36. A nurse is receiving change-of-shift report about the care of four clients. Which of the following

Question Answered step-by-step 36. A nurse is receiving change-of-shift report about the care of four clients. Which of the followingclients should the nurse see first?• A client who reports a pain level 4 on a scale of 0 to 10• A client who displays increased confusion over the past 4 hr• A client who has a blood glucose level of 128 mg/dl• A client who has a blood pressure of 138/88 mm Hg37. A nurse enters a client’s room and sees smoke coming from the bathroom. Which of thefollowing actions should the nurse take first?• Assist the client to a nearby common area• Use a fire extinguisher at the source of the smoke• Close the doors to the room and to the bathroom• Activate the fire alarm system.38. A nurse is caring for a client who is 8 hr postoperative following a left hiparthroplasty. Which ofthe following laboratory values indicates the nurse should notify the provider?• Hemoglobin 8.6 g/dl• Potassium 3.6 mEq/l• BUN 18/dl• Blood glucose 98 mg/dl39. A nurse is caring for a client who has been admitted with Addison’s disease. For which of thefollowing laboratory findings should the nurse plan to monitor and report to the provider.• Sodium 140 mEq/l• Glucose 55 mg/dl• BUN 15 mg/dl• Potassium 3.8 mE1/l40. A nurse is reinforcing teaching with a client who is starting metformin extended release. Whichof the following instructions should the nurse include in the instruction?• Expect muscle pain while taking this medication.• Take the medication with breakfast.• Monitor blood glucose while taking this medication• Chew the medication before swallowing.41. A nurse is collecting data from a client prior to administering hydrochlorothiazide for mildhypertension. Which of the following findings should the nurse identify as a contraindication toadministering the medication?• Potassium 2.8 mEq/l• 2+ pedal edema• History of GERO• Allergy to shellfish42. A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory resultsshould the nurse report to the provider?• Fasting blood glucose 70 mg/dl• Urine positive for ketones• Glycosylated hemoglobin 5.2%• Urine negative for bilirubin43. A nurse is collecting data from a client who had a left hemispheric stroke. Which of the followingfindings should the nurse report to the provider?• Inability to follow direction• Difficulty speaking• Right- sided weakness• A change in pupil size44. A nurse is planning care for a client who is receiving radiation therapy to treat throat cancer andreports a change in the taste of food. Which of the following interventions should the nurseinclude in the plan of care?• Provide three large meals daily• Heat food before serving• Add honey to sweeten fruit smoothies.• Offer artificial saliva frequently45. A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newlylicensed nurse. Which of the following should the nurse include in the teaching?• Avoid direct contact• Isolate for 24 hr after lesions appear• Place on airborne precautions• Administer abroad-spectrum antibiotic46. A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluidreplacement. Which of the following should the nurse contribute to the plan of care?• Limit oral fluids prior to bedtime.• Offer oral fluids every 4 hr.• Monitor pulse pressure every 6 hr• Check for neck vein distention.47. A nurse caring for a young adult client who has testicular cancer and expresses concern abouttheir sexual function following the involved testicle. Which of the following responses shouldthe nurse make?• “There are other ways to express intimacy besides intercourse.”• “The removal of a single testicle will not prevent you from having a erection.”• “You should focus on recovering from your cancer right now.”• “I’m sure any partner will understand that you have no control over this.”48. A nurse is obtaining a medication history from a client who is to start taking nitroglycerin forchest discomfort with activity. Which of the following medications should the nurse instruct theclient to avoid taking within 24 hr of using nitroglycerine?• Atorvastatin• Omeprazole• Metformin• Slidenafil49. A nurse is reviewing the results of a client’s fecal occult blood screening test. Which of thefollowing findings from the client’s history should the nurse identify as potentially causing afalse-positive result?• The client consumed citrus juice 3 days before test.• The client takes ibuprofen for headaches.• The client has a history of breast cancer.• The client had a hemorrhoidectomy 1 year ago.50. A nurse is caring for a client who has dysphagia and left-sided weakness following a stroke.Which of the following actions should the nurse take when assisting the client feeding?• Place the food on the affected side of the client’s mouth.• Position the client upright for 5 min after eating.• Offer the client sticky foods such as peanut butter• Instruct the client to place their chin to their chest when swallowing.51. A nurse is reinforcing teaching with a client about increasing her intake of fiber. Which of thefollowing foods should the nurse encourage the client to eat?• Yogurt• Pears• Eggs• Cheese52. A nurse is preparing to assist with the administration of peritoneal dialysis to a client. In whichorder should the nurse take the following steps? (Number them in the order of performance.Use all the steps)Measure the client’s abdominal girthRecord the client’s vital signsInfuse dialysate solution into the client’s peritoneal cavity.Prime the client’s catheter tubing with dialysate solutionOpen the client’s drainage tubing after 10 min of dwell time.53. A nurse is caring for an older adult client who has stomatitis due to poorly fitting dentures.Which of the following actions should the nurse take?• Rinse the client’s mouth twice daily with an alcohol-based mouthwash• Provide the client with a high- protein diet.• Offer the client hot beverage to drink• Increase the client’s fluid intake to 2.000 ml daily.54. A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease. Which ofthe following dietary instructions should the nurse include?