WGU D444 Prep test Complete with 100% accurate solutions + rationales

Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?

A Reduce intake of fatty foods

B Sip fluids with each meal

C Eat small frequent meals

D Chew slowly and thoroughly

C Eat small frequent meals

A client is admitted to the hospital for treatment of a simple goiter, And levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

A Muscle cramping and dry flushed skin

B Lethargy and lack of appetite

C Palpitations and shortness of breath

D Bradycardia and constipation

C Palpitations and shortness of breath

During a home visit, the nurse assesses the skin of a client with eczema who reports an exacerbation Of symptoms has occurred during the last week. Which information is most useful and determining the possible cause of symptoms?

A An old friend with eczema came for a visit

B A grandson and his new dog recently visited

C Corticosteroid cream was applied to eczema

D Recently received an influenza immunization

B A grandson and his new dog recently visited

An older adult client with psoriasis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment?

A Clear, dark amber colored urine

B Improved level of consciousness

C Decreased abdominal girth

D Prothrombin time with normal limits

C Decreased abdominal girth

The nurse is caring for a client who reports persistent, gnawing abdominal pain. To help the client manage the pain which assessment data is most important for the nurse to obtain?

A Activity of bowel sounds

B Level and amount of physical activity

C Eating patterns and dietary intake

D Color and consistency of feces

C Eating patterns of dietary intake

The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema in the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?

A Cardiac tamponade

B Left ventricular dysfunction

C Right sided heart failure

D Internal bleeding

C Right sided heart failure

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the clients medical record should the nurse recognize as a contraindication for peritoneal dialysis?

A Type two diabetes mellitus

B Latent hepatitis C

CCrohn's disease with colectomy

DNephrotic syndrome history

CCrohn's disease with colectomy

A client arrives to the medical surgical unit four hours after a transurethral resection of the prostate. A triple lumen catheter for continuous bladder irrigation with normal saline is infusion and the nurse observes dark pink tined outflow with blood clots in the tubing and collection bag. Which action should the nurse take?

A Discontinue infusion solution

B Irrigate the catheter manually

C Decreased the flow rate

D Monitor catheter drainage

D Monitor a catheter drainage

A client who had colon surgery three days ago is anxious and requesting assistance to reposition. While the nurse is turning the client the wound dehisces and eviscerates. The nurse moistens and available sterile dressing and place it over the wound. Which intervention should the nurse implement next?

A Obtain a sample of the drainage and sent to the laboratory

B Prepare the client to return to the operating room

C Auscultate the abdomen for bowel sound activity bring

D additional sterile dressing supplies to the room

B Prepare the client to return to the operating room

A client with a fracture of the right femur has a skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

A Assess the sites for signs of infection

B Remove traction every shift and provide skin care

C Assess the pulses proximal to the fracture site

D Administer pain medication at designated intervals around the clock

A Assess the pin site for signs of infection

A client with renal calculus reports, severe right flank pain, nausea, and vomiting which nursing problem has the highest priority?

A Risk for aspiration related to vomiting

B Impaired renal function related to pain

C Nutritional deficit related to nausea

D Acute pain related to renal calculus

A Risk for aspiration related to vomiting

An adult client who recently diagnosed with glaucoma tells the nurse I feel like I am driving through a tunnel. The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

A Eat a diet high in carotene

B Wear prescription glasses

C Avoid frequent eye pressure measurements

D Maintain prescribed eyedrop regimen

D Maintain prescribed eyedrop regimen

When conducting discharge teaching for a client diagnosed with diverticulitis, which diet instruction should the nurse include?

A Have small frequent meals and sit up for at least two hours after meals

B Eat a high fiber, diet and increase fluid intake

C Eat soft diet with increased intake of milk and milk products

D Eat a bland diet and avoid spicy food

B Eat a high fiber, diet and increased fluid intake

A client who works as a data in tree clerk is concerned as to how a recent diagnosis of Raynauds syndrome is going to affect the clients job performance. Which action should the nurse provide to this client?

A Obtain a keyboard design designated to limit wrist flexion

B Keep both hands elevated during work breaks

C Use a space heater to keep the workspace warm

D Take a multivitamin that contains vitamin D daily

C Use a space heater to keep the workspace warm

The nurse is caring for a client who reports a sudden, severe headache and facial numbness. The nurse asked the client to smile and observe and uneven smile with facial droop to the right side, and a hand grasp strength that is winker on the right side than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?

