B. Avoid alcohol consumption.C. Take acetaminophen for comfort.D. Wear a mask when in public places.E. Eat small frequent meals.
A. Limit physical activity.B. Avoid alcohol consumption.E. Eat small frequent meals.
A nurse is reinforcing teaching to a client who is to have an x-ray of the kidneys, ureters, and bladder (KUB). Which of the following statements should the nurse include in the teaching?A). “Contrast dye is given during the procedure.”B). “An enema is necessary before the procedure.”C). “You will need to lie in a prone position during the procedure.”D).“The procedure determines whether a kidney stone is present.
A nurse is monitoring for postoperative complications in a client who had a kidney biopsy. Which of the following complications causes the most immediate risk to the client?A) InfectionB) HemorrhageC) HematuriaD) Kidney failure
A nurse is reviewing a client’s laboratory findings for urinalysis. The findings indicate the urine is positive for leukoesterase and nitrites. Which of the following is an appropriate nursing action?A) Repeat the test early the next morning.B) Start a 24-hr urine collection for creatinine clearance.C) Obtain a clean-catch urine specimen for culture and sensitivityD). Insert a urinary catheter to collect a urine specimen.
A nurse is caring for a client who has type 2 diabetes mellitus and is to undergo excretory urography. Which of the following are appropriate nursing actions prior to this procedure? (Select all that apply.)A) Identify client allergy to seafood.B) Hold metformin (Glucophage) for 24 hrC) Administer an enema.D) Obtain client’s serum coagulation profile.E) Check client for history of asthma.
A nurse is caring for a client who was given captopril (Capoten) during renography (kidney scan). Which of the following is an appropriate action by the nurse?A) Monitor the client for hypertension.B) Limit the client’s fluid intake.C) Monitor for orthostatic hypotension.D) Encourage early ambulation
A nurse is reinforcing to teaching a client on how to manage an external fixation device upon discharge.Which of the following statements by the client indicates an understanding of safe management?(Select all that apply.)A. "I will clean the pins twice a day."B. "I will use a separate cotton swab for each pin."C. "I will report loosening of the pins to my doctor."D. "I will move my leg by lifting the device in the middle."E. "I will remove any crusting that forms at the pin site."
A nurse is collecting data on a client who has a casted compound fracture of the right forearm. Which ofthe following findings is an early indication of neurovascular compromise?A. ParesthesiaB. PulselessnessC. ParalysisD. Pallor
A nurse is collecting data on a client who had an external fixation device applied 2 hr ago for a fractureof the left tibia and fibula. Which of the following findings indicate compartment syndrome? (Select allthat apply.)A. Intense pain when the left foot is passively movedB. Edematous left toes compared to the rightC. Hard, swollen muscle in the left legD. Burning and tingling of the distal left footE. Minimal pain relief following a second dose of opioid medication
A. Intense pain when the left foot is passively movedC. Hard, swollen muscle in the left legD. Burning and tingling of the distal left footE. Minimal pain relief following a second dose of opioid medication
A nurse is reinforcing teaching to a client who had a wound debridement for osteomyelitis. Which ofthe following information should the nurse include in the teaching?A. Antibiotic therapy should continue for 3 months.B. Relief of pain indicates the infection is eradicated.C. Contact precautions are used during wound care.D. Dressing changes are performed using aseptic technique.
A. Antibiotic therapy should continue for 3 months.
A nurse is planning care for a client who has a right hip fracture. Which of the following immobilizationdevices should the nurse anticipate in the plan of care?A. Skeletal tractionB. Buck's tractionC. Halo tractionD. Gardner-Wells traction
A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? A. Superficial thicknessB. Superficial partial thickness C. Deep partial thickness D. Full thickness
A nurse is caring for a client who has sustained burns over 35% of his total body surface area. Of this total, 20% are full‐thickness burns on the arms, face, neck, and shoulders. The client's voice has become hoarse. He has a brassy cough and is drooling. The nurse should identify these findings as indications that the client has which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning
A nurse is assessing a client who sustained deep partial‐thickness and full‐thickness burns over 40% of his body 24 hr ago. Which of the following are findings should the nurse expect? (Select all that apply.) A. Dyspnea B. BradycardiaC. Hyperkalemia D. Hyponatremia E. Decreased hematocrit
A nurse is preparing to administer fentanyl to a client who sustained deep partial‐thickness and full‐thickness burns over 60% of his body 24 hr ago. The nurse should plan to use which of the following routes to administer the medication? A. Subcutaneous B. Oral C. Intravenous D. Transdermal
A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Limit visitors in the client's room. B. Encourage fresh vegetables in the diet. C. Increase protein intake. D. Instruct the client to consume 2,000 calories/day. E. Restrict fresh flowers in the room.