• Chew food thoroughly• Drink carbonated beverages with meals• Use a straw when drinking liquids• Limit meals to three per day with no snacking in between.55. A nurse is caring for a client who has Parkinson’s disease. The client displays difficulty usingutensils while eating at mealtime. For which of the following interdisciplinary team membersshould the nurse recommend a referral?• Speech therapist• Occupational therapist• Physical therapist• Recreational therapist56. A nurse is reinforcing teaching about decreasing the risk of osteoporosis to a client who ispostmenopausal. Which of the following instructions should the nurse include?• Add weight-bearing exercise regimen• Increase daily intake of vitamin E• Limit vitamin D intake.• Take calcium carbonate supplements once a day with breakfast.57. A nurse is collecting data about immunization from 65-year old client who has no identified riskfactors for disease. The nurse should identify the client’s need for which of the followingimmunizations?• Measles, mumps and rubella• Human papilloma virus• Inactivated polio virus• Herpes zoster58. A nurse is caring for a client who has a prescription for a sequential compression device (SCD).Which of the following actions should the nurse take when applying the SCD?• Ensure two fingers fit between the leg and the sleeve.• Wrap excess tubing to the side of each leg.• Ensure pressure of the device is at 25 mm Hg• Place each sleeve under each leg with the opening at the calf.59. A nurse is reinforcing teaching about a transcutaneous electrical nerve stimulation (TENS) unitfor a client who has a herniated intervertebral. Which of the following statements by the clientindicates an understanding of the teaching?• “I should adjust the TENS unit until I feel a tingling sensation.”• “I will need to charge the TENS unit for 2 hours each day.”• “The TENS unit should be applied at least 6 inches from the actual site of my pain.”• “The TENS unit administers continuous dose of pain medication.”60. A nurse is reviewing the medical record of a client who reports his urine is red-orange. The nurseshould identify that which of the following medication can cause this adverse effect?• Rifampin• Furosemide• Isoniazid• Metroprolol61. A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The clientreceived an opioid analgenic 1 hr ago an reports a pain level of 2 on ascale of 0 to 10. Which ofthe following actions should the nurse take?• Maintain client on bed rest• Administer an additional dose of pain medication• Apply a warm, moist compress to the incision area• Reposition the client62. A nurse is reinforcing teaching with a client who is to begin taking Lansoprazole. Which of thefollowing statements by the client indicates understanding of the teaching?• “I should expect the medication to cause indigestion.”• “I should report episodes of diarrhea.”• “I should take the medication following a meal.”• “I should chew the capsule thoroughly.”63. A nurse is collecting data from an older adult client which of the following findings shouldindicate to the nurse that the client has black fungus infection?• WBC count 9.000/mm3• Diminished reflexes• Changed mental status• Temperature 37.3oC(99.1F)64. A nurse is caring for a client who has returned to the unit following a cardiac catheterizationusing a femoral approach. Which of the following methods should the nurse use to monitor forcomplication?• Palpate the client’s brachial pulses and compare bilaterally.• Check the client’s blood pressure while the client lies supine, sits and stands.• Palpate the client’s pedal pulses and compare bilaterally.• Check for jugular vein distention while the client is supine.65. A nurse is caring for a client who is hypoxic and has a prescription for oxygen therapy at 40% viaventuri mask. Which of the following masks should the nurse identify as a venturi mask?ooo•66. A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronicarthritis which of the following interventions should the nurse include in the plan?• Apply foam handles to the client’s eating utensils• Ask the provider for a prescription for a pureed diet.• Obtain a referral for physical therapy• Have an assistive personnel feed the client.67. A nurse is collecting that from a client who has gastroenteritis with diarrhea and vomiting.Which of the following laboratory values should alert the nurse that the client is at risk for fluidvolume deficit?• Hematocrit 56mg/dl• Potassium 4.5 mEq/L• Sodium 140 mEq/L• Creatinin 1.1 mg/dl68. A nurse in a long term care facility is providing care for a client who has Alzheimer’s disease andis agitated. Which of the following interventions should the nurse implement?• Administer a prescribed oral dose of trazadone to the client.• Isolate the client in their room• Apply bilateral restraints to the client• Encourage the client to ambulate with a staff member.69. A nurse is caring for a client who is in skin traction which of the following actions should thenurse take ?• Loosen the ropes of the pulleys when repositioning the client in bed.• Inspect the client’s every 12 hours for signs of breakdown.• Ensure the weights hang freely from the client’s bed.• Maintain 6.8kg(15lb) of weight for the client’s skin traction.70. A nurse is preparing to administer diphenhydramine 25 mg PO every 6hr to an older adult whohas rhinitis. The amount available is diphenhydramine syrup 12.5 mg/5 ml. How many ml shouldthe nurse administer?(Round the answer to the nearest whole number. Use a leading zero if itapplies. Do not use a trailing zero.)71. A nurse is preparing a client for a colposcopy following an abnormal Papanicolau test(Pap).Which of the following actions should the nurse take?• Instruct the client to avoid sexual intercourse until the cervix is healed• Place the client in Sims’ position• Reinforce teaching that the procedure involves dilation of the cervix• Insert a tampon following the procedure.1072. A nurse is reinforcing teaching with a client about self-breast examination. Which of thefollowing statements by the client indicates understanding of the teaching?• “I will perform breast exams on the day my period begins.”• “I will perform breast exams every other month.”• “It is common for one breast to be larger than the other.”• “It is common for the skin on my breast to dimple.”  Health Science Science Nursing NUR 3463 Share QuestionEmailCopy link Comments (0)