Start two large bore IV catheters and review inclusion criteria for IV fibirnolytic therapy

Maintain elevated positioning and the dependent joints on affected side

Verify prescribed laboratory test include pron time and platelet count

Administer aspirin to prevent further clot formation and platelet clumping

Start two large bore IV catheters and review inclusion criteria for IV fibirnolytic therapy

a client with bilateral carpal tunnel syndrome, reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?

A Elevate the hands on two pillows at night

B Apply cold compress for 30 minutes before bedtime

C Wear braces on both wrist during the night

D Notify the healthcare provider as soon as possible

C Wear braces on both wrist during the night

Following a lumbar puncture, a client voices several concerns. Which concerns indicate to the nurse that the client is experiencing a complication of the procedure?

A I have a headache that gets worse when I sit up

B I am having back pain in my lower back when I move my legs

C My throat hurts badly when I swallow and when I talk

D I feel sick to my stomach and I'm going to throw up

A I have a headache that gets worse when I sit up

The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nursing encourage the client to follow?

A Increase intake of potassium rich foods, such as banana, bananas, or cantaloupe

B Increased intake of high fiber foods such as brand cereal

C Limit oral fluid to 500 ML/day

D Restrict protein intake by limiting meats and other high protein foods

D Restrict protein intake by limiting meats and other high protein foods

A client receive a prescription of 2 L of lactated ringers IV to be infused over 20 hours. How many ML/hr should the nurse program the infusion pump to deliver

100

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with crushing syndrome?

A Husky voice and troubled by hoarseness

B Visible swelling of the neck with no pain

C Central type obesity with thin extremities

D Warm, soft, moist salmon colored skin

C Central type obesity with thin extremities

A client receives a prescription of 1 L of lactated ringers to be infused IV over eight hours. Administration set delivers 15 get/mL How many ML/hr Should the nurse program the infusion pump to deliver?

125

The nurse is a developing a plan of care for a client who reports blurred vision and is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

A The client's daily blood pressure will be less than 140/80

B The nurse will encourage the client to walk 30 minutes every day

C The client's blood pressure readings will be less than 160/90

D The client's family will state signs and symptoms about the disease

A The clients daily blood pressure will be less than 140/80

A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH) as the client responds to the treatment. The clients room sodium level increases from 120 mEq/L to 125. Which intervention should the nurse implement?

A Assessed for increasing fluid volume overload

B Withhold next scheduled dose of treatment

C Increase neurologic checks to every two hours

D Maintain the prescribed fluid restriction

D Maintain the prescribed fluid restriction

The nurse assist a client with Parkinson's disease to ambulate in the hallway. The client appears to freeze and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

A Confirm that this is an effective technique to help with ambulation

B Assist the client to a carpeted area where he can walk more easily

C Plan to assess the client's cognition after returning to his room

D Re-orient the client to his present location and circumstance

A Confirm that this is an effective technique to help with ambulation

The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone perfusion site. During the preoperative assessment, the nurse determines that the client receives heparin sodium 5000 units sub Q daily. Which nursing action is a priority?

A Have the client sign the surgical and transfusion permits

B Observed the heparin injection sites for signs of bruising

C Ensure that the potential for bleeding is explained to the client

D Notify the healthcare provider of the client's medication history

D Notify the healthcare provider of the client's medication history

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instructions regarding skin care for the portal site should the nurse provide?

A Protect the skin of the radiation portal site from sunlight exposure

B Remove the ink marks of the portal after each radiation treatment

C Avoid washing the skin inside the radiation portal site

D Apply moisture lotions daily to the radiation portal site

A Protect the skin of the radiation portal site from sunlight exposure

A client is admitted to the medical unit during exaggeration, a systemic lupus erythematsous. It is most important to report which assessment finding to the healthcare provider?

A Low-grade fever

B Joint pain

C Muscle atrophy

D Hematuria

D Hematuria

The nurse is obtaining a client fingerstick glucose level. After gently milking the clients finger, the nurse observes that the distal tip of the finger appears red and engorged. Which action should the nurse take?

