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A nurse is assessing for early signs of compartment syndrome for a client who has a short leg fiberglass cast. which of the following findings should the nurse expect? a. capillary refill less than 2 sec b. bounding distal pulses c. intense pain with movement d. erythema of toes

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1

A nurse is assessing for early signs of compartment syndrome for a client who has a short leg fiberglass cast. which of the following findings should the nurse expect? a. capillary refill less than 2 sec b. bounding distal pulses c. intense pain with movement d. erythema of toes

c. intense pain with movement

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2

a nurse is monitoring a client who is receiving 2 units packed RBCs. which of the following manifestation indicated a hemolytic transfusion reaction? a. chills b. hypertension c. bradycardia d. back pain

d. back pain

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3

a nurse is caring for a client who had a total hip arthroplasty. which of the following actions should the nurse take to prevent hip dislocation? a. remove the wedge device when turning b. place two bed pillows between legs when in bed c. encourage the client to lean forward when attempting to stand d. elevate the knees higher than the hips when sitting

b. place two bed pillows between legs when in bed

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4

a nurse is assessing a client who is preoperative and reports an allergy to bananas. the nurse should recognize that the client is at risk for an allergic cross reactivity to which of the following substances? a. providing-iodine b. adhesive tape c. latex d. anesthetics

c. latex

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5

a nurse is teaching a client about the use of an incentive spirometer. which of the following instructions should the nurse include in teaching? a. place hands on the upper abdomen during inhalation b. position hands on the mouthpiece 2.5 cm from the mouth c. exhale slowly through pursed lips d. hold breaths about 3 to 5 seconds before exhaling

D. hold breaths about 3 to 5 seconds before exhaling

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6

a nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. the clients serum potassium level is 2.8, which of the following interventions should the nurse implement first? a. check the clients hand grasps b. administer IV potassium drip c. listen to client's bowel sounds d. initiate cardiac monitoring for the clients

b. administer IV potassium drip d. initiate cardiac monitoring for the clients

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7

a nurse is preparing to administer peritoneal dialysis to a client. which of the following actions should the nurse take? a. chill the dialysate before administration b. hang the drainage bag below the clients abdomen c. place the client in high fowlers position d. use clean technique to access the catheter

b. hang the drainage bag below the clients abdomen

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8

a nurse is performing a cranial nerve assessment on a client following a head injury. which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)? a. inability to smell b. loss of peripheral vision c. disequilibrium with movement d. deviation of the tongue from midline

c. disequilibrium with movement

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9

a nurse is planning care for a client who is one day postoperative following an open cholecystectomy. which of the following interventions should the nurse include in the plan of care? a. place pillows under the clients knees b. avoid use of anticoagulants c. discourage leg exercises while in bed d. apply compression stockings to the lower extremities

d. apply compression stockings to the lower extremities

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10

a nurse is caring for a male client having an exacerbation of heart failure. which of the following prescriptions should the nurse expect to receive from the provider? a. atropine 1mg IV bolus every 5 min up to 3mg b. adenosine 6mg rapid IV bolus now c. verapamil 80mg PO TID d. furosemide 40mg IV bolus every 6 hours

a. atropine 1mg IV bolus every 5 min up to 3mg

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11

a nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. which of the following statements by the client indicates an understanding of the teaching? a. I will keep my left arm flexed at the elbow as much as possible b. I should expect less than 25 ml of secretions per day in the drainage devices c. I will perform strength building arm exercises using a 15 pound weight d. I will have to wait 2 months before additional saltine can be added to my breast expander

b. I should expect less than 25 ml of secretions per day in the drainage devices

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12

a nurse is teaching a client about a metered dose rescue inhaler. which of the following statements should the nurse include in the first teaching? a. do not shake your inhaler before use b. exhale fully before bringing the inhaler to your lips c. use peroxide to clean the mouthpiece of your inhaler d. depress the catheter after you inhale

b. exhale fully before bringing the inhaler to your lips

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13

a nurse is caring for a client who has been receiving total parental nutrition for 1 week. for which of the following findings should the nurse notify the provider? a. calcium level 11.5mg/dl b. serum albumin level 3.9g/dl c. output 200ml more than intake over the past 12 hr d. fasting blood glucose level 105 mg/dl

