Exam 3 Medsurge Updated

A nurse is caring for a client who has heart failure (HF). Which of the following should the nurse identify as a cause for the client's decreased serum osmolality?

A. A decrease in intracellular fluid volume

B. An increase in hydrostatic pressure

C. An increase in serum sodium

D. An increase in vascular fluid volume

D. An increase in vascular fluid volume

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority?

A. Skin turgor

B. Mental Status

C. Weight

D. Urine Output

B. Mental Status

Hypermagnesemia

- cause: increased intake with decreased renal function

- Patient will be: lethargic, drowsy

- Nurse will: prevention!!, provide calcium chloride

A nurse is preparing to administer heparin subcutaneously to a client who has a deep vein thrombosis. Which of the following techniques should the nurse use?

A. Cleanse the skin with an alcohol swab, insert the needle, aspirate, and inject the heparin

B. Cleanse the skin with an alcohol swab, insert the needle, aspirate, inject the heparin, and massage the site

C. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding

D. Cleanse the skin with an alcohol swab, inject the heparin, aspirate, and observe for bleeding

C. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding

- Provides more water than electrolytes

- Monitor for mental status changes

Hypotonic Solutions

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect?

A. Drowsiness

B. Decreased BP

C. Hyperactive deep-tendon reflexes

d. Increased bowel sounds

C. Hyperactive deep-tendon reflexes

Which vitamin deficiency is commonly associated with anemia?

a. Vitamin A

b. Vitamin B12

c. Vitamin C

d. Vitamin D

B. Vitamin B12

A nurse is providing care to a client who has hypovolemic shock due to blood loss. The client has manifestations of tachycardia, tachypnea, oliguria, and orthostatic hypotension. Which of the following levels of blood loss do these manifestations indicate?

A. 18%

B. 6%

C. 24%

D. 12%

C. 24%

A nurse is caring for an antepartum client who has iron-deficiency anemia. when teaching the client about nutrition, the nurse should emphasize the need for an increased intake of high of the following foods?

A. milk and cheese

B. red meats and organ meats

C. fresh fruits

D. whole grain breads

B. Red meats and organ meats

Monitor the client for which of the following clinical manifestations for a client who is experiencing nausea and vomiting after chemotherapy?

A. Metabolic acidosis

B. Metabolic alkalosis

C. Respiratory acidosis

D. Respiratory alkalosis

B. Metabolic alkalosis

Day 1:

71-year-old admitted to the ED with reports of shortness of breath, fatigue, and weight loss. Will transfer to oncology unit for further evaluation. History of lung cancer and hypertension.

Day 2:

Client reports feeling short of breath and right shoulder pain. Rates pain as 8 on a scale of 0 to 10. Appears restless and is alert and oriented. Hoarse voice and coughing noted with talking. Edema noted to face, arms, and chest.

Blood pressure 130/88 mm Hg

Heart rate 94/min

Respiratory rate 32/min

Oxygen saturation 95% on 3 L of oxygen

Temperature 37.2° C (99.0° F)

BUN 22 mg/dL (10 to 20 mg/dL)

Which of the following findings should the nurse report to the health care provider?

- Cough

- Edema

- Absolute neutrophil count

- Temperature

- Pain

- Platelet count

- Hoarse voice

Cough, Edema, Pain, Hoarse Voice

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

A. Complete a vascular assessment.

B. Administer an antipyretic

C. Decrease environmental stimuli.

D. Assess the cranial nerves.

D. Assess the cranial nerves

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?

A. Dehydration

B. Seizures

C. Burns

D. Shivering

D. Shivering

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

a. Give morphine IV

b. Administer oxygen therapy

c. Start an IV infusion of lactated Ringer's

d. Initiate cardiac monitoring

B. Administer oxygen therapy

A nurse is contributing to the plan of care for a client following a lumbar puncture. Which of the following interventions should the nurse include?

a. Provide the client a low-sodium diet.

b. Change the client's dressing every 12 hr.

c. Place the client in high-Fowler's position.

d. Encourage oral fluids.