A Assess radial pulse volume

B Apply pressure to the site

C Select another finger

D Collect the blood sample

C Select another finger

A client reports to the nurse of recently experiencing symptoms of frequent urination, hunger, and great thirst. Which findings are more significant for the nurse to report to the healthcare provider?

Hematocrit

Random plasma glucose level

When caring for a client with a full thickness burn covering 40% of the body, the nurse observes prudent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the clients laboratory values?

A Platelet count

B hematocrit

C Blood pH level

D White blood cell count

D White blood cell count

The healthcare provider prescribes penicillin 200000 units. I am for a client with pneumonia. The available vile is labeled penicillin 500,000 units/mL. How many mL should the nurse administer to this client?

0.4

A client was stage five bone cancer is admitted to the hospital for pain control. The client verbalizes continuous severe pain of eight out of 10 which intervention should the nurse implement?

A Alternate IV and I analgesic meds

B Administer opioid and non-opioid medication simultaneously

C Give maximum dosage when score reaches 10

D Educate client on signed symptoms of narcotic dependency

B Administer opioid and non-opioid medication simultaneously

The nurse assess a client with petechiae ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

A Hemoglobin levels

B white blood cell count

C platelet count

D red blood cell count

C Platelet count

A client who has developed acute kidney injury due to an aminoglycoside anabiotic has moved from the oliguric phase to the diuretic phase of an AKI. Which parameters are the most important for the nurse to plan to carefully monitor?

A Side effects of total parental nutrition, and Intralipids

B Elevated creatine and blood urea nitrogen

C Hypovolemia and electrocardiograph changes

D Uremic irritation of mucus membranes, and skin surfaces

D uremic irritation of mucus, membranes, and skin surfaces

The nurse is developing a plan of care for a client with type two diabetes mellitus. When providing teaching on lowering blood glucose levels and increasing serum, high density Lipo protein levels which instructions should the nurse include?

A Monitor blood glucose levels daily

B Limit calories on days, unable to exercise

C Monthly appointments with the dietitian

D Regular exercise with medical approval

D Regular exercise with medical approval

The nurse is caring for a client in the post anesthesia care unit who underwent a thoracotomy two hours ago. The nurse observes the vital signs as a heart rate of 140 bpm respirations 26 bpm and a blood pressure of 140/90. Which intervention is the most important for the nurse to implement?

A Medicate for pain and monitor vital signs according to protocol

B Encourage the client to splint the incision with a pillow to cough and deep breathe

C Apply oxygen at 10 L via nonrebreather mask and monitor pulse oximeter

D Administer intravenous fluid bolus as prescribed by the healthcare provider

A Medicaid for pain and monitor vital signs according to protocol

Choose the most likely options for the information missing from the statement below

The nurse recognizes that the most serious complication after having gastric bypass surgery is............, as evidenced by increased back, shoulder, or abdominal pain, restlessness,.............., and tachycardia

Septic shock

Hypotension

The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is the most essential in this client's plan of care?

A Provide frequent mouth care

B Ensure oral suction is available

C Maintain the client in a semi Fowlers position

D Keep the room at a comfortable temperature

B Ensure oral suction is available

The nurse is providing teaching to a client about self management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?

A Restrict alcoholic beverages to know more than one to two per week

B Get an influenza vaccine every year as soon as available

C Using salt herbs and spices will improve the flavor of foods

D Eating a protein snack 30 minutes before exercise workout

B Get an influenza vaccine every year as soon as available

The nurse is caring for a client who test positive for sexually transmitted infection gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?

A Discuss that partners without similar symptoms may not be infected

B Emphasize that using safe, sex practices removes the risk of STI's

C Teach importance of medication regimen and follow up protocol

D Clarify that all STI's are transmitted through sexual intercourse

C Teach importance of medication regimen and follow up protocol

A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed to the healthcare provider?

A Hydromorphone

B Fentanyl

C Morphine

D Oxycodone

C Morphine

A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale and febrile. After reviewing the clients most recent laboratory results which reveals a platelet count of 25,000/mm, which intervention should the nurse include in the plan of care?

A Remove cold, frozen foods from dietary trays

B Monitor urine and stool for occult blood regularly

C Wrap bruised areas with elastic bandage dressings

D Ensure a large gauge catheter is used to obtain blood samples

B Monitor urine and stool for occult blood regularly

59-year-old male presents to the clinic reporting pain in the right great toe.