a. calcium level 11.5mg/dl

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14

a nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. the nurse should clarify which of the following prescriptions with the provider? a. take tub baths instead of showers b. may place a small pillow under the head while sleeping c. may operate a motor vehicle when no longer taking analgesics d. increase intake of fiber rich foods

c. may operate a motor vehicle when no longer taking analgesics

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15

a nurse is setting up a sterile field before performing a dressing change on a client who is postoperative. which of the following actions should the nurse plan to take to maintain the sterile field? a. grasp 2.5 cm (1 inch) of the outer edge to open the surgical wrap b. open the first flap of the sterile package towards the nurse's body c. place a surgical pack with a sterile drape on the work surface d. sleet a work surface at the nurse's waist level

a. grasp 2.5 cm (1 inch) of the outer edge to open the surgical wrap b. open the first flap of the sterile package towards the nurse's body c. place a surgical pack with a sterile drape on the work surface

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16

a nurse in the emergency department is preparing a client for emergency surgery. the clients blood alcohol is 180mg/dl. which of the following actions is the nurse's priority? a. obtain consent for surgery b. insert an indwelling urinary catheter c. insert an NG tube d. apply anti embolic stockings

c. insert an NG tube

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17

a nurse is assessing a client who has increased intracranial pressure. the nurse should recognize that which of the first sign of deteriorating neurological status a. pupillary dilation b. cheyne strokes respirations c. decorticate posturing d. altered level of consciousness

d. altered level of consciousness

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18

a nurse is performing skin cancer screening on a group of clients. which of the following findings should the nurse identify as an indication of melanoma a. flat lesion with irregular borders b. raised lesion with a rolled border c. scaly lesion with the crusted appearance d. reddened lesion with dilated blood vessels

a. flat lesion with irregular borders

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19

a nurse is caring for a client who has diabetes insipidus. which of the following medications should the nurse plan to administer? a. lithium b. desmopressin c. regular insulin d. furosemide

b. desmopressin

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20

a nurse is preparing to assist with the insertion of anon tunneled central venous catheter for a client who is malnourished. which of the following actions should the nurse plan to take? a. cleanse the site with hydrogen peroxide solution b. instruct the client to cough as the catcher is inserted c. confirm the correct position of the line by obtaining a blood sample d. place the head of the clients bed lower than the foot

c. confirm the correct position of the line by obtaining a blood sample

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21

a nurse is caring for a client who had an arterial revascularization of the lower extremity. which of the following is the priority action the nurse should plan to take after contacting the provider. a. increase the insulin rate per protocol b. increase the heparin infusion per protocol c. change the PCA timing of the patient control bolus to every 15 min d. start an IV bolus of .9% sodium chloride 500 ml to infuse over 1hr

a. increase the insulin rate per protocol

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22

a nurse is providing discharge teaching to a client who has chronic urinary tract infections. the client has a prescription for ciprofloxacin 250mg PO twice daily. which of the following instructions should the nurse include in the teaching a. monitor heart rate once daily b. take a laxative to prevent constipation c. drink 2-3 L of fluids daily d. take an antacid 30 min before taking the medication

c. drink 2-3 L of fluids daily

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23

a nurse is providing discharge teaching for a client who has HIV. which of the following information is the priority for the nurse to review with the client? a. list some ways you can cope with the stress of your illness b. name a few things you will change about your diet c. tell me why its important to have your CD4 count checked d. describe your daily medication schedule

d. describe your daily medication schedule

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24

a nurse is administering packed RBCs to a client. the client reports chills, lower back pain, and nausea 10 min after the infusion begins. which of the following actions should the nurse take first? a. stop the infusion b. collect a urine sample c. check the client's vital signs d. administer oxygen to the client

a. stop the infusion

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25

a nurse is preparing to assist the provider with a thoracentesis for a client who has left pleural effusion. which of the following interventions is the priority for the nurse? a. reinforce the importance of lying still during the procedure b. determine whether the client has a allergy to local anesthetics c. administer a sedative medication d. describe the sensations the client will feel during the procedure

b. determine whether the client has a allergy to local anesthetics

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26

a nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. which of the following actions should the nurse take? a. use contact isolations while providing care b. move the client to a negative pressure room c. apply pressure to venipuncture pressure room d. instruct the client to avoid eating raw fruit