D. Encourage Oral Fluids

A nurse is caring for a client who has brain cancer and his undergoing radiation therapy which of the following manifestations to the nurse report immediately?

A. Chest pain and dyspnea

B. Seizures

C. Hematuria

D. Swelling of the extremities

- B. Seizures (multiple choice)

- A and B (Select all)

A nurse is caring for a client who has prostate cancer which of the following manifestations does the nurse attribute to advancing disease process?

A. Anemia due to long-term bleeding

B. A dark colored or elevated lesion

C. Blood in the urine or semen

D. An enlarged liver or gallbladder

C. Blood in the urine or semen

A nurse is caring for a client who reports pain in their lower extremities following surgery. Which of the following should the nurse address first?

A. Last bowel movement 2 days ago

B. Reports pain as a 5 on a scale of 0 to 10

C. Been on bedrest for 3 days

D. Consumed 35% of meals for 12 hours

C. Been on bedrest for 3 days

A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)

a. Elevate the client's head of bed.

b. Insert a urinary catheter.

c. Encourage fluid intake.

d. Monitor the puncture site for hematoma.

e. Apply a cervical collar to the client.

C. Encourage fluid intake

D. Monitor the puncture site for hematoma

A nurse is providing teaching about iron deficiency anemia to the parents of a toddler. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?

A. Limit intake of high-protein foods

B. Include fluoridated water in the toddler's diet

C. Administer fat-soluble vitamins daily

D. Avoid a diet that consists primarily of milk

D. Avoid a diet that consists primarily of milk

A nurse's reinforcing education to a client who has a central nervous system tumor. Which of the following information should the nurse include in the teaching?

A. Malignant brain tumors often originate from another part of the body

B. Primary CNS tumors commonly spread to other parts of the body

C. Most CNS tumors are spinal tumors

D. Ependymomas are primarily brain tumors

A. Malignant brain tumors often originate from another part of the body

A nurse is reinforcing teaching with a class about preventing deep-vein thrombosis. The nurse should include in the teaching that which of the following is a risk factor for this disorder? (Select all that apply.)

Dehydration, Oral Contraceptives, and Immobility

A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe?

0.45% sodium chloride.( Indication of hypernatremia. Hypotonic solution)

A nurse is caring for a client following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)

a. Maintain fetal position

b. Provide oral fluids

c. Monitor for nausea

d. Check sensation in the toes

e. Check level of consciousness

B, C, D, E

A nurse is obtaining a health history from a client who has cancer of the cervix. Which of the following manifestations should the nurse expect?

A. Weight gain

B. Oliguria

C. Vaginal bleeding

D. Back pain

C. Vaginal Bleeding

A nurse is caring for a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?

A. Hypokalemia

B. Hypercalcemia

C. Hypovolemia

D. Hyperglycemia

D. Hyperglycemia

A client has a history of osteoarthritis. Which signs and symptoms should the nurse expect to find on physical assessment?

- Joint pain

- Crepitus

-Heberden's nodes

A nurse is planning care for a client who experienced an anaphylactic reaction. Which of the following findings should the nurse identify as the most important indication for a referral to an allergy specialist?

A. The client was administered epinephrine

B. The client experienced a biphasic reaction

C. The client required the administration of glucagon in addition to epinephrine

D. The client does not know what triggered the reaction

D. The client does not know what triggered the reaction

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

A. Furosemide

B. Dexamethasone

C. Heparin

D. Atropine

C. Heparin

A charge nurse is providing an in-service to a group of nurses about hypomagnesemia. Which of the following should the charge nurse include as risk factors for this condition? (Select all that apply.)

A. Clients who have had gastric bypass surgery

B. Clients who have renal failure

C. Clients receiving opioid pain medications

D. Clients who are in the intensive care unit

E. Clients undergoing hemodialysis

A,D

A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging?