Which findings in the client health records should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.

Daily aspirin

Sleep apnea

Drinks beer nightly

Obesity

Hypertension

Type 2 diabetes mellitus

59-year-old male presents to the clinic reporting pain in the right great toe.

Click to indicate if the findings are consistent with acute gout attack, chronic gout attack, or both

Visible tophi- chronic

Renal dysfunction- chronic

Pain at the affected joint- acute

Low-grade fever- acute

Occurs in more than one joint- both

59-year-old male presents to the clinic reporting pain in the right great toe.

The healthcare provider, places prescriptions to determine the extent of the clients condition.

Drag from the word choices to complete this sentence

Based on the client's laboratory findings, the nurse recognizes that the client is having an acute gout attack and is at most risk for............ and .............. in his affected joint

Pain and inflammation

59-year-old male presents to the clinic reporting pain in the right great toe.

The healthcare provider is considering medication to treat the clients gout.

For each medication used to treat gout choose the most likely therapeutic outcome and the teaching associated with the medication

Colchicine- increase acid excertion- avoid grapefruit

naproxen- manage pain- do not take....

prednisone- reduced inflammation- stop when....

allopurinol- lowe4rs uric acid levers- drink 2 liters...

59-year-old male presents to the clinic reporting pain in the right great toe.

The healthcare provider prescribes colchicine, naproxen, and prednisone for the treatment of gout, and the client is being discharged with the follow up appointment in one week

Choose the most likely options for the information missing from the statement

The nurse should teach the client that a gout attack can be limited by keeping a diet that is............. And a lifestyle free from ...........

Low purine

Alcohol

59-year-old male presents to the clinic reporting pain in the right great toe.

The nurse is reviewing the client's dietary choices for opportunities to promote better outcomes of limiting gout attacks. Select three dietary choices that are not part of the recommended diet for client with gout

Shrimp, sardines, liver

Complete the diagram

Congestive cardiomyopathy

12 lead

BP

Urine

Cardioversion

A 34 year-old male client presents to the emergency department for an acute asthma attack, which began after jogging through a local park.

Based on the client's history in assessment data, the nurse hypothesis is that the client's vital signs are most likely the result of a disease process medication use or neither each column must have at least one but may have more than one answer selected.

Temperature- neither

Heart rate 112 bpm- disease process, and medication use

All others disease process

A 34 year-old male client presents to the emergency department for an acute asthma attack, which began after jogging through a local park.

Complete the following sentences by choosing from the list of corresponding options.

Based on history in assessment data, the nurse should prioritize............. As the priority problem for this client as evidence by the client statement............

Impaired tissue perfusion

I just can't catch my breath

A 34 year-old male client presents to the emergency department for an acute asthma attack, which began after jogging through a local park.

Based on the client history and the assessment data, which action should the nurse anticipate? Select all that apply.

Provide client teaching

Apply oxygen via nasal cannula

Ask the client for a list of current medications

Administer medication's as prescribed

A 34 year-old male client presents to the emergency department for an acute asthma attack, which began after jogging through a local park.

After administration of medication, the client remains short of breath wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen.

Which actions should the nurse take next select all that apply

Raise the head of the bed

Administer additional nebulizer treatment as prescribed

Increased oxygen flow

Take and monitor vital signs

A 34 year-old male client presents to the emergency department for an acute asthma attack, which began after jogging through a local park.

The nurse has implemented additional needed actions

Click the assessment data which indicates the interventions were successful, and which assessment data provides no indication that the interventions were successful.

Blood pressure 122/84- no indication

All others- successful indications

Complete the diagram

Rheumatoid arthritis

educate

Consult dietitian

Pain

Skin breakdown

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse

provide to the client to improve gas exchange?

A Increase breathing rate for a full 30 seconds.

B Lay down on each side with knees bent and breathe from abdomen.

C Raise hands above the head to expand the diaphragm.

D Draw air in through nose and exhale slowly through pursed lips.

D Draw air in through nose and exhale slowly through pursed lips.

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that

frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

A Topical antifungal.

B Topical corticosteroids.

C Topical analgesics.

D Colloidal oatmeal-based lotion.

B Topical corticosteroids

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When

changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

A Place knots of the ties laterally to prevent irritation and pressure.

B Secure tracheostomy ties by making knots close to the tube.

