MedSurg 9 2 2022

Question 1

The nurse in the cardiac unit assesses rhythm strips of clients on telemetry. Which action should the nurse take? Click the exhibit button for additional information.
a. Administer atropine 0.5 mg IV push
b. Immediately NOTIFY the health care provider
c. Prepare the client for transcutaneous pacing
d. Review the client’s previous rhythm strips and medications

Answer 1

d. Review the client’s previous rhythm strips and medications (assess)

Question 2

The clinic nurse receives a call from a client with hyperthyroidism who was prescribed propylthiouracil 4 days ago. The client states, “I think I need a higher dose of this medicine. It does not seem to work for me.” Which response by the nurse is appropriate at this time?
a. “Have you been taking your medication the way we talked about in the clinic?”
b. “Please come into the clinic tomorrow, or as soon as you can, to see the health care provider.”
c. ‘Would you like for me to ask the health care provider about changing the prescription?’
d. “You may not see or notice an improvement until 7-14 days after starting the medication.

Answer 2

d. “You may not see or notice an improvement until 7-14 days after starting the medication.

Question 3

A nurse provides a staff education conference about myasthenia gravis (MG). Which statement by a staff member indicates a need for further teaching?
a. “Corticosteroids are administered to decrease production of autoantibodies.”
b. “Drugs such as pyridostigmine can help reduce muscle weakness in MG.”
c. “Plasmapheresis can provide symptom relief during an acute exacerbation.”
d. “The client’s muscles are typically strongest later in the afternoon.”

Answer 3

d. “The client’s muscles are typically strongest later in the afternoon.”

Question 4

The home health nurse is caring for a client with type 1 diabetes mellitus who has been unable to achieve target blood glucose levels over the past month. Which of the following actions by the nurse are appropriate? Select all that apply.
a. Assess the client’s use of rotation for insulin injections
b. Inquire about the client’s eating habits and changes in diet
c. Inspect location where the client stores insulin and supplies
d. Observe the client’s procedure for drawing up and administering insulin
e. Review the clients logbook of glucose levels over the past month

Answer 4

a. Assess the client’s use of rotation for insulin injections
b. Inquire about the client’s eating habits and changes in diet
c. Inspect location where the client stores insulin and supplies
d. Observe the client’s procedure for drawing up and administering insulin
e. Review the clients logbook of glucose levels over the past month

Question 5

The registered nurse supervises a new graduate nurse caring for a client with urge incontinence. Which action by the graduate nurse requires the registered nurse to intervene?
a. Advises the client to limit fluid intake to 1500 mL or less per day
b. Ask unlicensed assistive personnel to assist the client to the toilet every 2 hours
c. Encourage the client to choose caffeine free foods and beverages from the menu
d. Instructs the client on how to perform pelvic floor muscle exercises

Answer 5

a. Advises the client to limit fluid intake to 1500 mL or less per day

Question 6

The nurse is preparing to educate a client with gastroesophageal reflux disease on factors that may increase symptoms. Which of the following client factors should the nurse plan to address? Select all that apply.
a. Client drinks 2 or 3 glasses of red wine daily
b. Client drinks peppermint tea nightly
c. Client has a BMI of 45 kg/m2
d. Client performs vigorous exercise daily
e. Client smokes a pack of cigarettes daily

Answer 6

a. Client drinks 2 or 3 glasses of red wine daily
b. Client drinks peppermint tea nightly
c. Client has a BMI of 45 kg/m2
e. Client smokes a pack of cigarettes daily

Question 7

The nurse is reinforcing education for a client with aortic stenosis who is recovering from a mechanical aortic valve replacement via sternotomy, and prescribed warfarin. Which statement by the client indicates that further education is needed?
a. “Because I have mechanical valve, I will need antibiotics prior to dental procedures”
b. “I will have to refrain from my weiantina exercises for several months.”
c. “I will need to take the prescribed warfarin until my incision and sternum heal completely.”
d. “I will need to use an electric razor and a soft bristled toothbrush.”

Answer 7

c. “I will need to take the prescribed warfarin until my incision and sternum heal completely.”