A. Decrease in systolic blood pressure

B. Increase in saliva production

C. Increase in percentage of body water

D. Decrease in kidney function

D. Decrease in kidney function

What is a common manifestation of iron deficiency anemia?

A. Pain

B. Slurred Speech

C. Fatigue

D. Confusion

C. Fatigue

A nurse is providing discharge teaching to a client who has hyperkalemia. Which of the following foods should the nurse teach the client to avoid? (Select all that apply.)

Spinach, Carrots, Tomatoes, and Bananas

Which nursing action is most effective in reducing the potential for sepsis while caring for a client who has sickle cell disease (SCD)?

A. Monitoring for abnormal laboratory values

B. Checking vital signs every 4 hours

C. Performing frequent and thorough handwashing

D. Administering prophylactic drug therapy

C. Performing frequent and thorough handwashing

Which action will the nurse to perform first when caring for a female client who is in sickle cell crisis?

A. Asking the client about possible triggers

B. Teaching the client about barrier forms of contraception

C. Ensuring adequate oral and IV fluid intake

D. Providing pain medication

D. Providing pain medication

Does sickle cell anemia cause tiredness and fatigue?

True

Which new-onset symptom in a client with sickle cell disease (SCD) will the nurse report immediately to the health care provider to prevent harm?

A. Distention of neck veins in the sitting position

B. Itching of the extremities

C. Priapism lasting 30 minutes

D. Increased urinary output

A. Distention of neck veins in the sitting position

Which assessment finding will the nurse associate as a complication of a client having three episodes of sickle cell crisis in the past 3 months?

A. Deeply yellowed sclera

B. Worsening hypertension

C. Several episodes of priapism

D. Increased deep tendon reflexes

A. Deeply yellowed sclera

Which condition or event within the past 24 hours will the nurse identify as a possible cause of the current crisis episode in a client with sickle cell disease (SCD)?

A. Participating in an archery tournament

B. Spraining a wrist while stopping a fall

C. Binge-drinking wine at a party

D. Engaging in sexual intercourse

C. Binge-drinking wine at a party

Which medication will the nurse prepare to administer to a client who is in sickle cell crisis and requests "something for pain"?

A. Intramuscular (IM) meperidine

B. Intravenous (IV) hydromorphone

C. Oral ibuprofen

D. Oral morphine sulfate

B. Intravenous (IV) Hydromorphone

Which laboratory trend indicates to the nurse that drug therapy with hydroxyurea is effective in the client who has sickle cell (SCD)?

A. Increasing hemoglobin-F levels

B. Decreasing blood osmolarity

C. Increasing platelet levels

D. Increasing blood iron levels

A. Increasing hemoglobin F-levels

Which lab values would the nurse expect to see for a client with sickle cell disease? (Select all that apply.)

A. Decreased total bilirubin

B. Increased hematocrit

C. Decreased iron levels

D. Increased reticulocyte count

E. Elevated total white blood cell count

F. 80% hemoglobin

D, E, F

With which member of the interprofessional team will the nurse collaborate when providing instructions for a client who has anemia cause by vitamin B12 acid deficiency?

A. Registered dietitian nutritionist

B. Mental health professional

C. Physical therapist

D. Wound care specialty nurse

A. Registered dietitian nutritionist

Which foods will the nurse help the client with vitamin B12 deficiency to increase in the diet?

A. Grains

B. Unsaturated fats

C. Red meat

D. Starchy vegetables

C. Red Meat

Which electrolyte imbalance will the nurse expect to find in a client with polycythemia vera (PV)?

A. Hyperkalemia

B. Hypokalemia

C. Hyponatremia

D. Hypernatremia

A. Hyperkalemia

Which client will the nurse monitor most closely for development of a febrile transfusion reaction?

A. A 50 year old receiving multiple transfusions for severe hemorrhage

B. A 60 year old receiving an intraoperative autologous transfusion

C. A 40 year old receiving two units of fresh-frozen plasma

D. A 70 year old receiving a rapid transfusion

A. A 50 year old receiving multiple transfusions for sever hemorrhage

Which serum electrolyte will the nurse monitor most closely in a client who receiving four units of packed red blood cells (PRBCs) over the next 12 hours?

