1A nurse is reinforcing teaching with a client who had diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include?
a. Withdraw both types of insulin and then add 0.2mL of air into the syringe
b. Gently shake the NPH insulin prior to withdrawing the dose
c. Withdraw the regular insulin before withdrawing the NPH insulin
d. Inject air into the NPH vial after withdrawing regular insulin
c. The nurse should remind the client to withdraw the regular insulin before withdrawing the NPH insulin. This will protect the regular insulin from contamination with the NPH insulin
2A nurse is reinforcing teaching with a client who has chronic kidney disease management. Which of the following statements by the client indicates an understanding of the teaching?
a. I will add a banana to my morning cereal
b. I will decrease my intake of carbohydrates
c. I will limit my daily intake of protein
d. I will season my foods with a salt substitute
c. The client should decrease their intake of protein to slow the progression of kidney failure. Therefore, the nurse should identify this statement as an understanding of the teaching.
3A nurse is assisting with the care for a client who is 2 hours postoperative following the amputation of a foot. Which of the following actions should the nurse take first?
a. Obtain the client's temperature
b. Observe for phantom pain
c. Measure urinary output
d. Check the incisional dressing
d. The greatest risk to the client is hemorrhage following an amputation of the lower extremity. Therefore, the first action the nurse should take is to check the client's incisional dressing for excessive bleeding.
4A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication?
a. Elevated sodium
b. Elevated blood pressure
c. Decreased potassium
d. Decreased urine output
c. The nurse should notify the provider immediately about a decreased potassium level because potassium is lost when a diuretic, such as furosemide, is administered, which can cause hypokalemia
5A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include?
a. Use barrier methods for sexual contact when lesions are present
b. Look for lesions that have a wart-like appearance
c. The virus can be transmitted without lesions being present
d. The lesions resolve in 2 weeks and usually do not recur
c. The nurse should reinforce teaching with the client that viral shedding and spreading of the infection can occur even when lesions are not present
6A nurse is assisting with the care for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG?
a. Position the client in lateral semi-prone recumbent position before electrode placement
b. Ensure that each electrode is dry before application
c. Cleanse the client's skin prior to electrode placement
d. Place the electrodes on the client's abdomen and back
c. The nurse should cleanse the client's skin prior to electrode placement to improve electrode conduction
7A nurse is reinforcing dietary teaching with a client about increasing the intake of foods containing vitamin C to enhance absorption of oral iron supplements. Which of the following food choices should the nurse include in the teaching?
a. 1 cup of cooked brown rice
b. 1 cup of boiled broccoli
c. 1 cup of cottage cheese
d. 1 cup of scrambled eggs
b. The nurse should recommend boiled broccoli to the client because 1 cup contains 115mg of vitamin C per serving
8A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect?
a. Increased weight
b. Increased heart rate
c. Decreased urinary output
d. Decreased shortness of breath
d. The nurse should expect the client to have decreased shortness of breath. Digoxin increased the contractility of the heart, which decreases pulmonary congestion
9A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care?
a. Apply a mask to the client if transport if needed
b. Wear a mask when working within 4 feet of the client
c. Don a gown when visiting with the client
d. Wear an N95 mask when entering the client's room
a. The nurse should apply a mask to a client who has manifestations of pertussis during transport to prevent exposure to others
10A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider.
-History and Physical
History of type 2 diabetes mellitus and hypertension
Allergies: Penicillin reaction severe; Aspirin; Heparin
a. Ceftriaxone
b. Diltiazem
c. Pioglitazone
d. Hydrocodone 5mg/acetaminophen 500mg
a. Clients who have a severe sensitivity to penicillin can have a cross-sensitivity reaction to ceftriaxone, a cephalosporin. Therefore, the nurse should contact the provider to clarify the prescription
11A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction?
a. Decreased lipase
b. Decreased erythrocyte sedimentation rate (ESR)
c. Elevated creatinine
d. Elevated troponin
d. Laboratory evaluation of troponin is used specifically to detect cardiac muscle injury. Therefore, the nurse should identify an elevated troponin level as an indication that the client is experiencing a myocardial infarction.