d. instruct the client to avoid eating raw fruit

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27

a nurse is reviewing the medical record of a client who is 1 day postoperative following an appendectomy. which of the following findings should the nurse report to the provider? a. reports pain of 4 on a scale of 0 to 10 when coughing b. WBC count of 8400/mm3 c. serosanguinous exudate noted on dressing change d. hemoglobin 10mg/dl

d. hemoglobin 10mg/dl

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28

a nurse is caring for a client who was admitted with nausea, vomiting, and possible bowel obstruction. An NG tube is place and set to low intermittent suction. which of the following findings should the nurse report to the provider? a. the amount of drainage is gradually decreasing b. the drainage is bright green in color with brown fecal material c. the clients abdomen becomes distended and firm d. the client reports being extremely thirst with a sore throat

c. the clients abdomen becomes distended and firm

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29

a nurse is reviewing the medical record of a client who is schedules for a CT scan with a contrast media. which of the following medications should the nurse instruct the client to withhold for 48hr following the procedure a. carvedilol b. metformin c. clopidogrel d. furosemide

b. metformin

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30

a nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. which of the following actions should the nurse plan to take first? a. instill .9% sodium chloride solution into the affected eye b. administer proparacanie eye drips into the affected eye c. place a strip of PH paper onto the cul-de-sace of the affected eye d. collect information about the irritant that caused the injury

a. instill .9% sodium chloride solution into the affected eye

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31

a nurse is providing instructions about foot care who a client who has peripheral arterial disease. the nurse should identify that which of the following statements by the client indicated an understanding of the teaching? a. I use my heating pad on a low setting to keep my feet warm b. I apply a lubricating lotion to the cracked areas on the soles of my feet every morning c. I rest in my recliner with my feet elevated for about an hour every afternoon d. I soak my feet in hot water before trimming my toenails

c. I rest in my recliner with my feet elevated for about an hour every afternoon

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32

a nurse is collecting data from a client who has toxmoplasmosis and is HIV positive. which of the following questions should the nurse ask to gather about toxoplasmosis? a. do you have any household pets such as a cat? b. was anyone in your family recently exposed to a viral disease? c. are your immunizations current> d. have you been out of the country in the last 30 days?

a. do you have any household pets such as a cat?

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33

a nurse is collecting data from a client who toxoplasmosis and is HIV positive. which of the following findings should alert the nurse to a potential complication of the client's mobility? a. polyuria b. confusion c. blurred vision d. diarrhea

b. confusion

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34

a nurse is checking a client's ventilator settings. the nurse should understand the positive end expiratory pressure has which of the following purposes? a. to deliver a set tidal volume b. to prevent alveolar collapse c. to control the rate of ventilations d. to provide positive airway pressure during inspiration

b. to prevent alveolar collapse

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35

a nurse is caring for a client who is postoperative following a partial thyroidectomy. which of the following findings is the priority for the nurse to report to the provider? a. client report of pain at the incision site b. loose tracheal secretions c. hypoactive bowel sounds d. high pitched sound on inspiration

d. high pitched sound on inspiration

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36

a nurse on a medical unit is planning care for a group of clients. which of the following clients should the nurse attend to first? a. a client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% b. a cleft who has left sides paralysis and slurred speech from a prior stroke c. a client who has multiple sclerosis and reports ataxia and vertigo d. a client who has thrombocytopenia and reports a nosebleed

d. a client who has thrombocytopenia and reports a nosebleed

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37

a nurse is caring for a client who has a newly inserted chest tube. the nurse should clarify which of the following prescriptions with the provider? a. vigorously strip the chest tube twice daily b. notify the provider when tiddling ceases c. administer morphine 2 mg IV bolus every 3hr PRN for pain d. assist the cleft out of bed three times daily

a. vigorously strip the chest tube twice daily

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38

a nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. which of the following actions should the nurse include in the plan of care? a. instruct the client to avoid lifting the right arm for 72hr b. check blood pressure in the right arm c. insert a saline lock into a site 10 cm (4 in) distal to the graft d. palpate the site for a thrill

d. palpate the site for a thrill

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39

a nurse is providing discharge teaching for a client who has osteomyelitis in the left leg. which of the following finding should the nurse identify as requiring a referral? a. a client has a prescription for furosemide b. the client has a prescription for long term IV antibiotic therapy c. the client has a WBC count of 20,000/mm3 d. the client has type 2 diabetes mellitus and HDA1C of 5%