A. Chloride

B. Sodium

C. Calcium

D. Potassium

D. Potassium

Which changes in ADLS are most appropriate for the nurse to suggest to a client newly diagnosed anemia about conserving energy? Which instructions would the nurse give to the client? (Select all that apply.)

A. "Cluster your care together to get through them more quickly."

B. "Accept help from others when you feel especially tired."

C. "Take a complete bath or shower daily to promote relaxation."

D. "Stop activity when you feel short of breath or palpitations are present."

E. "Try eating four to six small, easy-to-eat meals daily instead of three larger ones."

F. "Sit instead of standing for some tasks such as cutting vegetables."

B, D, E, F

Which findings should a nurse include when teaching a client pulmonary embolism (PE) manifestations?

A. Chest pain that worsens with deep breathing

B. Shortness of breath

C. Bloody sputum

D. Difficulty speaking

E. Facial weakness that worsens at night

A, B, C

A client who has sickle cell anemia. Which of the following manifestations should the nurse expect with this condition?

A. Sleeplessness

B. Pain

C. Depression

D. Anxiety

E. Difficulty Speaking

A, B, C, D

Which manifestation should a nurse include when teaching a client about untreated vitamin B12 deficiency?

A. Mood changes

B. Mobility challenges

C. Visual deficits

D. Shortness of breath

E. Sleep disturbance

A, B, C

A 35-year-old female patient presents to the clinic with complaints of fatigue, dizziness, and pallor. Her laboratory results indicate a hemoglobin level of 9 g/dL. Which of the following management strategies is most appropriate for this patient?

A. Advise the patient to increase physical activity to boost energy levels.

B. Prescribe a blood transfusion immediately to increase hemoglobin levels.

C. Increase dietary intake of iron-rich foods and prescribe oral iron supplements.

D. . Recommend vitamin B12 injections to correct the anemia.

C. Increase dietary intake of iron-rich foods and prescribe oral iron supplements

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as possible risk factors for iron deficiency anemia?

(Select All that Apply.)

A. The client eats red meat daily.

B. The client has had gastric bypass surgery.

C. The client has had treatment for gastrointestinal cancer.

D. The client eats mostly prepackaged, processed foods.

E. The client has ulcerative colitis.

B,C,D,E

A nurse is admitting a client who has sickle cell anemia. Which of the following manifestations should the nurse expect with this condition?

(Select All that Apply.)

A. Pain

B. Anxiety

C. Sleeplessness

D. Difficulty speaking

E. Depression

A, B, C, E

Which of the following are signs and symptoms commonly associated with sickle cell disease?

(Select All that Apply.)

A. Fatigue

B. Hypertension

C. Pain episodes (vaso-occlusive crises)

D. Frequent infections

E. Jaundice

F. Hyperglycemia

A, C, D, E

A charge nurse is providing an in-service to a group of nurses about chronic myelogenous leukemia (CML). Which of the following should the nurse include in the teaching as risk factors for this condition?

(Select All that Apply.)

A. Being a white male

B. Hormone therapy

C. Chemotherapy

D. Under the age of 50 years old

E. Radiation exposure

A, C, E

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following health promotion strategies should the nurse include in the teaching?

(Select All that Apply.)

A. Frequent handwashing

B. Avoiding the annual flu vaccine

C. Taking an iron supplement daily

D. Visiting the eye doctor annually

E. Joining a support group

A, D, E

A charge nurse is teaching a newly licensed nurse about risk factors for chronic myelogenous leukemia (CML). Which of the following information should the nurse include?

A. Exposure to radiation

B. Family history

C. Another type of cancer

D. Genetic mutation

A. Exposure to radiation

Which findings should a nurse recognize as indicative of pulmonary edema when assessing a client with the condition?