12A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching?
a. The expected therapeutic reference range for HbA1c for a client who has diabetes mellitus is 9.5%-10%
b. An HbA1c level above the expected reference range indicates ineffective glucose control
c. HbA1c results measure glucose control for the prior 3 months
d. HbA1c testing is used to provide a diagnosis of diabetes mellitus
c. HbA1c testing reflects average overall glucose control over a 3-month period. The nurse should reinforce teaching with the client that HbA1c testing is the best measure of long-term glucose control
13A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include?
a. Place a "no visitors" sign on the client's door
b. Have the client wear an N95 respiratory mask during transport
c. Initiate droplet precautions for the client
d. Place the client in a negative-pressure airflow room
d. The nurse should place the client in a negative-pressure airflow room to filter the air and prevent the transmission of micro-organisms
14A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increase intracranial pressure (ICP). Which of the following actions should the nurse include in the plan?
a. Measure rectal temperature every 4 hours
b. Remind the client to cough as needed
c. Use a turn sheet to reposition the client
d. Apply wrist restraints
c. The nurse should change the client's position slowly to prevent sudden increases in ICP. The use of a turn sheet to reposition the client provides the nurse with the ability to better control the client's movement and alignment. The nurse should remind the client eo exhale during the position change to prevent an increase in ICP
15A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?
a. A client who had a colectomy 2 days ago and has a nasogastric tube attached to low suction
b. A client who is dehydrated, has mental confusion, and has tried to get out of bed several times during the night
c. A client who had a right lower lobectomy 4 days ago and has 50mL/hr of serous drainage from a chest tube
d. A client who has pneumonia, has an elevated oral temperature, and is requesting medication for a cough
b. When using the urgent vs. nonurgent approach to client care, the nurse should determine that a client who has mental confusion and is getting out of bed without assistance is the first client the nurse should see. The client is experiencing manifestations of dehydration, which increases the risk for falls
16A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (SATA)
a. I should expect to feel sleepy after using my albuterol inhaler
b. I never forget to rinse my mouth after using my budesonide inhaler
c. Between office visits, I keep a record of how many times I use my albuterol inhaler
d. I use my albuterol inhaler before swimming
e. I should use my budesonide inhaler before using my albuterol inhaler
B, C, D
17A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration?
a. Instill 10 mL of air through the NG tube
b. Place the client in the supine position
c. Irrigate the NG tube
d. Pinch the NG tube
d. The nurse should pinch the NG tube to prevent secretions from draining into the client's throat, which can cause aspiration
18A nurse is reinforcing teaching about GERD with a client. Which of the following statements by the client indicates an understanding of the teaching?
a. I should wait at least 2 hours after eating before going to bed
b. I should eat three meals a day without eating snacks between meals
c. I should season my food with garlic
d. I should drink my liquids through a straw
a. The client should wait to lie down or go to bed at least 2 hours after eating to minimize reflux
19A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication?
a. Frequent colds
b. Vitamin deficiency
c. Increased urination
d. Orthostatic hypotension
a. The nurse should reinforce teaching with the client that corticosteroids can increase susceptibility to infection by suppressing the immune response. The nurse should reinforce teaching with the client about infection prevention measures to implement while taking a corticosteroid
20A nurse is assisting with the care for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration?
a. Provide small, frequent meals
b. Tell the client to extend their neck when swallowing
c. Provide mouth care before meals
d. Give the client liquids with increased viscosity
d. Thickened liquids are easier for the client to swallow and can prevent aspiration
21A nurse is assisting with the care for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome?
a. Place the client in the supine position after meals
b. Administer pancreatic enzymes before meals
c. Encourage the client to drink 240mL of fluids with meals
d. Offer the client three meals a day
a. The nurse should encourage the client to lie in the supine position for a short time following meals to decrease rapid gastric emptying
22A nurse is reinforcing discharge teaching about wound care with the caregiver of a client who is postoperative. Which of the following instructions should the nurse include in the teaching?
a. Administer an analgesic following wound care
b. Irrigate the wound with providone iodine
c. Cleanse the wound with a cotton-tipped applicator
d. Report purulent drainage to the provider
d. The nurse should remind the caregiver to report manifestations of infection, including purulent drainage, to the provider
23A nurse is assisting with the care for a client who has dementia due to Alzheimer's disease. Which of the following actions should the nurse take to reduce the client's confusion?
a. Restrict visitors to three at a time
b. Avoid touching the client during care
c. Encourage reminiscence of past experiences
d. Give the client multiple options for daily events
c. The nurse should encourage reminiscence of past experiences to reduce the client's confusion
24A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as an expected change associated with aging?