b. the client has a prescription for long term IV antibiotic therapy

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40

a nurse is caring for a client who has an IV in the left forearm whose infusion pump has alarmed several times. which of the following actions should the nurse take? a. ensure the tubing connections are secure b. reposition the clients left arm c. flush the catheter d. check the IV site for redness

d. check the IV site for redness

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41

A nurse is caring for a client who is 6hr postoperative following application of an external fixator for a tibial fracture. which of the following actions should the nurse take? a. maintain the affected extremity in a dependent position b. wrap sterile gauze on the sharp point of the pins c. adjust the clamps on the fixator frame d. palpate the doralis pedis pulse

d. palpate the doralis pedis pulse

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42

a nurse is caring for a client following a total knee arthroplasty. the client reports a pain level on a pain scale of 0 to 10. which of the following interventions should the nurse take? a. place pillows under the clients knee b. gently massage the area around the client's incision c. apply an ice pack to the clients knee d. perform range of motion exercise to the clients knee

c. apply an ice pack to the clients knee

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43

a nurse is teaching a client and his partner about performing peritoneal dialysis at home. when discussing peritonitis, which of the following manifestation should the nurse identify as the earliest indication of this complication? a. fever b. cloudy effluent c. increased heart rate d. generalized abdominal pain

b. cloudy effluent

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44

a nurse in an emergency department is caring for a client who is to receive tissue plasminogen activator (TPA) for the treatment of an ischemic stroke. in which oder should the nurse complete the following actions? check for contraindications transfer the client to CCU weigh the client administer TPA

weigh the client check for contraindications administer TPA transfer the client to CCU

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45

a nurse in the emergency department admitted a client who is having a myocardial infarction. the client has been placed on the heart monitor. which of the following electrocardiogram strips is indicative of a myocardial infarction?

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46

a nurse is assessing a client who has acute pancreatitis and has been receiving a total parental nutrition for the past 72hr. which of the following findings requires the nurse to intervene a. capillary blood glucose level 164mg/dl b. crackles in bilateral lower lobes c. WBC count 13,000/mm3 d. right upper quadrant pain

b. crackles in bilateral lower lobes

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47

a nurse is caring for a group of clients. the nurse should obtain a blood pressure reading using only the left extremity for which of the following clients? a. a client who has a right upper extremity arteriovenous fistula b. a client who has left sided Bell's palsy c.a client who has right sided weakness due to Parkinson's disease d. a cleft who has peripherally inserted central catheter in the left arm

a. a client who has a right upper extremity arteriovenous fistula

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48

a nurse is caring for a client in diabetic ketoacidosis (DKA). which of the following is the priority interventions by the nurse? a. administer .9% sodium chloride b. initiate a continuous IV insulin infusion c. check potassium levels d. begin bicarbonate continuous IV infusion

a. administer .9% sodium chloride

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49

A nurse is preparing to administer levofloxacin 750mg via intermittent over 90 min to a client. available is levofloxacin 750mg/150ml. how many ml/hr should the nurse set to the IV pump to administer?

100 ml

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50

a nurse is caring for a client who has been prescribed an antibiotic. the client tell the nurse " I don't like taking mediations because I don't think I need them" which of the following response should the nurse make? a. if you don't take this medication you will feel worse b. most clients feel better after taking the antibiotic c. your provider would prescribe this medication if it weren't necessary d. I will tell your provider that you do not want to take this medication

c. your provider would prescribe this medication if it weren't necessary

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51

a nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. which of the following instructions should the nurse include? a. cover electrical outlets in the clients home with tape b. keep the clients bedroom dark at night c. hang a monthly calendar in the patients bedroom d. place a large face clock in the clients bedroom

d. place a large face clock in the clients bedroom

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52

a nurse is assessing the pain status of a group of cents. which of the following findings indicates a client is experiencing referred pain? a. a client who has peritonitis reports generalized abdominal pain b. a client who is postoperative reports incisional pain c. a client who has angina reports substernal chest pain d. a client who has pancreatitis reports pain in the left shoulder

d. a client who has pancreatitis reports pain in the left shoulder

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53

a nurse is reviewing the medical record of a client who is to undergo open heart surgery. which of the following findings should the nurse report to the provider as a contraindication to receiving heparin? a. rheumatoid arthritis b. thalassemia c. COPD d. thrombocytopenia