A nurse is caring for a client who has blood glucose of 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first?A. Recheck blood glucose in 15 min.B. Provide carbohydrate and protein food.C. Provide 4 oz grape juice.D. Report findings to the provider.
C. Provide 4 oz grape juice
A nurse is preparing to administer a morning dose of aspart insulin (Novolog) to a client who has type 1 diabetes mellitus. Which of the following is an appropriate action by the nurse?A. Check the client's blood glucose immediately after breakfast.B. Administer the insulin when breakfast arrivesC. Hold breakfast for 1 hr after insulin administrationD. Clarify the prescription because insulin should not be administered at this time
A nurse is preparing to administer the morning doses of glargine (Lantus) insulin and regular (Humulin R) insulin to a client who has a blood glucose of 278 mg/dL. Which of the following is an appropriate nursing action?A. Draw up the regular insulin and then the glargine insulin in the same syringe.B. Draw up the glargine insulin then the regular insulin in the same syringe.C. Draw up and administer regular and glargine insulin in separate syringes. D. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin.
A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes. Which of the following should the nurse include in the information? (Select all that apply)A. Eat less meat and processed foodsB. Decrease intake of saturated fatsC. Increase daily fiber intakeD. Limit saturate fat intake to 15% of daily caloric intakeE. Include omega-3 fatty acids in the diet.
A nurse is teaching foot care to a client who has diabetes. Which of the following information should the nurse include in the teaching? (Select all that apply)A. Remove calluses using OTC remediesB. Apply lotion between toesC. Perform nail care after bathingD. Trim toenails straight acrossE. Wear closed-toe shoes
A nurse is assisting with the care of a client who has diabetic ketoacidosis. The nurse should anticipate that the client's condition will be treated intitially with which of the following IV solution?A. Dextrose 5% in 0.9% sodium chlorideB. 0.45% sodium chlorideC. 0.9% sodium chlorideD. Dextrose 5% in 0.45% sodium chlorine
A nurse is reviewing the laboratory findings for a client who has hyperglycemic hyperosmolar state (HHS). Which of the following is an expected finding for this client?A. Serum sodium 143B. Serum glucose 625C. Serum BUN 15D. Serum pH 7.35 (adsbygoogle = window.adsbygoogle || []).push({});
A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The clientreports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratoryfindings should the nurse anticipate ? (Select all that apply.)A. Positive ANAB. Increased hemoglobinC. 2+ urine proteinD. Increased serum C3 and C4 complementE. Elevated BUN
A nurse is providing teaching about self-care to a client who has SLE. Which of the following statementsby the client indicates a need for further teaching?A. "I should avoid sun exposure."B. "I will apply powder to any skin rash."C. "I should use a mild hair shampoo."D. "I will call my doctor if I have a cough."
A nurse is providing teaching to a client who has a new prescription for prednisone (Deltasone). Whichof the following should be included in the teaching? (Select all that apply.)A. Hypotension can occur.B. Weight gain is expected.C. Abdominal striae may appear.D. Loss of appetite may be present.E. Moon facies may be evident.