a. I sweat more than I used to
b. Sometimes, I can't remember my kids names
c. I seem to have more loose stools than I used to
d. My food tastes bland even after I add seasoning
d. As clients age, there is a decrease in the number of taste buds of the tongue due to tongue atrophy
25A nurse is assisting with the care for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client?
a. Intrauterine devide
b. Latex condom
c. Combination oral contraceptives
d. Contraceptive sponge
c. The nurse should identify that combination oral contraceptives are contraindicated for this client because they increase estrogen levels, which can stimulate the growth of any remaining cancerous breast cells
26A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process?
a. I should call my doctor if I get a headache
b. I might develop gastric reflux
c. I might develop excessive bruising
d. I should call my doctor if my ankles swell
d. Swelling of the ankles can indicate heart failure. The client should report this finding to the provider
27A nurse is assisting with the care for a client who has a prescription for digoxin 0.25mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take?
a. Give the dose as prescribed
b. Use a different route to administer the medication
c. Administer half of the prescribed dose
d. Withhold the dose
d. The nurse should withhold the digoxin dose for an apical pulse of less than 60/min and notify the provider. Digoxin slows the heart rate so administering the dose can cause harm to the client
28A nurse is assisting with the care for a client who has neutropenia. Which of the following nursing interventions should the nurse implement?
a. Offer the client fresh fruits and vegetables
b. Monitor the client's platelet count daily
c. Limit visitors to healthy adults
d. Apply firm pressure to injection sites
c. The nurse should limit visitors to healthy adults to minimize the client's risk for exposure to infection
29A nurse is assisting in the care of a client who is experiencing withdrawal from heroin. Which of the following medications should the nurse expect the provider to prescribe?
a. Disulfiram
b. Varenicline
c. Bupropion
d. Methodone
d. The nurse should expect the provider to prescribe methadone for a client who has heroin-related opioid use disorder during the process of detoxification. Methadone is a synthetic opioid that lessens the cravings for heroin
30A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first?
a. Insert the suction catheter into the tracheostomy
b. Rinse the catheter with sterile 0.9% sodium chloride
c. Ventilate the client with 100% oxygen
d. Occlude the vent on the catheter for 10 seconds
c. According to evidence-based practice, the first action the nurse should take is to ventilate the client with 100% oxygen before suctioning to prevent hypoxemia when removing air and debris from the upper airway
31A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching?
a. Apply cold packs to the inflamed joints
b. Participate in high-impact exercise
c. Carry a hand purse rather than a shoulder bag
d. Sleep on a soft foam mattress
a. The nurse should remind the client to use both warm and cold packs on inflamed joints to decrease pain
32A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions?
a. I apply rubbing alcohol to my feet every day to prevent infection
b. I will wear clean, knee-high wool socks everyday to help improve my circulation
c. I use hot water bottles to keep my feet warm at night
d. I don't cross my legs anymore
d. Clients who have peripheral vascular disease should not cross their legs because it can impede circulation
33A nurse is assisting with the care for a client who is receiving chemotherapy. The client mentions that they have a loss of appetite because of sores in their mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make?
a. Drink water before and after each bite
b. Consume foods that are served hot rather than cold
c. Rinse with a glycerin-based mouthwash before meals
d. Eat several small-portioned meals daily
d. Clients who have difficulty eating because of pain or anorexia can usually tolerate small amounts of food at one time. Eating several small meals daily can increase the client's caloric intake
34A nurse is contributing to the plan of care for a client who has Meniere's disease. Which of the following interventions should the nurse include in the plan of care?
a. Increase the client's fluid intake
b. Assist the client with changing positions often
c. Encourage the client to rest in a well-lit room
d. Administer an antiemetic to the client
d. The nurse should plan to administer an antiemetic to a client who has Meniere's disease to reduce the duration and severity of the attack
35The nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching?
a. The HbA1c test sshould be performed 2 hours after I eat a meal that is high in carbohydrates
b. The HbA1c test can help detect the presence of ketones in my body
c. I will have my HbA1c checked twice per year
d. I will plan to fast before I have my HbA1c tested
c. An HbA1c test provides the client's average glucose level for the preceding 3 months. The nurse should remind the client to have their HbA1c tested twice yearly to manage their glucose
36A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT?