d. thrombocytopenia

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54

a nurse is reviewing the medical record of a cleft to identify risk factors for colorectal cancer. the nurse should identify which of the following findings as increasing the clients risk? a. history of crohns disease b. bmi of 24 c. diet high in fiber d. age 46 years

a. history of crohns disease

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55

a nurse is completing discharge with a client who has a peripherally inserted central catheter line in the left arm. which of the following instructions should the nurse include in the teaching? a. do not elevate the arm above the level of the heart b. use a 10ml syringe to flush the line c. change the catheter dressing daily d. clean the insertion site using 20ml of hydrogen peroxide

b. use a 10ml syringe to flush the line

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56

a nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. which of the following routine medications to give at 0800 should the nurse withhold? a. metoprolol b. fluticasone c. metformin d. valproic acid

c. metformin

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57

a nurse is caring for a client who has developed a heart rate of 38/min and reports tremors and feeling faint. which of the following mediations should the nurse anticipate administering? a. digoxin b. atropine sulfate c. diltiazem d. magnesium sulfate

b. atropine sulfate

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58

a nurse is reviewing the medial record of a client who has pneumonia. which of the following serum laboratory values should the nurse expect? a. hematocrit 35% b. sodium 135mg/dl c. WBC count 15000/mm3 d. BUN 8mg/dl

c. WBC count 15000/mm3

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59

a nurse in an emergency department is caring for client who has sinus bradycardia. which of the following actions should the nurse take first? a. prepare the client for temporary pacing b. initiate IV fluid therapy for the client c. administer atropine to the client d. measure the clients blood pressure

d. measure the clients blood pressure???

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60

a nurse is caring for a client who has tuberculosis and is taking rifampin. the client reports that her saliva has turned red orange color. which of the following response should the nurse make? a. you will need to increase your fluid intake to resolve this problem b. this finding may indicate possible medication toxicity c. this is an expected adverse effect on this medication d. your provider will prescribe a different medication regime

c. this is an expected adverse effect on this medication

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61

a nurse is providing discharge teaching about foot care to a client who is newly diagnosed with type 1 diabetes mellitus. which of the following information should the nurse include? a. inspect the feet everyday b. apply lotion between the toes c. soak the feet twice a day d. trim toenails straight across

d. trim toenails straight across

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62

A nurse is reviewing the following ABG results for a postoperative client pH 7.27. PaCO22 49mm Hh HCO3 22.Eq/L. the nurse should interpret the findings as which of the following imbalances? a. metabolic acidosis b. metabolic alkalosis c. respiratory alkalosis d. respiratory acidosis

d. respiratory acidosis

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63

a nurse is caring for a client who has amnesia. which of the following assessment findings should the nurse anticipate with the clients conditions? a. flushed skin color b. bradycardia c. heat intolerance d. headache

d. headache

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64

a nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2g per day. which of the following statements by the client indicates an understanding of the teaching? a. I can season my food with garlic and onions b. I can have a frozen fruit juice bar for dessert c. I can have mayonnaise on my sandwich d. I can drink vegetable juice with a meal

b. I can have a frozen fruit juice bar for dessert

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65

a nurse on an oncology until is caring for a client who is receiving internal radiation therapy. which of the following actions should the nurse take? a. allow visitors to hold the clients hand leave the door to the clients room open c. place the dosimeter film badge on the clients door d. wear a lead apron when providing care

d. wear a lead apron when providing care

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66

a nurse is assessing a client for a positive chvostek's sign following a thyroidectomy. which of the following areas on the client's head should the nurse tap to assess the client for tetany?

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67

a nurse is teaching a group of clients who have cancer about radiation therapy. which of the following activities should the nurse include in the teaching? a. limit engaging in sport activities that can cause bruising b. decrease intake of fresh fruits and vegetables c. limit socializing in large crowds d. decrease time spent outdoors

a. limit engaging in sport activities that can cause bruising

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68

a nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. which of the following medications hauled the nurse plan to have at the bedside? a. acetylcysteine b. flumazenil c. protamine sulfate d. vitamin k

c. protamine sulfate

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69

a nurse is providing discharge teaching to a client who has ileostomy. which of the following client statements indicated an understanding of the teaching? a. I will empty my bag when it is full b. I will take a laxative when I am constipated c. I will eat a high fiber diet d. I will expect my stools to be loose

d. I will expect my stools to be loose

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70

a nurse is reviewing a client's cardiac monitor for dysrhythmias. which of the following findings should the nurse identify as an indication for the placement of a permanent pacemaker? a. complete AV block with rates slower than 40/mm b. sinus tachycardia with rates faster than 80/mm c. vasovagal bradycardia with syncope d. asymptomatic second degree AV block

a. complete AV block with rates slower than 40/mm

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71

a nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. which of the following findings should the nurse identify as a contraindication to receiving this alternate therapy? a. uticaria b. lymphedema c. headaches d. mouth sores

b. lymphedema mouth sores???