Question 8

The nurse is caring for a client with gastroesophageal varices and an esophagogastric balloon tamponade tube. Which action by the nurse is the priority?
a. Deflates device balloons per facility policy
b. Provides oral care and suctioning frequently
c. Records and monitors position of the tube
d. Repositions the client every two hours

Answer 8

c. Records and monitors position of the tube

Question 9

Exhibit: The nurse is caring for a client with hyperosmolar hyperglycemic syndrome. Which prescriptions should the nurse implement first?
a. 0.9% sodium chloride 2 L IV bolus
b. Cefepime 2 g IVPB
c. Potassium chloride 10 mEq (10 mmol) IVPB
d. Regular insulin continuous infusion

Answer 9

a. 0.9% sodium chloride 2 L IV bolus

Question 10

The nurse working at a gastroenterology clinic is reviewing several client charts. The nurse recognizes which client is at risk for gastric cancer?
a. Client who is a vegan and takes a vitamin B12 supplement
b. Client who receives iron infusions for iron deficiency anemia
c. Client whose latest colonoscopy shows areas of diverticulosis
d. Client whose stool sample is positive for Helicobacter pylori

Answer 10

d. Client whose stool sample is positive for Helicobacter pylori

Question 11

The nurse is providing first aid to a client who was stung by a bee while attending an outdoor music festival. The nurse observes that the affected site is red and swollen, and the client reports moderate itching. Which of the following actions are appropriate? Select all that apply
a. Administer an over-the-counter antihistamine
b. Assess the client for a history of allergy to bee stings
c. Monitor for development of hives and respiratory distress
d. Place a cold compress on the affected area
e. Quickly remove the stinger if present in the skin

Answer 11

a. Administer an over-the-counter antihistamine
b. Assess the client for a history of allergy to bee stings
c. Monitor for development of hives and respiratory distress
d. Place a cold compress on the affected area
e. Quickly remove the stinger if present in the skin

Question 12

The nurse is reinforcing teaching to minimize dumping syndrome with a client who recently underwent a gastrojejunostomy. Which statement by the client indicates a need for further education?
a. “I will drink chocolate milk with my breakfast.”
b. “I will eat toast with peanut butter instead of jelly.”
c. “I will lie down for at least 30 minutes after eating.”
d. “I will try to eat a small meal every few hours.”

Answer 12

a. “I will drink chocolate milk with my breakfast.”

Question 13

The nurse Is caring for a client who was brought to the clinic with slurred speech, contusion, and paresthesia. After reviewing the clinical data, which action by the nurse is appropriate? Click the exhibit button for additional information
a. Collect a detailed health history to identify any causes of the client’s symptoms
b. Immediately have the client chew two 325-mg tablets of aspirin
c. Obtain the client’s capillary blood glucose level with a point-of-care glucometer
d. Perform a urine toxicology screen to identify possible intoxicants

Answer 13

c. Obtain the client’s capillary blood glucose level with a point-of-care glucometer

Question 14

The nurse is caring for a client who has developed delirium after being admitted 4 days prior with necrotizing pancreatitis. Which of the following factors could contribute to the client’s delirium? Select all that apply.
a. Client has been awakened hourly since admission for finger-stick blood glucose checks
b. Client has consumed 10-12 beers daily for the last 2 years
c. Client is wearing prescribed hearing aids and eyeglasses
d. Client underwent open laparotomy surgery the previous day and has had uncontrolled pain
e. Client was recently diagnosed with mild Alzheimer dementia

Answer 14

a. Client has been awakened hourly since admission for finger-stick blood glucose checks
b. Client has consumed 10-12 beers daily for the last 2 years
d. Client underwent open laparotomy surgery the previous day and has had uncontrolled pain
e. Client was recently diagnosed with mild Alzheimer dementia

Question 15

The nurse is educating a client with heart failure about foods to include while on the prescribed 2-gram sodium restriction diet. Which of the following foods are appropriate to include? Select all that apply.
a. Canned broths and soups
b. Cheeses
c. Frozen vegetables
d. Packaged lunch meats
e. Prepackaged tomato juice
f. Whole grain breads

Answer 15

c. Frozen vegetables
f. Whole grain breads

Question 16

The clinic nurse is reviewing new prescriptions for a client with bacterial rhinosinusitis who has a history of asthma and Raynaud phenomenon. Which prescription should the nurse clarify with the health care provider before discharging the client?
a. Amoxicillin/clavulanate 1 tablet PO q12h for 5 days
b. Fexofenadine/pseudoephedrine 1 tablet PO daily
c. Guaifenesin 2 tablets PO q12h PRN for cough
d. Ipratropium bromide 2 sprays in each nostril 3x a day