a. Five-year history of menopause manifestations
b. History of treatment for blood clots
c. Topiramate use for migraine headaches
d. Increased serum cholesterol levels
b. Estrogen increases the risk for blood clots. Therefore, a female client who has a history of blood clots should not receive HRT
37A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching?
a. Weekly sputum cultures will be needed
b. Household family members should be tested for TB
c. TB is no longer contagious after 2-3 days of medication therapy
d. Family members should wear N95 masks when in contact with the client
b. The nurse should reinforce teaching with the client that family members or others who have been in close contact with the client should schedule testing for TB
38A nurse is reviewing the medical record of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery?
a. Serous drainage from the incision
b. WBC count of 15000
c. Temperature of 37.2 C (99F)
d. Urine output of 400 mL over the past 8 hours
b. The nurse should monitor laboratory findings for indications of a postoperative complication. This WBC count is above the expected reference range and indicates the presence of infection
39A nurse is providing information regarding transmission-based precautions for a client who has Clostridium difficile to an AP. Which of the following instructions should the nurse include? (SATA)
a. Provide the client with disposable utensils and dishes for meals
b. Leave blood pressure equipment in the client's room
c. Clean contaminated surfaces with a bleach solution
d. Use an alcohol-based hand sanitizer after client care
e. Wear a face mask when in the client's room
a, b, c
40A nurse is reinforcing teaching with a client prior to the removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching?
a. I will scrub the skin to remove the old skin flakes
b. I can expect my leg to be swollen after the cast is removed
c. I can go back to my usual activities as soon as the cast is off
d. I will feel vibrations on my leg from the cast cutter
d. The client will feel heat and vibrations from the cast cutter on the affected extremity. The nurse should assure the client that cast removal should not cause any pain
41A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective?
a. Adventitious lung sounds
b. Decrease in exertional dyspnea
c. Respiratory rate of 26/min while sitting in a chair
d. Elevation of the head of the bed is required to sleep
b. A decrease in exertional dyspnea indicates the antibiotics are resolving the infection and the albuterol treatments are facilitating effective ventilation. Therefore, the nurse should evaluate the therapeutic regimen as effective for the client
42A nurse in a health clinic is reinforcing teaching with a client about tuberculosis (TB). Which of the following client statements indicates an understanding of the teaching?
a. I can develop TB by breathing in the infection
b. After exposure, I could develop TB within 5 days
c. A positive reaction to a TB test means I'm currently infected
d. I need to wear a mask in my house if I become infected
a. TB is spread by airborne transmission. Therefore, the nurse should identify this statement as an understanding of the teaching
43A nurse is examining a client's IV site and notes a hardened vein above their IV site. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy?
a. Thrombophlebitis
b. Infiltration
c. Hematoma
d. Venous spasms
a. The nurse should identify pain, warmth, and a hardened vein above the IV site as indications of thrombophlebitis
44A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma?
a. Scaly patches
b. Silvery plaques
c. Irregular borders
d. Raised edges
c. The nurse should report irregular borders of a skin lesion to the provider because it can indicate malignant melanoma
45A nurse is reinforcing teaching with a client who has coronary artery disease. Which of the following instructions should the nurse include in the teaching?
a. Maintain a fat intake of 40% of your total daily calories
b. Limit consumption of whole milk products to 8 ounces three times per week
c. Exercise for 20 minutes twice per week
d. Add oily fish to your diet twice weekly
d. The nurse should reinforce teaching about dietary changes to manage coronary artery disease, such as eating fish that are rich in omega-3 fatty acids, like tuna, mackerel, or salmon, twice per week
46A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include?
a. You can take acetaminophen for pain
b. Consume a diet that is high in animal protein
c. Sleep lying flat on your back
d. Consume foods that are low in sodium
d. The nurse should remind the client to consume foods that are low in sodium to reduce the development of edema and ascites
47A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify that which of the following client statements indicates an understanding of the teaching?
a. I should perform pursed-lip breathing exercises before going to bed
b. When I'm fatigued, I should inhale slowly through pursed lips
c. Pursed-lip breathing works best for activities like walking up stairs
d. I will exhale through my nose after breathing in through pursed lips
c. The nurse should acknowledge that performing pursed-lip breathing during times of activity, such as walking up stairs, helps increase airway pressure and reduce the amount of trapped air in the lungs. This breathing technique helps eliminate excess carbon dioxide that clients who have COPD might retain
48A nurse is assisting with the care for a client who is postoperative and has a portable wound bulb suction device. Which of the following actions should the nurse take?
