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A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (Ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?: a. Headache b. Infection c. Aphasia d. Hypertension - correct answers-b. Infection Monitor for infection and use strict asepsis to avoid life-threatening meningitis. A nurse is providing education to a client who is to undergo an EEG the next day. Which of the following info should the nurse include in the teaching? a. "Do not wash your hair the morning of the procedure." b. "Try and stay awake most of the night prior to the procedure." c. "The procedure will take approximately 15 mins." d. "You will need to lie flat for 4 hours after the procedure." - correct answers-b. "Try and stay awake most of the night prior to the procedure." Tell the client to remain awake to provide cranial stress and increase the possibility of abnormal electrical activity A nurse is caring for a client who is postprocedural following a lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? SATA. a. Use the GCS scale to assess the client b. Assist the client into a supine position c. Administer an opioid analgesic d. Encourage the client to increase PO fluid intake e. Instruct the client to perform coughing and deep breathing - correct answers-B, D A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider? a Output equal to the instilled irrigate b. Client reports bladder spasms c. Viscous urinary output with clots d. Reports of strong urge to urinate - correct answers-c. Viscous urinary output with clots Urine that is bright red with clots is an indication of arterial bleeding. A nurse is monitoring the ECG of a client who has hypocalcemia. Which of the following findings should the nurse expect? a. Flattened T waves b. Prolonged QT intervals c. Shortened QT intervals d Widened QRS complexes - correct answers-b. Prolonged QT intervals Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. A nurse is preparing a client who has a brain tumor for a CT scan. Which of the following factors affects the manner in which the nurse will prepare the client for the scan? a. No food or fluids consumed for 4 hours b. Difficulty recalling recent events Manifestations of bacterial meningitis include increase protein in the CSF, decreased glucose. RBCs can indicate bleeding, however, WBCs are what indicates bacterial meningitis. Anurse is providing teaching to a client who has a new diagnosis of myasthenia gravis (MG). Which of the following pieces of information should the nurse include? A. Use enemas to treat constipation caused by daily medications B. Take a hot bath when muscles ache C. Eat a low-calorie diet D. Set an alarm to ensure medication dosages are taken on time - correct answers-D, Set an alarm to ensure medication dosages are taken on time The nurse should instruct the client to take medication dosages on time to maintain a therapeutic blood level. Dosages should not be missed or postponed because this can cause an exacerbation of the disease. A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (Select all that apply.) A. Lost vision can improve with eye drops. B. Administer eye drops as needed far vision loss. C. Glasses will be necessary to correct the accompanying presbyopia. D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor. - correct answers-D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor. A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? A. Ecchymosis of the thigh B. Serous drainage at the pin site C. Chest petechiae D. Muscle spasms in the left leg - correct answers-C. Chest petechiae The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients who have fractures of the long bones such as the femur are at increased risk of fat emboli. Fat emboli typically occur 12 to 48 hours after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress to acute respiratory failure. A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect? A. Nonproductive cough, fever, and shortness of breath B. Lesions on the retina that produce blurred vision C. Onset of progressive dementia D. Reddish-purple skin lesions - correct answers-D. Reddish-purple skin lesions Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following a biopsy, the lesions are treated with radiation and/or chemotherapy. A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? A. Chest pain is relieved soon after resting. B. Nitroglycerin relieves chest pain. C. Physical exertion does not precipitate chest pain. D. Chest pain lasts for longer than 15 min. - correct answers-D. Chest pain lasts for longer than 15 min. B. Limit fluid intake with meals C. Provide oral hygiene with a firm-bristled toothbrush after each meal D. Avoid salty foods - correct answers-D. Avoid salty foods Stomatitis is an inflammation of the mucosa of the mouth, usually with ulcerations. Foods that are spicy, acidic, or salty should be avoided to prevent further irritation and damage to the oral mucosa. Anurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? A. The client will need intensive smoking-cessation education. B. After surgery, the prognosis for clients with lung cancer is usually good. C. Lung cancer usually has metastasized before the client presents with symptoms. D. Oxygen therapy is ineffective following a lobectomy. - correct answers-C. Lung cancer usually has metastasized before the client presents with symptoms. The nurse should be aware that lung cancer is usually at an advanced stage before the client has any manifestations. This has implications for both short-term and long-term care options for the client. Anurse is examining the ECG of a client wha has hyperkalemia. Which of the following ECG changes should the nurse expect? A. Elevated ST segments B. Absent P waves C. Depressed ST segments. D. Varying PP intervals - correct answers-A. Elevated ST segments Elevated ST segments can indicate hyperkalemia and pericarditis. Anurse is caring for a client during the first 72 hr following a cerebrovascular accident (CVA). Which of the following actions should the nurse take? A. Turn the client's head to the side with the head of the bed elevated 60° B. Place the head of the bed flat with