Answer 16

b. Fexofenadine/pseudoephedrine 1 tablet PO daily

Question 17

The nurse supervises a graduate nurse who is administering and reading tuberculin skin tests at a community clinic. Which action by the graduate nurse would require intervention?
a. Administers a skin test intradermally and instructs the client to return in 48-72 hours
b. Obtains a chest x-ray prescription or a client who has previously had a positive skin test
c. Records a 6-mm area of induration as a positive result for a client with HIV
d. Requires an asymptomatic client with a 16-mm area of induration to wear a surgical mask

Answer 17

d. Requires an asymptomatic client with a 16-mm area of induration to wear a surgical mask

Question 18

The nurse is preparing discharge teaching for a client who was admitted with an ischemic foot attributed to Buerger disease. Which statement by the nurse is essential?
a. “Examine our arms and legs dailv for small cuts and scrapes. Clean any wounds with soap and water.”
b. “These intermittent pneumatic compression sleeves can be put on your calves to ease the foot pain.”
c. “Whenever possible, tr each dav to accomplish at least 30 minutes of aerobic exercise such as brisk walking
d. “You must stop using any tobacco. nicotine, and cannabis products. I will get you a smoking cessation information packet.”

Answer 18

d. “You must stop using any tobacco. nicotine, and cannabis products. I will get you a smoking cessation information packet.”

Question 19

The nurse reviews clinical data for a client diagnosed with pneumonia and exacerbation of chronic obstructive pulmonary disease. Which clinical finding is the priority to report to the health care provider?
a. Arterial pH of 7.35 → normal
b. PaCO2 of 59 mm Hg (7.85 kPa)
c. PaO2 of 50 mm Hg (6.65 kPa)
d. Respiratory rate of 27/min

Answer 19

c. PaO2 of 50 mm Hg (6.65 kPa)

Question 20

The nurse is caring for a client 1 hour after femoral cardiac catheterization. During assessment of the groin site, the nurse notes a large hematoma forming. Which action is the priority for the nurse?
a. Applying firm pressure to the femoral puncture site
b. Obtaining blood for serum coagulation studies
c. Outlining the edges of the hematoma with a marker
d. Reinforcing the dressing with foam pressure tape

Answer 20

a. Applying firm pressure to the femoral puncture site

Question 21

The nurse reviews discharge teaching with the parent of a teen diagnosed with hepatitis A virus. Which of the following instructions are appropriate for the nurse to include? Select all that apply.
a. Family members should avoid sharing the client’s silverware or drinking glasses
b. Family members should receive the hepatitis A virus vaccine
c. Family members should wash their hands after toileting and before eating
d. The client should avoid taking acetaminophen and consuming alcohol
e. The client should be isolated from other family members for 2 weeks

Answer 21

a. Family members should avoid sharing the client’s silverware or drinking glasses
b. Family members should receive the hepatitis A virus vaccine
c. Family members should wash their hands after toileting and before eating
d. The client should avoid taking acetaminophen and consuming alcohol

Question 22

Exhibit: The clinic nurse is caring for a client who reports a 3-day history of nausea, vomiting, intolerance to light, and persistent headache. The client states, “My neck feels so stiff. I just can’t turn my head.” What is the priority nursing action?
a. Administer prescribed antipyretic medication
b. Initiate prescribed antibiotic therapy
c. Place a surgical mask on the client
d. Prepare to draw blood cultures

Answer 22

c. Place a surgical mask on the client

Question 23

A client is seen in the clinic for an annual wellness check. During the examination, the nurse observes a nevus on the client’s arm. Which of the following data from the client’s history and examination raise concern for melanoma? Select all that apply.
a. Client has had the mole since birth without any changes
b. Clients mother died from skin cancer
c. Color is varied, ranging from black to a bluish hue
d. Nevus borders are jagged, irregular, and not symmetrical
e. Occupational history includes working outdoors and raising livestock

Answer 23

b. Clients mother died from skin cancer
c. Color is varied, ranging from black to a bluish hue
d. Nevus borders are jagged, irregular, and not symmetrical
e. Occupational history includes working outdoors and raising livestock