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72

a nurse is caring for a client who is receiving continues bladder irrigation following a transurethral resection of the prostate. the client reports lower abdominal pain. which of the following actions should the nurse take first? a. increases the client's fluid intake b. administer PRN pain medication c. check the clients urine output d. reposition the client in bed

c. check the clients urine output

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73

a nurse is assessing a client who has malnutrition. which of the following findings should the nurse expect? a. hypermagnesemia b. diplopia c. hyperthermia d. cachexia

d. cachexia

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74

a nurse is assessing a client who has a gravity drain in place following an open cholecystectomy. which of the following images should the nurse identify as a gravity drain?

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75

a home health nurse is assessing the home environment of a client who has cystic fibrosis. which f the following equipment should the nurse plan to recommend? a. peak flow meter b. NG tube with suction apparatus c. chest physiotherapy vest d. chest tube with a drainage system

c. chest physiotherapy vest

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76

a nurse is caring for a client who has a severe burn injury. the nurse should recognize which of the following client findings as an indication of hypovolemic shock? a. urine output 45ml/hr b. PaCO2 37 mmg Hg c. capillary refill 1.5 seconds d. potassium 5.2 mEq/L

d. potassium 5.2 mEq/L

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77

a nurse is assessing a client who has a serum sodium of 120 mEq/L. which of the following findings should the nurse expect? a. decreased bowel sounds b. increased central venous pressure c. confusion d. hyperreflexia

c. confusion

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78

a nurse is assessing a client who is receiving valsartan to treat heart failure. which of the following findings should the nurse identify as an indication that the medication is effective? a. increased heart rate b. decreased urinary output c. increased potassium level d. decreased blood pressure

d. decreased blood pressure

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80

A nurse is caring for client who has cervical cancer and a sealed radiation implant. which of the following actions should the nurse take? a. attach a dosimeter badge to the clients gown b. place long handled forceps at the clients bedside c. leave unused equipment in the clients room until discharged d. move the clients soiled linens to a designated container outside the room

b. place long handled forceps at the clients bedside

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81

a nurse is caring for a client who is taking digoxin .125mg PO daily and is at risk for developing digoxin toxicity. the nurse should monitor the client for an imbalance of which of the following electrolytes because it can increase the risk of dioxin toxicity? a. phosphatase b. calcium c. potassium d. magnesium

c. potassium

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82

a nurse is admitting a client who reports chest pain and has been place on a telemetry monitor. which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction? a. ST segment b. T wave c. PR interval d. QRS duration

a. ST segment

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83

a pacu nurse is monitoring the drainage from a client's NG tube following abdominal surgery. which of the following findings in the first postoperative hour should the nurse report to the provider? a. 200ml of brown discharge b. 100ml of red drainage c. 75ml of greenish yellow discharge d. 150ml of serosanguineious discharge

a. 200ml of brown discharge

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84

a nurse is caring for client who understands a prescribed surgical procedure but can't read or write. which of the following actions should the nurse take? a. allow the client to sign the consent with an x b. notify the surgical team that the client is unable to sign the consent c. inform a family member of the need to sign the consent d. contact the clients power of attorney to sign the consent

d. contact the clients power of attorney to sign the consent

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85

a nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2g sodium diet. which of the following client statements should the nurse identify as an understanding of the teaching? a. I can season my foods with lemon juice b. I should use canned instead of frozen vegetables c. I can use baking soda when I bake d. I should use salt sparingly while cooking

a. I can season my foods with lemon juice

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86

a nurse is reviewing ECG rhythm strips for a group of clients. the nurse should identify which of the following rhythms indicates bradycardia?