A. Jugular vein distention

B. Tachypnea

C. Pink Frothy Sputum

D. Atelectasis

E. Ascites

F. Edema of the extremities

A, B, C

Which of the following information should the nurse include when educating a client who has pulmonary edema as a result of a pre-existing cardiac condition?

A. Weight control if the client's BMI is greater than 35

B. Healthy lifestyle

C. Smoking cessation

D. Heart disease prevention

E. Glycemic control if the client is diabetic

A, B, C, D, E

Community health nurse is assessing a client who reports numbness of the hands and feet for the past two weeks. This finding is associated with which of the following nutritional deficiencies?

A. Folic acid

B. Potassium

C. Vitamin B 12

D. Iron

C. Vitamin B12

A nurse is providing teaching to a client who has vitamin B 12 deficiency. Which of the following foods should the nurse instructed the client to consume? (Select all that apply.)

A. Meat

B. Flaxseed

C. Beans

D. Eggs

E. Milk

A, D, E

What is a contributor to hydrostatic pressure?

A. Osmotic pressure

B. Pressure exerted by contraction of the heart

C. Pressure applied by plasma proteins

D. Excretion of calcium by the kidneys

B. Pressure exerted by contraction of the heart

What is the nurse's priority when viewing lab values for a patient with sickle cell anemia?

A. Monitor hemoglobin level

B. Monitor white blood cell count

C. Evaluate white blood cell count

D. Assess liver function tests

A. Monitor hemoglobin level

Which findings should a nurse monitor in a postoperative client with intermittent gastric suction?

A. Metabolic Alkalosis

B. Respiratory Acidosis

C. Metabolic Acidosis

D. Respiratory Alkalosis

A. Metabolic Alkalosis

Which clinical finding is indicative of deep vein thrombosis (DVT)?

A. Swelling of affected limb

B. High fever and chills

C. Chest pain and difficulty breathing

D. Nausea and vomiting

A. Swelling of affected limb

What is a cause for the client's decreased serum osmolality in heart failure (HF)?

A. Increase in vascular fluid volume

B. Decrease in intracellular fluid volume

C. Increase in hydrostatic pressure

D. Increase in serum sodium

A. Increase in vascular fluid volume

What finding should the nurse anticipate with a client who has serum brain natriuretic peptide (BNP) of 1200 pg/mL? (Select all that apply)

A. Dyspnea

B. Rales in the lungs

C. Dry mucous membranes

D. Weight loss

A and B

What suggestion should be included in the discharge education for a client with hypokalemia?

A. Report new onset muscle weakness

B. Increased consumption of apples and broccoli

C. Avoid salt substitutes

D. Report fall, due to high risk of osteoporosis

A. Report new onset muscle weakness

What manifestation is an indication of effective treatment for a dehydrated client?

A. Lightheadedness

B. Decreased pulse pressure

C. Urine output 75 mL in 1 hour

D. Urine specific gravity 1.038

C. Urine output 75 mL in 1 hour

What should the nurse assess regularly for a client with a pulmonary embolism?

A. Emotional support

B. Respiratory status

C. Deep vein thrombosis

D. Oxygen saturation

B and D

Which life-threatening conditions should a nurse manager include in an in service on thromboembolism for nurses?

A. Deep Vein Thrombosis

B. Ischemic Stroke

C. Pulmonary Embolism

D. Myocardial Infarction

E. Hematoma

A, B, C, D

A nurse is reinforcing teaching with a newly licensed nurse about causative risk factors for deep vein thrombosis (DVT). Which of the following should be included in the teaching? (Select all that apply.)

a. Immobility

b. Fracture

c. Atrial fibrillation

d. Anticoagulant therapy

e. Estrogen therapy

A, B, C, E

A nurse is caring for a client who has deep vein thrombosis (DVT) of their right lower leg. Which of the following manifestations should the nurse expect? (Select all that apply.)