C Remove ties to secure a disposable, soft foam collar with hook and loop fastener.

D Leave the old ties in place until the new ones are secure.

D Leave the old ties in place until the new ones are secure.

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant

granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

A Replace the gauze with a transparent dressing.

B Leave the dressing off until consulting with the healthcare provider (HCP).

C Apply a hydrocolloidal gel dressing.

D Increase the frequency of the dressing changes.

C Apply a hydrocolloidal dressing

The nurse is preparing a teaching plan for a group of well-educated clients who were found to be HIV positive within the last year. Members of the group express an interest in learning about the pathology of the AIDS virus. The nurse should explain that the

human immunodeficiency virus (HIV) acts in which way to suppress the immune system?

A Increase in B-lymphocytes and IgM.

B Proliferation of suppressor T-cells.

C Destruction of helper T-cells and CD4 cells.

D Deficiency of cytotoxic T cells.

C Destruction of helper T-cells and CD4 cells

A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit (ICU), the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

A Determine client's last dose of corticosteroids.

B Determine neurological baseline prior to the fall.

C Administer a PRN IV antiemetic as prescribed.

D Complete head to toe neurological assessment.

D complete head to toe neurological assessment

An older adult female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the

nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

A Raise voice volume to a shout.

B Over-enunciate word syllables.

C Decrease speaking speed.

D Exaggerate nonverbal expressions.

C decrease Speaking speed

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

A Advise the client to limit foods that are high in calcium and iron.

B Describe the use of an elimination diet to find trigger foods.

C Explain that the need to restrict fluids is the primary limitation.

D Instruct the client to avoid foods with gluten, such as wheat bread.

B Describe the use of an elimination diet to trigger foods

The antitubercular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness of this

medication, which outcome can the nurse expect this client to exhibit?

A A positive sputum smear and culture.

B Decreased appetite and weight loss.

C Decreased cough and sputum.

D Vertigo and tinnitus.

D decreased cough and sputum

A client presents to the emergency department (ED) with muscle aches, headache, fever, and describes a recent loss of taste

and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

A Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient.

B Report the COVID-19 result to the local health department according to Centers for Disease Control and Prevention (CDC)

guidelines.

C Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.

D Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment PPE

D isolate the client from other clients family and healthcare workers not wearing proper PPE

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who develops an onset of dyspnea and

tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

A Attach humidification to oxygen delivery.

B Obtain a pulse oximetry reading.

C Coach through using huff coughing.

D Provide nebulizer breathing treatment.

B obtain a pulse oximeter reading

A client who is newly diagnosed with erosive esophagitis secondary to gastrosophageal reflux disease (GERD) reports to the

home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week.

Which action should the nurse take?

A Notify the healthcare provider (HCP) that the client may need a change in dosage.

B Confirm that the client is taking the medication one hour after meals.

C Auscultate the client's bowel sounds and measure the abdominal girth.

D Advise the client that healing typically takes several weeks to occur.

D advisor client that healing typically take several weeks to occur

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement

immediately following the procedure?

A Provide an eye shield to be worn while sleeping.

B Encourage deep breathing and coughing exercises.

C Teach a family member to administer eye drops.

D Obtain vital signs every 2 hours during hospitalization.

A provide an ice shield to be worn while sleeping

Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?

A Observe the skin for lesions.

B Palpate large joints for nodules.

C Palpate the lymph nodes.

D Observe the client's fingers.

D observe the clients fingers

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and

reports increasing fatigue. Which of the client's serum laboratory values is most important for the nurse to review?

A Total protein.

B Hemoglobin.

C Sodium.

D Glucose.

B Hemoglobin

A 43-year-old female arrives to the emergency

department (ED) reporting pain in her abdomen.

The nurse performed a focused assessment and obtained vital signs

Select five symptoms or findings that require immediate

Heart rate 112 bpm

Temperature

Dark urine

Pain 9 out of 10

Abdominal rigidity

A 43-year-old female arrives to the emergency

department (ED) reporting pain in her abdomen.

The healthcare provider believes the client may have Choleliyhiasis.

For each condition, click to indicate if the listed findings in the client, history and physical increase the risk or if it has no effect

All our increased risk

A 43-year-old female arrives to the emergency

department (ED) reporting pain in her abdomen.