A nurse is admitting a client who has suspected SLE. Which of the following clinical findings supportsthis diagnosis?A. Weight lossB. Petechiae on thighsC. Increased hair growthD. Alopecia
A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon.Which of the following clinical findings should the nurse anticipate?A. Swelling of joints of the fingersB. Pallor of toes with cold exposureC. Feet become reddened with ambulationD. Client report of intense feeling of heat in the fingers
A nurse is caring for a client who has rheumatoid arthritis, which of the following laboratory tests are used to diagnose this disease? SELECT ALL THAT APPLYA. UrinalysisB. ESRC. BUND. ANA titerE. WBC count
A nurse is teaching a client who has a new diagnosis of RA. Which of the following statements should the nurse include in the teaching?a. you can experience morning stiffness when you get out of bedb. you can experience abdominal painc. you can experience weight gaind. you can experience low blood sugar
A nurse is working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY)a Recent influenzab. Decreased ROMc. Hypersalivationd. Increased BPe. Pain at rest
A nurse is teaching a client about the risk for cancer. Which of the following client statements indicatesthe need for further teaching?A. "I see a dermatologist regularly for the mole on my thigh."B. "I take Milk of Magnesia for occasional constipation."C. "I tan using an indoor tanning lotion instead of laying out in the sun."D. "I used to smoke but switched to chewing tobacco 3 years ago."
A nurse is teaching a client about maintaining a diet that may prevent certain cancers. The nurse shouldinform the client that the intake of which of the following may be beneficial? (Select all that apply.)A. Low saturated fatsB. FiberC. Red meatsD. Simple carbohydratesE. Fish
A nurse is caring for a client who has lung cancer and is exhibiting manifestations of syndrome ofinappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report tothe provider? (Select all that apply.)A. Behavioral changesB. Client report of headacheC. Urine output 40 mL/hrD. Client report of nauseaE. Increased urine specific gravity
A nurse in an oncology clinic is reviewing the health record of a client who had surgery to stage ovariancancer. The nurse reviews the following diagnostic notation on the pathology report: T2-N3-MX. Which ofthe following is an expected finding that supports this diagnosis?A. The tumor is 4 cm in size involving the ovary and adjacent tissues.B. No lymph nodes contain cancer cells.C. The tumor is receptive to current medication therapy.D. The cancer has metastasized to other areas in the body.
A nurse is planning care for a client who has malnutrition due to cancer. Which of the followinginterventions should the nurse include in the plan of care? (Select all that apply.)A. Have the client keep a food diary.B. Encourage tooth brushing before and after meals.C. Assess laboratory test report of ferritin.D. Monitor for changes in mental status.E. Explain that fluid intake should occur between meals.
A nurse in a clinic is caring for a client who has suspected uterine cancer. Which of the followingassessment techniques should the nurse anticipate the provider will perform on this client?A. Bimanual pelvic examinationB. Papanicolaou (Pap) test with culturesC. Digital rectal examinationD. Percussion of the upper abdominal quadrants for tympany
A nurse at a health fair is reviewing possible warning signs of cancer that a client should watch for.Which of the following information should be included in this review? (Select all that apply.)A. Presence of a fever of 102° F (38.9° C) for more than 48 hrB. A sore that does not healC. Difficulty swallowingD. Presence of unusual dischargeE. Weight gain of 4 lb (1.8 kg) in 2 weeks
A nurse is reviewing preoperative teaching with a client who will undergo a shave biopsy for suspectedcancer. Which of the following statements by the client indicates understanding of the procedure?A. "A test of my bone marrow will be performed."B. "A lymph node will be removed."C. "A needle will be inserted into the mass."D. "A small skin sample will be obtained."
A nurse is completing preprocedure teaching for a client who will undergo nuclear imaging for suspectedcancer. Which of the following is an appropriate statement by the nurse?A. "The presence of a liver enzyme will be identified."B. "You will be given an injection of a radioactive substance."C. "An endoscope will be inserted through your mouth."D. "The tumor will be aspirated."
A nurse is assisting in the planning of care for a client who will undergo a liver biopsy for suspected cancer. Which of the following interventions should the nurse recommend to include in the plan of care?A. Monitor the client for an allergic reaction to contrast dyeB. Administer an anticoagulant prior to the procedureC. Verify the prescription for a tumor marker assayD. Ensure the client is placed on the left side after testing
A nurse is planning care for a client who is undergoing chemotherapy and is placed on neutropenicprecautions. Which of the following interventions should be included in the plan of care? (Select all that apply.)A. Encourage a high-fiber diet.B. Remove plants from the room.C. Have the client wear a mask when leaving the room.D. Have client-specific equipment remain in the room.E. Eliminate raw foods from the client's diet.