Question 24

The nurse is caring for a client after a perforated duodenal ulcer repair. The client is anxious and cool. clammy skin. Which action by the nurse is appropriate based on the client’s clinical data? Click the exhibit button for additional information.
a. Administer supplemental oxygen and obtain a set of blood cultures
b. Give prescribed IV lorazepam and reassess vital signs in 30 minutes
c. Teach the client relaxation techniques to slow the respiratory rate
d. Transport the client to radiology for STAT chest and abdominal x-rays

Answer 24

a. Administer supplemental oxygen and obtain a set of blood cultures

Question 25

A client with a genital herpes outbreak is describing self care measures to the clinic nurse. Which of the following client statements indicate a correct understanding of self care management for genital herpes? Select all that apply.
a. “I can soak in a warm bath to help soothe painful lesions if needed”
b. “I will always wear gloves when applying medication to the lesions”
c. “I will try to avoid stressful situations so that i do not trigger future outbreaks”
d. “If I take valacyclovir every day, the herpes infection will be cured within several months”
e. “Once my lesions or symptoms go away, i can have sexual intercourse without condoms”

Answer 25

a. “I can soak in a warm bath to help soothe painful lesions if needed”
b. “I will always wear gloves when applying medication to the lesions”
c. “I will try to avoid stressful situations so that i do not trigger future outbreaks”

Question 26

The nurse is caring for a client with coronary artery disease and type 2 diabetes mellitus who is awaiting a diagnostic cardiac catheterization. The client develops chest pain rated as 6 on a scale of 0-10. Which prescription should the nurse implement first? Vital signs: blood pressure 118/78, heart rate: 98/min, RR: 20/min, sPO2 94%
a. Aspirin 81 mg PO daily
b. Morphine sulfate 2 mg IV push
c. Nitroglycerin 0.4 mg sublingual
d. Oxygen 2 L per nasal cannula

Answer 26

c. Nitroglycerin 0.4 mg sublingual

Question 27

The community health nurse is providing an education program about risk factors for breast cancer. Which of the following risk factors should the nurse include? Select all that apply
a. First pregnancy at age <30
b. First degree relative with breast cancer
c. Hormone replacement therapy after menopause
d. Menarche at age <12
e. Obesity, especially after menopause

Answer 27

b. First degree relative with breast cancer
c. Hormone replacement therapy after menopause
d. Menarche at age <12
e. Obesity, especially after menopause

Question 28

The nurse is participating in a community health presentation about osteoporosis. Which of the following statements by the nurse are appropriate? Select all that apply
a. Ensure that you’re receiving adequate intake of calcium and vitamin D
b. Limit your intake of alcohol and do not smoke cigarettes
c. Regular weight bearing exercise decreases the risk for osteoporosis
d. White and an Asian people have an increased risk for osteoporosis
e. Woman have a higher risk of developing osteoporosis than men

Answer 28

a. Ensure that you’re receiving adequate intake of calcium and vitamin D
b. Limit your intake of alcohol and do not smoke cigarettes
c. Regular weight bearing exercise decreases the risk for osteoporosis
d. White and an Asian people have an increased risk for osteoporosis
e. Woman have a higher risk of developing osteoporosis than men

Question 29

The nurse assesses a client with systemic lupus erythematosus who has been taking high dose prednisone for several months. Which of the following does the nurse recognize as potential adverse effects of prednisone therapy? Select all that apply
a. Increased glycosylated hemoglobin (HbA1c) level
b. Increased muscle mass in the extremities
c. Pale, reddish purple linear marks on abdomen skin
d. Prominent fat pads over the supraventricular region
e. Significant weight gain without trying

Answer 29

a. Increased glycosylated hemoglobin (HbA1c) level
c. Pale, reddish purple linear marks on abdomen skin
d. Prominent fat pads over the supraventricular region
e. Significant weight gain without trying

Question 30

The nurse is admitting a client with a history of severe ulcerative colitis who reports having abdominal pain rate as 8 on a scale of 0-10, dizziness, a racing heart rate, and >12 stools per day at home. Which nursing action is the priority to include in the interdisciplinary plan of care?
a. Administering prescribed analgesic medications
b. Initiating strict, hourly urine output monitoring
c. Obtaining and trending hemoglobin and hematocrit levels
d. Offering a client high protein foods during meals and snacks