The nurse assesses the clients ultrasound and laboratory results.

Choose the most likely options for the information missing from the statement

The client is at most risk for............. As evidence by..............

cholangitis

Ultrasound findings

A 43-year-old female arrives to the emergency

department (ED) reporting pain in her abdomen.

For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have one response item selected.

Start anabiotic therapy-Indicated

Ambulate three times daily-Non-essential

Insert NG tube-Contraindicated

Increase IV fluids-Indicated

High protein, meal supplements-Contraindicated

Manage pain with IV opioids-Indicated

A 43-year-old female arrives to the emergency

department (ED) reporting pain in her abdomen.

The following morning, the client is brought to surgery for a laparoscopic cholecystectomy. The nurse is preparing to care for the client postoperatively.

Choose the most likely options for the information missing from the statement

A postoperative client presents with................ And as a result, the nurse should....................

Nausea

Maintain NPO status

A 43-year-old female arrives to the emergency

department (ED) reporting pain in her abdomen.

The client is preparing to be discharged home today

Select the four statements that require further education

I should keep the incision dressings on for one week

I can eat anything as long as it is tolerated

A diet that is low in fiber and calcium is advised

I can expect some redness, swelling, and pus from the incision

Which information should the nurse include when giving discharge instructions to the Client following a left eye cataract extraction with lens implant?

A Sleep flat in a supine position.

B Turn, cough, and deep breathe every 2 hours.

C Observe pupil response of the right eye.

D Administer a stool softener.

D Administer stool softener

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain to prior

to administering the medication?

A Trouble sleeping.

B Unexplained weight loss.

C Recent oral intake.

D Difficulty with urination.

C recent oral intake

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

A Instruct the client to breathe shallow and fast.

B Perform the drainage immediately after meals.

C Obtain an arterial blood gas (ABG) prior to the procedure.

D Explain that the client may be placed in five positions.

D explain that the client may be placed in five positions

A client is being cared for in the emergency department (ED) with acute abdominal pain and a provisional diagnosis of pancreatitis. The nurse assesses the client and obtains the results from laboratory studies. Which information is most valuable in

reporting the client's status to the healthcare provider (HCP)?

A Presence of bowel sounds and degree of abdominal pain.

B Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts.

C Severity of nausea and vomiting and serum amylase results.

D Reports of chronic constipation and serum gastrin levels.

C Severity of nausea and vomiting and serum amylase results.

A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the

infection. Which response should the nurse provide?

A Instruct the client that over-the-counter medications are sufficient to manage influenza symptoms.

B Advise the client that once symptoms occur it is too late to receive an influenza vaccination.

C Explain to the client that antibiotics are not useful in treating viral infections such as influenza.

D Refer the client to the healthcare provider at the clinic to obtain a medication prescription.

D Refer the client to the healthcare provider at the clinic to obtain a medication prescription.

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of

which problem?

A Clay colored stool.

B Anorexia.

C Hematemesis.

D Brown, foamy urine.

C Hematemesis

A 78-year-old female was admitted three days

ago with a stage 3 pressure injury at the coccyx.

The wound care nurse is preparing to change the client's

dressing.

For each technique item, click to indicate whether the technique is

indicated or not indicated. Each row must have one option selected.

Apply sterile gloves prior to changing- Ind

Place sterile gauze directly on wound bed- Not

Maintain clean medical asepsis- Not

Thoroughly clean wound using normal saline prior to redressing- Ind

Apply sterile foam dressing over wound bed- Ind

Gather materials to change- Not

A adolescent boy is admitted to the emergency department (ED) following a bee sting. He arrives with a body rash and 30

minutes later he becomes short of breath. The nurse obtains vital signs with a blood pressure of 90/52 mm Hg, heart rate 130

beats/minute, and respiratory rate 40 breaths/minute. The client is exhibiting clinical manifestations of which type of immune

reaction?

A Autoimmune response.

B IgE response hypersensitivity.

C Cell mediated hypersensitivity.

D Type Il hypersensitivity.

B IgE response hypersensitivity.

Before administering a newly prescribed dose of terbinafine CL to a client with a fungal toenail infection, which assessment

finding is most important for the nurse to address?

Reference Range:

White Blood Cell (WBC) [5,000 to 10,000/mm3 (5 to 10 x 10%/L)]

A Reported history of alcoholism.