A nurse is caring for a client who is undergoing chemotherapy and reports severe nausea. Which of thefollowing statements is appropriate for the nurse to make?A. "Your nausea will lessen with each course of chemotherapy."B. "Hot food is better tolerated because of the aroma."C. "Try eating several small meals throughout the day."D. "Increase your intake of red meat as tolerated."
A nurse is planning care for a client who has a platelet count of 25,000/mm3. Which of the followinginterventions should be included in the plan of care?A. Apply prolonged pressure to puncture site after blood sampling.B. Administer epoetin alfa (Epogen) as prescribed.C. Place the client in a private room.D. Have the client use an oral topical anesthetic before meals.
A nurse is caring for a client who has cervical cancer and undergoing brachytherapy. Which of thefollowing are appropriate nursing interventions? (Select all that apply.)A. Permit visitors to stay 30 min at a time.B. Place the client on bed rest.C. Insert an indwelling urinary catheter.D. Administer fiber laxatives.E. Allow the skin "tattoo" guides for therapy to remain in place.
A nurse is caring for a client who has mucositis due to chemotherapy to treat cancer. Which of thefollowing actions should the nurse take?A. Use a glycerin-soaked swab to clean the client's teeth.B. Encourage increased intake of citrus fruit juices.C. Obtain a culture of the lesions.D. Provide an alcohol-based mouthwash for oral hygiene.
A nurse is caring for a client who has leukemia and has developed thrombocytopenia. Which of thefollowing is the priority nursing intervention?A. Plan rest periods throughout the day.B. Encourage cough, turn, and deep breathing every 2 hr.C. Assess temperature every 4 hr.D. Monitor platelet counts.
A nurse is reviewing the health record of a client who has suspected ovarian cancer. Which of thefollowing findings supports this diagnosis? (Select all that apply.)A. Previous treatment for endometriosisB. Family history of colon cancerC. First pregnancy at age 24D. Report of scant mensesE. Use of oral contraceptives for 10 years
A nurse is caring for a client who is 24 hr postoperative liver lobectomy for hepatocellular carcinoma.Which of the following laboratory reports should the nurse monitor?A. Urine specific gravityB. Blood glucoseC. Serum amylaseD. D-dimer
A nurse is providing education regarding colon cancer to a group of women ranging from 45 to 65 yearsof age. Which of the following is an appropriate statement by the nurse?A. "Colonoscopies for individuals with no family history of cancer should begin at age 40."B. "A sigmoidoscopy is recommended every 5 years beginning at age 60."C. "Fecal occult blood tests should be done annually beginning at age 50."D. "An endoscopy provides a definitive diagnosis of colon cancer."
A nurse is caring for a client who has multiple types of skin lesions. Which of the following skin lesionsare suggestive of a malignant melanoma? (Select all that apply.)A. Diffuse vesiclesB. A uniformly colored papuleC. Area with asymmetric bordersD. A rough, scaly patchE. Irregular colored mole
A nurse is caring for a client who has cancer pain. Which of the following is the most reliable indicatorof the client's pain?A. Change in pulse rateB. Facial expression of painC. Verbal report of painD. Massaging an area of pain
A nurse is caring for a client who has chronic cancer pain and has a permanent epidural catheter foradministration of a fentanyl/bupivacaine solution. The nurse should monitor the client for which of thefollowing findings? (Select all that apply.)A. Respiratory depressionB. HypotensionC. SedationD. Muscle spasticityE. Motor blockage
A nurse is caring for a client who is to undergo neurolytic ablation. The nurse should recognize that thistreatment is used only when other measures have failed due to the risk ofA. irreversible nerve damage.B. increased pain.C. myelosuppression.D. thrombocytopenia.
A nurse is caring for a client who has cancer. The goal of palliative pain management is to increasewhich of the following?A. Mental acuityB. Physical mobilityC. Bowel functionD. Quality of life
A nurse is planning care for a client who has cancer and is to undergo cryoanalgesia. Which of thefollowing interventions should be included in the plan of care?A. Monitor oxygen saturation during the procedure.B. Instruct client to apply heat to the insertion site.C. Assess for irritated oral mucous membranes following the procedureD. Evaluate bladder control after the procedure. |
A nurse is reinforcing discharge teaching with a client who has systemic lupus erythematosus
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