Answer 30

c. Obtaining and trending hemoglobin and hematocrit levels → possible hemorrhage

Question 31

The nurse assists with data collection during a urology clinic screening event. Which of the following client statements include risk factors for bladder cancer? Select all that apply.
a. I have a distant relative who was diagnosed with breast cancer last year
b. I have at least 5-6 urinary tract infections each year
c. I have smoked a pack of cigarettes each day for 8 years
d. I received radiation treatment for cervical cancer 2 years ago
e. I worked in an industrial chemical factory for 15 years

Answer 31

b. I have at least 5-6 urinary tract infections each year
c. I have smoked a pack of cigarettes each day for 8 years
d. I received radiation treatment for cervical cancer 2 years ago
e. I worked in an industrial chemical factory for 15 years

Question 32

The nurse is caring for a client with coronary artery disease who reported new chest pain. One dose of nitroglycerin 0.4 mg sublingual was given at 0800, and the client was reassessed at 0805. Which action by the nurse is best? Click the exhibit
a. Administer a second dose of nitroglycerin 0.4 mg sublingual
b. Administer morphine sulfate 2 mg IV push once
c. Initiate supplemental oxygen at 2 L/min via nasal cannula
d. Obtain blood samples for cardiac measurement

Answer 32

a. Administer a second dose of nitroglycerin 0.4 mg sublingual

Question 33

The women’s health nurse is caring for multiple clients. Which client does the nurse recognize as having risk factors for endometrial cancer?
a. 29-year-old client who has a history of recurrent gonorrhea and takes an oral contraceptive
b. 32-year-old client who has a levonorgestrel intrauterine device and a history of two elective abortions
c. 43-year-old client who is obese and has menstrual cycles every 2-4 months
d. 4-vear-old client who had two full-term preanancies and has menopausal smotoms

Answer 33

c. 43-year-old client who is obese and has menstrual cycles every 2-4 months

Question 34

The nurse evaluates a client’s understanding of appropriate oral hygiene practices for mucositis resulting from external radiation treatments following laryngeal cancer. Which of the following client statements indicate a correct understanding? Select all that apply.
a. “I quit brushing my teeth and use only mouth rinses to avoid damaging my gums.”
b. “I read the mouthwash labels and buy only those that do not contain alcohol.”
c. “I remove my dentures after I eat and soak them in an antimicrobial solution
d. “I rinse my mouth using a saline and baking soda solution several times a day.
e. “I use artificial saliva when my mouth becomes verb dry between meals

Answer 34

b. “I read the mouthwash labels and buy only those that do not contain alcohol.”
c. “I remove my dentures after I eat and soak them in an antimicrobial solution
d. “I rinse my mouth using a saline and baking soda solution several times a day.
e. “I use artificial saliva when my mouth becomes verb dry between meals

Question 35

The nurse in a women’s health clinic is caring for several clients during well-woman visits. The nurse recognizes that which of the following clients has a risk factor for cervical cancer? Select all that apply.
a. Client who has a human papillomavirus infection but a normal Pap test
b. Client who has multiple sexual partners
c. Client who has never been pregnant
d. Client who has smoked a pack of cigarettes daily for many years
e. Client with systemic lupus who takes dailv immunosuppressants

Answer 35

a. Client who has a human papillomavirus infection but a normal Pap test
b. Client who has multiple sexual partners
d. Client who has smoked a pack of cigarettes daily for many years
e. Client with systemic lupus who takes dailv immunosuppressants

Question 36

The nurse assesses a client for development of peritonitis following a perforated gastric ulcer. Which of the following assessments support development of this complication? Select all that apply.
a. Apical pulse of 138/min
b. Rebound tenderness with guarding
c. Rigid abdomen on palpation
d. SpO2 of 95% on room air
e. Worsening diffuse abdominal pain

Answer 36

a. Apical pulse of 138/min (normal apical pulse 60-100)
b. Rebound tenderness with guarding
c. Rigid abdomen on palpation
e. Worsening diffuse abdominal pain

Question 37

The clinic nurse Is assessing a 55-year-old client who reports persistent fatigue and lethargy. After previous laboratory results are reviewed, which question is most important for the nurse to ask the client? Click the exhibit button for additional information.
a. “Do you frequently feel like you are cold when others are not?”
b. ‘Do you have a shortness of breath with physical activity?’
c. “Have you noticed changes in bowel movement texture or color?”
d. “Have you noticed your heart beating too fast or skipping beats?”