a. Warmth

b. Erythema

c. Swelling

d. Numbness

e. Bleeding

A, B, C

A nurse is caring for a client who is receiving warfarin therapy to prevent a deep vein thrombosis. Which of the following medications should the nurse have available in the event of an overdose?

a. Epinephrine​

b. Atropine​

c. Protamine​

d. Vitamin K

D. Vitamin K

A charge nurse is providing an in-service for a group of staff nurses about deep vein thrombosis (DVT). Which of the following information should the nurse include about this condition?

a. DVTs cannot be prevented.

b. Clients only develop DVTs if they have clotting disorders.

c. Approximately half of DVTs occur during a hospitalization.

d. There are always warning signs of a DVT.

C. Approximately half of DVTs occur during a hospitalization

A nurse is reinforcing teaching about the prevention of deep vein thrombosis (DVT) with a group of newly licensed nurses. Which of the following interventions should the nurse include in the teaching?

a. Massage lower extremities daily.

b. Check for positive Homans' sign.

c. Limit movement of the lower extremities.

d. Place sequential compression devices bilaterally

D. Place sequential compression devices bilaterally

A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?

a. Apply ice to the extremity

b. Monitor platelet levels

c. Restrict oral fluids

d. Administer vasodilating medications

B. Monitor platelet levels

A nurse is caring for a client who has a deep vein thrombosis, who received IV heparin for the past 5 days, and now has a new prescription for oral warfarin in addition to the heparin. The client asks the nurse if both medications are necessary. Which of the following is an appropriate response by the nurse?

a. "Heparin enhances the effects of the warfarin."

b. "I will ask the charge nurse to call your provider and get an explanation."

c. "Both heparin and warfarin work together to dissolve the clots."

d. "Heparin will be continued until the warfarin reaches a therapeutic level."

d. "Heparin will be continued until the warfarin reaches a therapeutic level."

A nurse is assisting with the care of a postoperative client following a total knee replacement. Which of the following medications should the nurse anticipate the provider to prescribe to prevent the formulation of a deep vein thrombosis (DVT)?

a. Clopidogrel

b. Alteplase (tPA)

c. Warfarin

d. Enoxaparin

D. Enoxaparin

A nurse is obtaining a health history from a client who reports right calf pain. Which of the following findings place the client at risk for deep vein thrombosis (DVT)? (Select all that apply.)

a. Age 50 years old

b. Consumes a 2-gram sodium diet

c. Knee surgery 1 week ago

d. Works at an office desk 8 hr a day

e. Commutes 1 hr to work

A, C, D, E

A nurse is reinforcing teaching with a client about the prevention of deep vein thrombosis (DVT). Which of the following recommendations should the nurse include in the teaching? (Select all that apply.)

a. Avoid crossing your legs when sitting.

b. Reduce ambulation after a surgery.

c. Move frequently while on an airplane.

d. Discontinue estrogen therapy if your medical provider recommends.

e. Stop smoking and avoid secondhand smoke.

A, C, D, E

A nurse is reinforcing teaching for a client who has a new prescription for warfarin. Which of the following information should the nurse include?

a. Mild nosebleeds are common during initial treatment.

b. The client should use an electric razor while on this medication.

c. If he misses a dose, he should double the dose at the next scheduled time.

d. Warfarin increases the risk for deep vein thrombosis

B. The client should use an electric razor while on this medication

A nurse is caring for a client who has deep vein thrombosis (DVT). Which of the following findings should cause the nurse to suspect the client has a pulmonary embolism? (Select all that apply.)

a. Hemoptysis

b. Visual deficit

c. Shortness of breath

d. Lightheadedness

e. Tachycardia

A, C, D, E

A nurse is collecting data from a client who is postoperative following abdominal surgery. Which of the following findings should cause the nurse to suspect deep-vein thrombosis (DVT)?

a. Coolness of the leg

b. Decreased pedal pulses

c. Petechiae on the foot and ankle

d. Unilateral leg edema

D. Unilateral leg edema

A nurse is assisting with the plan of care for a client who has a new deep-vein thrombosis (DVT) in his leg. Which of the following interventions should the nurse include in the plan?

a. Apply cool compresses to the client's affected leg.

b. Rub the client's affected leg every 4 hr.

c. Keep the client's affected leg elevated.

d. Ambulate the client every shift.