a. Fill the bulb reservoir with 0.9% sodium chloride
b. Prepare for the drain to be removed after 24 hours
c. Cut a slit in a gauze sponge and apply it around the tubing insertion site
d. Compress the bulb reservoir and then close the drainage valve
d. The nurse should fully compress the bulb reservoir and then replace the valve plug using aseptic technique to establish suction after emptying or activating a portable wound bulb suction device
49A nurse is assisting with the care for a client who is undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect.
a. Muscle spasticity
b. Tremors at rest
c. Ptosis
d. Ascending paralysis
a. Muscle spasticity is a manifestation of multiple sclerosis
50A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate?
a. Blurred vision
b. Insomnia
c. Bradycardia
d. Weight loss
c. The nurse should identify that bradycardia is a manifestaion of hypothyroidism that is caused by a decrease in the client's metabolic rate
51A nurse is contributing to the plan of care for a client who has COPD and is dyspneic. Which of the following interventions should the nurse include in the plan?
a. Encourage abdominal breathing
b. Direct the client to inhale with pursed lips
c. Set the oxygen therapy at 5L/min
d. Direct the client to lean back when coughing
a. The nurse should encourage abdominal breathing, which reduces the workload on the accessory muscles of respiration during dyspneic episodes
52A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking their medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis?
a. Metoprolol
b. Methimazole
c. Furosemide
d. Prednisone
d. Prednisone is administered to replace glucocorticoids, which are deficient in adrenocortical insufficiency. Abrupt withdrawal of the medication can lead to an adrenal crisis
53A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort?
a. Sleep on a firm mattress
b. Try jogging in place when joints feel stiff
c. Use a soft chair or recliner for sitting
d. Apply ice packs to painful joints
a. A firm mattress or a bed board helps the client maintain joint alignment while sleeping
54A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate?
a. Elevated serum amylase level
b. Hypertension
c. Bradycardia
d. Decreased leukocyte count
a. The nurse should anticipate an elevation in the client's serum amylase level due to injury of the pancreatic cells
55A nurse is assisting with the care for a client who has age-related macular degeneration. Which of the following findings should the nurse expect?
a. Seeing halos around artificial lights
b. Distorted central vision of the eyes
c. Colored spots before the visual fields
d. Spontaneous tearing of the eyes
b. Macular degeneration results in distortion and blurring of central vision. The client might completely lose central vision and view a dark spot in the center
56A nurse is reinforcing teaching with a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching?
a. I will eat a banana every day
b. I will walk for 20 minutes 3 days per week
c. I will limit my coffee intake
d. I will take vitamin E at bedtime
c. The nurse should encourage the client to limit their intake of caffeinated products, such as coffee and soda. Coffee can cause excretion of calcium through diuretic effects
57A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching?
a. Mohs surgery is a horizontal shaving of thin layers of the tumor
b. Mohs surgery uses liquid nitrogen to destroy the cancerous tissue
c. Mohs surgery is the preferred treatment for melanoma skin cancer
d. Mohs surgery is a palliative treatment for metastatic skin cancer
a. Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure, which involves a horizontal shaving of thin layers of a tumor, had a high success rate
58A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?
a. Place the client on a low-calorie diet to prevent weight gain
b. Remind the client to take tub baths instead of showers
c. Use small area rugs in the client's home for traction
d. Remind the client to avoid watching their feet when walking
d. The nurse should remind the client's caregivers to frequently remind the client to maintain correct posture and prevent falls by not watching their feet when walking
59A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
a. Lower the side rails of the client's bed
b. Apply wrist restraints to the client
c. Position the client in the semi-Fowler's position
d. Loosen clothing around the client's neck
d. The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration
60A nurse is assisting with the care for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following?
a. Cirrhosis of the liver
b. Hypermotility of the bowel
c. Intra-abdominal bleeding
d. Acute cholecystitis
c. Ecchymosis around the umbilicus is a sign of intra-abdominal bleeding, which is a finding consistent with pancreatitis
61A home health nurse is assisting with the care for a client who has COPD. The client reports shortness of breath while eating, despite the use of home oxygen. Which of the following recommendations should the nurse make?