Answer 37

c. “Have you noticed changes in bowel movement texture or color?” → possible bleeding

Question 38

The clinic nurse provides care to multiple clients. Which of the following client statements does the nurse recognize as being a warning sign for cancer? Select all that apply.
a. “Eating isn’t enjoyable. After I swallow, it feels like there’s food stuck in my throat.”
b. “I have a firm lump in my underarm, but it doesn’t hurt or bother me in any way.”
c. “I used to have constipation, but I recently started having diarrhea a few times each day.”
d. “I’ve noticed that by midatternoon each day my right ankle and foot are swollen.
e. “This sore on my face has been there for 2 months. I hope it heals before my wedding.’

Answer 38

a. “Eating isn’t enjoyable. After I swallow, it feels like there’s food stuck in my throat.”
b. “I have a firm lump in my underarm, but it doesn’t hurt or bother me in any way.”
c. “I used to have constipation, but I recently started having diarrhea a few times each day.”
e. “This sore on my face has been there for 2 months. I hope it heals before my wedding.’

Question 39

The nurse is presenting at a community center seminar about colorectal cancer. Which of the following information should the nurse include in the presentation? Select all that apply.
a. Clients age >30 are at the highest risk for colorectal cancer, regardless of health status
b. Clients of a healthy weight who eat plenty of fruits and vegetables may reduce the colorectal cancer risk
c. Clients who consume low amounts of red meat may reduce the risk for colorectal cancer
d. Clients with a parent or sibling with colorectal cancer should have screenings earlier and more often than low-risk clients
e. Clients with inflammatory bowel disease have a greater chance for developing colorectal cancer

Answer 39

b. Clients of a healthy weight who eat plenty of fruits and vegetables may reduce the colorectal cancer risk
c. Clients who consume low amounts of red meat may reduce the risk for colorectal cancer
d. Clients with a parent or sibling with colorectal cancer should have screenings earlier and more often than low-risk clients
e. Clients with inflammatory bowel disease have a greater chance for developing colorectal cancer

Question 40

The nurse admits a client diagnosed with acute diverticulitis who has fever, left lower quadrant
pain, abdominal distension, and vomiting. Which new prescription from the health care provider should the nurse clarify?
a. Administer 2g cefepime IV q12h
b. Give soap suds enema once, now
c. Initiate striet NO status
d. Place the nasogastric tube to low; Intermittent suction

Answer 40

b. Give soap suds enema once, now

Question 41

The clinic nurse evaluates the plan of care for a client with hypothyroidism. Which of the following client statements indicate that treatment has been effective? Select all that apply
a. “I do not need to wear a jacket all the time anymore.”
b. “I have lost some weight and my clothes are not as tight now.”
c. “I have to take psyllium powder to have a bowel movement every 4 days.”
d. “I sleep 6-8 hours each night and no longer need daily naps”
e. “I started taking my dog out for a run every day after work.

Answer 41

a. “I do not need to wear a jacket all the time anymore.”
b. “I have lost some weight and my clothes are not as tight now.”
d. “I sleep 6-8 hours each night and no longer need daily naps”
e. “I started taking my dog out for a run every day after work.

Question 42

Exhibit: A nurse Is caring for a client who has a urinary tract infection with flank pain, chills, and decreased level of consciousness. The health care provider diagnosed septic shock. Which prescribed intervention should the nurse perform first?
a. Administer supplemental oxygen with a nonrebreather mask
b. Establish IV access and infuse 1L 0.9% sodium chloride IV bolus
c. Initiate antibiotics after obtaining blood cultures from 2 sites
d. Start continuous IV insulin to maintain serum glucose ≤180 mg/dL (≤10 mmol/L)

Answer 42

a. Administer supplemental oxygen with a nonrebreather mask

Question 43

The nurse is supervising a graduate nurse who is planning care for a client who underwent a hemorrhoidectomy yesterday. Which intervention in the care plan indicates a need for additional instruction?
a. Assist the client with a warm sitz bath 3 times daily
b. Ensure that the client is out of bed and using the bedside chair during the day
c. Provide the client with moist cleansing wipes to use instead of toilet paper
d. Teach the client how to identify high fiber foods on the menu