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87

a nurse is planning care for a client who has clostridium difficile gastroenteritis. which of the following is an appropriate nursing action? a. obtain a stool specimen with gloves b. wash hands which alcohol based hand rubs c. clean surfaces with chlorhexidine d. place the client in a protective environment

a. obtain a stool specimen with gloves

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88

a nurse is preparing to administer a unit of packed RBCs over 1 hr. which of the following actions should the nurse plan to take? a. initiate venous access with a 21 gauge needle b. obtain the client's first set of vital signs after initiating the transfusion c. administer the unit of packed RBCs over 1hr d. use Y tubing with .9% sodium chloride when administering the transfusion

d. use Y tubing with .9% sodium chloride when administering the transfusion

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89

a nurse is caring for a client following a below the knee amputation. the client states "my life is over" which of the following responses should the nurse make? a. why do you think your life is over b. you are upset. we can talk about this later c. would you like to meet with another client who is a amputee? d. most people can adjust following this surgery

a. why do you think your life is over

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90

a nurse is assessing a client who has a pressure ulcer. which of the following findings should the nurse expect as an indication that the wound is healing? a. light yellow exudate b. dry brown eschar c. dark red granulation tissue d. wound tissue is firm to palpation

a. light yellow exudate

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91

a nurse is providing teaching to a client who has left sides heart failure. which of the following manifestations should the nurse include in the teaching? a. hacking cough b. neck vein distention c. ankle edema d. anorexia

a. hacking cough

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92

a nurse in a providers office is caring for a client who has total vision loss and is the handler of service dog. which of the following actions should the nurse take to show consideration for the client in the service animal? a. command the dog to sit while talking to the client b. pet the dog briefly to demonstrate acceptance c. consult the client before approaching the dog d. offer the dog a bowl of water to demonstrate caring

c. consult the client before approaching the dog

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93

a nurse is reviewing laboratory results for 4 clients who are schedule for surgery. which of the following laboratory values should the nurse report to the surgeon? a. HCT 42% b. INR of 1.6 c. platelets 95.000/mm3 d. WBC count 8.000/mm3

c. platelets 95.000/mm3

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94

*a nurse is providing discharge teaching to a client who has impaired immune system due to chemotherapy. which of the following information should the nurse include in the teaching? a. wash your toothbrush in the dishwasher once each month b. wash your perineal area two times each day with antimicrobial soap c. change your pets litter box daily d. change the water in your drinking glass every 4 hours

d. change the water in your drinking glass every 4 hours

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95

a nurse is assessing a client who has acute kidney failure. which of the following findings should the nurse report to the provider? a. urine specific gravity 1.045 b. peripheral pulses 2+ bilaterally c. creatinine .8ml/dl d. weight gain 1.1 kg in 24hr

a. urine specific gravity 1.045

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96

a home health nurse is providing care to an older adult during the winter. during an income visit the nurse notes that the thermostat is set to 12.8 degrees celsius. the client tells the nurse I keep the heat set low because I cannot afford to pay the bill. which of the following actions should the nurse take? a. contact the clients family members to tell the the clients financial status b. recommend staying at a local shelter until the client can afford the bill c. contact the local department of health and human services for the client d. provide the client with written information about the degrees of hypothermia

c. contact the local department of health and human services for the client

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97

a nurse is caring for a client following a bronchoscopy. which of the following actions should the nurse take first? a. inform the client they might experience a low grade fever b. check the clients gag reflex c. instruct the client to report bleeding d. provide client with sips of water

b. check the clients gag reflex

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98

a nurse is teaching about measures to prevent urinary infections with a female client. which of the following information should the nurse include in the teaching? a. void every 6hr during the day b. take a warm bubble bath daily c. drink low fructose cranberry juice d. wipe the perineal area from front to back after urinating e. drink 3L of fluid daily

c. drink low fructose cranberry juice d. wipe the perineal area from front to back after urinating e. drink 3L of fluid daily

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99

a nurse is caring for a client who experiencing an acute asthma attack. which of the following should the nurse identify as a contributing factor to the clients manifestations? a. decreased responsiveness of the airways to allergens b. acute loss of alveolar elasticity c. surpassed bronchiolar inflammatory response d. inability to exhale retained carbon dioxide

d. inability to exhale retain carbon dioxide

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100

a nurse is caring for client who is schedule for a mastectomy. the client tells the nurse im not sure I want to have a mastectomy. which of the following statements should the nurse take? a. I can give you additional information about the procedure b. you will be cancer free if you have the procedure c. I can give you a list of other people who had the same procedure d. you should get a second opinion regarding the procedure

a. I can give you additional information about the procedure

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