B Employed as a construction worker.

C White blood cell count of 8,500/mm3 (8.5 x 10%L).

D Toenails appear thick and yellow.

A reported history of alcoholism

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

A Auscultate bowel sounds.

B Measure oxygen saturation.

C Assess body temperature.

D Check serum creatinine.

D Check serum creatinine

A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the

electronic medical record (EMR) for which condition?

A Radiation exposure.

B Corneal abrasion.

C Foreign body.

D Chemical burn.

B Corneal abrasion

A client receives a prescription for vancomycin 500 mg IV piggyback (IVPB) every 8 hours. The medication is provided in 500 mg per 100 mL of dextrose 5% in water. To administer the medication over an hour, the nurse should set the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

100

A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming

nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

A Belching.

B Yellow sclera.

C Flatulence.

D Amber urine.

B Yellow sclera

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat

and protect the duodenal ulcer. Which is the best follow up action by the nurse?

A Suggest that the client also plan to eat frequent small meals to reduce discomfort.

B Review with the client the need to avoid foods that are rich in milk and cream.

C Reinforce the teaching by asking the client to make a list of snack foods high in dairy content.

D Remind the client that it is also important to switch to decaffeinated coffee and tea.

B Review with the client the need to avoid foods that are rich in milk and cream.

A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened,

tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most

important for the nurse to instruct the client about self care?

A Call the clinic if undesirable side effects of medications occur.

B Teach anxiety reduction methods for feelings of suffocation.

C Increase the daily intake of oral fluids to liquefy secretions.

D Avoid crowded enclosed areas to reduce pathogen exposure.

C Increase the daily intake of oral fluids to liquefy secretions.

An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse

provide the UAP?

A Offer the client mouthwash for thorough cleansing after brushing teeth.

B Wear sterile gloves when cleansing any areas of infected mucosa.

C Assist with personal care, but leave oral care for the nurse to complete.

D Provide a soft-bristled toothbrush for the client to use during oral care.

D Provide a soft-bristled toothbrush for the client to use during oral care.

A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation

device. Which statement indicates that the client understands the instructions for using this medication?

A When I cough up sputum, the secretions should be less thick.

B If I have sudden shortness of breath, I will use this inhaler.

C I should use this medication in its handihaler every day.

D I will use my other inhaler in between uses.

C I should use this medication in its handihaler every day

electronic medical record (EMR) for which medication?

A Loperamide.

B Ipratropium.

C Famotidine.

D Aspirin.

D Aspirin

The client is a 42-year-old male who had a

Roux-en-Y gastric bypass 6 months ago.

Complete the diagram

Dumping Syndrome

Reeducate

collect

weight

signs of malnutrition

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler.

Which action indicates to the nurse that additional teaching is needed?

A Rinses the mouth after each use.

B Attaches spacer device to the inhaler.

C Primes the inhaler with 7 pumps.

D Stores the medication at room temperature.

C Primes the inhaler with 7 pumps

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports

the client's respiratory acidosis?

A Blood oxygen levels are stimulating the respiratory rate.

B Carbon dioxide is converted in the kidneys for elimination.

C Hyperventilation is eliminating carbon dioxide rapidly.

D High levels of carbon dioxide have accumulated in the blood.

D High levels of carbon dioxide have accumulated in the blood.

To assess the quality of an adult client's pain, which approach should the nurse use?

A Identify effective pain relief measures.

B Ask the client to describe the pain.

C Provide a numeric pain scale.

D Observe body language and movement.

B Ask the client to describe the pain.

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8

on a 0 to 10 scale, dysphagia, anorexia, anxiety and a hoarse voice. Which nursing problem is the priority for this client?

A Imbalanced nutrition less than body requirements.

B Risk for aspiration related to difficulty swallowing.

C Anxiety and grieving related to progression of disease.

D Chronic pain related to tissue destruction by tumor

B Risk for aspiration related to difficulty swallowing.

A client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on

room air, and an oral temperature of 100° F (37.80 C). The client has a weak cough effort and is using accessory muscles to

breathe. Which intervention should the nurse implement first?

A Obtain arterial blood gases.

B Offer a prescribed PRN analgesic.

C Suction to clear secretions from airway.

D Administer a prescribed antipyretic.

C Suction to clear secretions from airway.