Answer 43

c. Provide the client with moist cleansing wipes to use instead of toilet paper

Question 44

The nurse is supervising care for a client who is receiving chemotherapy and has developed severe stomatitis (ie, mucositis in the oral cavity). Which of the following instructions can the nurse provide to the unlicensed assistive personnel? Select all that apply.
a. “Help the client apply water-based lubricant to dry lips.”
b. “Help the client rinse the mouth with a baking soda-saline solution every 2 hours.
c. “Instruct the client to swish and swallow the prescribed antifungal suspension.”
d. “Record the client’s 24-hour fluid and food intake, including meals and snacks
e. “Use sponge swabs to assist the client with oral care after meals.”

Answer 44

a. “Help the client apply water-based lubricant to dry lips.”
b. “Help the client rinse the mouth with a baking soda-saline solution every 2 hours.
d. “Record the client’s 24-hour fluid and food intake, including meals and snacks
e. “Use sponge swabs to assist the client with oral care after meals.”

Question 45

A client with chronic hypertension, who is currently prescribed amlodipine and hydrochlorothiazide, is being seen for an annual health checkup. The client’s blood pressure is 188/96 mm Hg. Which question should the nurse ask first?
a. “Are you currently taking any over-the-counter medications?”
b. “Can you describe your typical diet and salt intake?”
c. “Have you been using any cigarettes or tobacco products?”
d. “How often are you taking your prescribed medications?”

Answer 45

d. “How often are you taking your prescribed medications?”

Question 46

Exhibit: The nurse reviews several prescriptions for a client with ulcerative colitis who had an ileostomy created 3 days ago. Which prescription should the nurse clarify with the health care provider?
a. Acetaminophen 500 mg/15 mL PO a6h PRN for fever
b. Enoxaparin 40 mg/0.4 mL subcutaneous once daily
c. Metformin extended-release 500 mg PO once daily
d. Potassium 10 mE PO once daily

Answer 46

c. Metformin extended-release 500 mg PO once daily

Question 47

The nurse is administering a unit of pooled platelets to a client. Shortly after the transfusion begins, the client develops itching, flushing, and shortness of breath. Which of the following actions by the nurse are appropriate? Select all that apply.
a. Administers prescribed PRN diphenhydramine IV push
b. Connects new tubing and maintains IV access with normal saline
c. Documents the transfusion reaction in the electronic health record
d. Remains with the client and frequent assesses vital signs
e. Stops the transfusion and disconnects tubing at the IV catheter hub

Answer 47

a. Administers prescribed PRN diphenhydramine IV push
b. Connects new tubing and maintains IV access with normal saline
c. Documents the transfusion reaction in the electronic health record
d. Remains with the client and frequent assesses vital signs
e. Stops the transfusion and disconnects tubing at the IV catheter hub

Question 48

The emergency department nurse is caring for a client with severe altered mental status and a history of type 1 diabetes mellitus. After the client’s clinical data are reviewed, which of the following actions by the nurse are appropriate? Select all that apply.
Click the exhibit button for additional information.
a. Administer regular insulin continuous IV infusion
b. Help the client rebreathe air using a paper bag
c. Initiate prescribed 2 L normal saline IV bolus
d. Monitor blood glucose hourly with bedside glucometer
e. Place the client on continuous cardiac monitoring

Answer 48

a. Administer regular insulin continuous IV infusion
c. Initiate prescribed 2 L normal saline IV bolus
d. Monitor blood glucose hourly with bedside glucometer
e. Place the client on continuous cardiac monitoring

Question 49

The nurse provides self-care management teaching for a client with systemic lupus erythematosus. Which of the following client statements indicate that teaching has been effective? Select all that apply
a. “I have an antibacterial cleanser for the rash en my face”
b. “I need to rest between activities to avoid feeling fatigued.”
c. “I plan to enroll in a yoga class to help manage my stress.
d. “I should avoid people who are sick with a cold or the flu.
e. “I will wear a wide-brimmed hat and long sleeves when I am in the sun.

Answer 49

b. “I need to rest between activities to avoid feeling fatigued.”
c. “I plan to enroll in a yoga class to help manage my stress.
d. “I should avoid people who are sick with a cold or the flu.
e. “I will wear a wide-brimmed hat and long sleeves when I am in the sun.