C. Keep the client's affected leg elevated

A nurse is planning care for a client who has a deep-vein thrombosis (DVT) in the right leg. Which of the following interventions should be included in the plan of care?

a. Dorsiflex the feet.

b. Apply compression stockings.

c. Immobilize both legs.

d. Position the legs dependently.

B. Apply compression stockings

A nurse is caring for a client who has a pulmonary embolism. The nurse should identify that the release of inflammatory mediators leads to which of the following pathologic findings?

a. Respiratory alkalosis

b. Hypercapnia

c. Decreased pulmonary vascular resistance

d. Hypoventilation

A. Respiratory Alkalosis

A nurse is reviewing laboratory data from a client who has pulmonary embolism and is receiving IV heparin. Which of the following findings should the nurse report to the provider?

a. Hematocrit 45%

b. Partial thromboplastin time (PTT) 55 seconds

c. White blood cell count 8,000/mm3

d. Platelets 74,000/mm3

D. Platelets 74,000 mm3

Which health promotion strategies should a nurse include in the discharge teaching for a client post-sickle cell crisis?

A. Frequent hand washing

B. Joining a support group

C. Visiting the eye doctor annually

D. Avoiding the annual flu vaccine

E. Taking an iron supplement daily

A, B, C

What should a client with heart failure expect to experience occasionally when standing up?

A. Eating fruits and vegetables

B. Low blood pressure

C. Occasional Dizziness

D. Increased sodium intake

C. Occasional Dizziness

What are common findings in clients with chronic respiratory acidosis due to COPD?

A. Anxiety and Depression

B. Delirium

C. Osteoporosis

D. Polyuria

A. Anxiety and Depression

What is a risk for a client with hypomagnesemia following a myocardial infarction?

A. Ventricular Fibrillation

B. Decreased urine output

C. Polydipsia

D. Hypocalcemia

A. Ventricular Fibrillation

Which medication is commonly prescribed to prevent deep vein thrombosis after surgery?

A. Warfarin

B. Heparin

C. Enoxaparin

D. Alteplase

C. Enoxaparin

What electrolyte imbalance is indicated by a positive Trousseau's sign and bone pain?

A. Hypermagnesemia

B. Hypocalcemia

C. Hyponatremia

D. Hyperkalemia

B. Hypocalcemia

What indicates that the teaching on diuretic use was effective for a client with heart failure?

A. Expecting occasional dizziness when standing up

B. Expecting low blood pressure when standing

C. Increasing sodium in the diet

D. Eating plenty of fruits and vegetables

A. Expecting occasional dizziness when standing up

Which assessment findings might indicate a possible cause of metabolic alkalosis in a client?

A. Overuse of antacids

B. History of vomiting

C. Serum potassium level 4.8 mg/dL (3.5 to 5 mg/dL)

D. Polycythemia

E. Blood urea nitrogen (BUN) 25 mg/dL (10-20 mg/dL)

A and B

Actions a nurse should plan when administering IV potassium supplements to a client with a potassium level of 2.5 mEq/L?

A. Ensure the client's urine output is at least 1 mL/kg/hour

B. Educate client regarding high-potassium food sources

C. Repeat blood serum potassium

D. Cardiac monitoring during infusion

E. Ensure potassium infusion prepared with 5% dextrose solution

A, B, C, D

What condition should the nurse monitor a client with HIV and low CD4-T cell count for?

A. Chlamydia

B. Hepatitis

C. Tuberculosis

D. Gonorrhea

C. Tuberculosis

Who is at increased risk for HIV?

A Insulin pump users

B. Alcohol Use Disorder

C. Pregnant Individuals

D. Low socioeconomic Children

B. Alcohol Use Disorder