a. Limit the intake of protein in your diet
b. Drink beverages throughout your meal
c. Use a bronchodilator 30 minutes before your meal
d. Lie down for 1 hour after finishing a meal
c. The client should use a bronchodilator 30 minutes before meals to prevent shortness of breath while eating
62A nurse is changing the dressing for a client who has an abdominal incision and a closed-suction drain. Which of the following actions should the nurse take?
a. Secure the drainage tube to the client's bedding
b. Wear sterile gloves to empty the drainage system
c. Cut an absorbent gauze dressing to fit around the drainage tube
d. Cleanse the drainage plug with alcohol swabs
d. The nurse should cleanse the drain opening and plug with alcohol swabs to remove excess drainage and discourage pathogens from entering the drainage system
63A nurse is assisting with the care of a client who is at risk for developing pressure injuries. Which of the following actions should the nurse take?
a. Position pillows between the bony prominences
b. Check for incontinence every 3 hours
c. Massage areas indicating potential breakdown of the skin
d. Elevate the head of the bed to 45 degrees
a. The nurse should use positioning devices to keep bony prominences from being in direct contact with each other, which will prevent skin breakdown and pressure injury development
64A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching?
a. I will perform the exam before I shower
b. I will check my testicles every 6 months
c. I understand that testicular cancer
d. I understand that pea-sized lumps are normal
c. Clients should report a lump that is not painful because testicular cancer is typically painless
65A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching?
a. You should thaw frozen meat at room temperature
b. You should use paprika as a seasoning for your food
c. You should place your toothbrush in hydrogen peroxide
d. You should use a glycerin-based soap while bathing
c. Clients who are receiving chemotherapy should clean their toothbrushes by soaking them in a hydrogen peroxide or bleach solution. The solution rids the toothbrush of bacteria and prevents infection
66A nurse is assisting with the care of a client who has restricted movement of the chest due to a burn injury. The nurse should anticipate preparing the client for which of the following procedures?
a. Fasciotomy
b. Escharotomy
c. Skin grafting
d. Hyperbaric oxygen therapy
b. The nurse should anticipate a prescription for an escharotomy to relieve constriction of the client's chest due to a burn injury. Following removal of eschar, chest wall movement will be possible, and the cient's oxygenation should improve
67A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority?
a. Encourage the client to participate in self-care
b. Assist the client with active range-of-motion exercises
c. Keep the client in a side-lying position
d. Maintain the client's body alignment
c. The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying, position to allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction equipment available in the event that any secretions are present in the oral cavity
68A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching?
a. Do not eat or drink for 6 hr prior to the test
b. Ensure that the stool specimen is obtained in the morning
c. Take ibuprofen for mild pain until the test is complete
d. Avoid eating red meat for 3 days prior to the test
d. The nurse should remind the client to avoid eating red meat for 3 days prior to the guaiac fecal occult blood test because this can lead to a false positive result
69A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include?
a. Your partner will not require treatment for this infection
b. You can resume sexual activity as soon as you begin treatment
c. You are at risk for infertility with this infection, regardless of treatment
d. You will not be at further risk for this infection following treatment
c. The nurse should reinforce teaching with the client that there is a risk for infertility as a result of this infection
70A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity?
a. Potassium chloride
b. Famotidine
c. Levothyroxine
d. Furosemide
d. The nurse should identify that loop diuretics, such as furosemide, increase the urinary excretion of potassium, which can lead to hypokalemia. Hypokalemia increases the risk for the development of digoxin toxicity
71A nurse in a telemetry unit is collecting data from a client who has a newly inserted permanent pacemaker. Which of the following findings should the nurse report to the provider?
a. The client experiences hiccups when sitting
b. The client's pulse rate is 5/min faster than present pacemaker rate
c. There is the presence of a pacing spike before the P-wave on the ECG rhythm strip
d. The dressing over the insertion site is dry and intact
a. The nurse should monitor clients who have a newly-inserted permanent pacemaker for hiccups because this finding can indicate that the pacemaker wires are displaced or that the pacemaker is not firing properly. Therefore, the nurse should report this finding to the provider
72A nurse is reinforcing discharge teaching with a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching?
a. I will notify my dentist about this procedure
b. I will take an enteric-coated aspirin daily
c. I will use a firm-bristled toothbrush
d. I will weigh myself once a week
a. The nurse should remind the client to notify their dentist about the mechanical mitral valve replacement before any procedures so antibiotic therapy can be initiated to reduce the risk for endocardial infection