pillows under the client's neck and feet C. Elevate the head of the bed 25° to 30° with the client in a neutral midline position D. Position the client in a dorsal recumbent position with pillows under the head and knees - correct answers- Anurse is caring for a client who is taking streptomycin. Which of the following medications increases the client's risk of developing ototoxicity when taken with streptomycin? A. Cefoxitin B. Furosemide C. Naproxen D. Amphotericin B - correct answers-B. Furosemide Furosemide, a high-ceiling (loop) diuretic, increases the risk of developing ototoxicity when taken with streptomycin, an aminoglycoside. Anurse is preparing to administer an IM injection for a client. Which of the following factors should the nurse identify as a potential contraindication to administering the medication via the IM route? A. The medication is a depot preparation. B. The client is taking an anticoagulant. C. The medication is a particulate suspension. D. The client has been vomiting. - correct answers-B. The client is taking an anticoagulant. Because of the risk of bleeding from the injection site, anticoagulant therapy (e.g. warfarin) is a contraindication to receiving medications via the IM route. A nurse is caring for a client with Clostridium difficile who has contact-isolation precautions in place. Which of the following actions should the nurse perform? An emergency room nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? A. Monitor urinary output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure precautions - correct answers-C. Provide supplemental oxygen The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to provide supplemental oxygen. The client might require an artificial airway and mechanical ventilation because these findings indicate decerebrate positioning, which is associated with brainstem injury and can lead to brain herniation and death. A nurse is teaching a client who has persistent cancer pain about the adverse effects of opioids. Which of the following statements should the nurse include in the teaching? A. "Opioids do not relieve pain without causing severe adverse effects." B. "Physical dependence is not the same as addiction." C. "Tolerance typically means that the medication will no longer be effective." D. "The most common adverse effect is respiratory depression with prolonged use." - correct answers-B. "Physical dependence is not the same as addiction." The nurse should explain that physical dependence can occur in all clients who take opioids, and the client may develop abstinence syndrome if the opioid is abruptly withdrawn. Physical dependence is not the same as addiction, but it can result in addiction. Addiction results when the opioid is continued despite physical or psychological harm. A nurse is preparing a client who is scheduled to have an arthroscopy the following day. Which of the following statements indicates that the client understands the pre-procedure teaching? A. "Lhave to keep my leg straight throughout the whole procedure." B. "The dactor will be able to see if | have signs of rheumatoid arthritis." C. "| should expect to stay overnight until | can walk around." D. "I'll have a scar that will be about an inch long." - correct answers-B. "The doctor will be able to see if | have signs of rheumatoid arthritis." An arthroscopy helps with diagnosing musculoskeletal disorders such as rheumatoid arthritis, osteoarthritis, and internal joint injuries. A nurse is caring for a client who has manifestations of acute tubular necrosis (ATN) following a kidney transplantation. Which of the following interventions should the nurse anticipate for this client? (Select all that apply.) A. Hemodialysis B. Biopsy C. Immunosuppression D. Balloon angioplasty E. Surgical repair - correct answers-A, B, C Clients wha develop ATN after transplantation surgery might need dialysis until they have an adequate urine output and their BUN and creatinine levels stabilize. Because the development of ATN after transplantation surgery mimics the symptoms of rejection of the transplanted kidney, clients have to undergo a biopsy to determine the correct diagnosis. Immunosuppressive medication therapy is essential after kidney transplantation to protect the new kidney. Anurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? A. "Because most of my colon is still intact and functioning, my stool will be formed." B. "My stoma will appear large at first, but it will shrink over the next several weeks." C. "My colostomy will begin to function in 2 to 6 days after surgery." D. "I'll have to consume a soft diet after surgery." - correct answers-D. "I'll have to consume a soft diet after surgery." C. Infection D. Sunlight - correct answers-A. Exercise SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks healthy body tissue. This attack results in generalized inflammation and creates manifestations associated with the specific involved tissues. Most clients who have SLE can follow an exercise program to increase their cellular aerobic capacity and improve immune function, and the client should follow a program with her provider's assistance. This client needs additional teaching about the importance of exercise to keep her muscles and joints active. A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect? A. Kussmaul respirations B. Diaphoresis C. Decreased skin turgor D. Ketonuria - correct answers-B. Diaphoresis A client who has a blood glucose level below 70 mg/dL will exhibit manifestations of hypoglycemia. Expected findings associated with hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness, and confusion. A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect? A. Hypokalemia B. Hypernatremia C. Elevated Het D. Decreased Hgb - correct answers-C. Elevated Hct The nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit level as blood volume is reduced by vascular dehydration. Incorrect Answers: A. The nurse should expect the client to have hyperkalemia as a result of potassium being leaked from cellular injury. B. The nurse should expect the client to have hyponatremia once sodium leaks into the interstitial space, causing decreased levels in the blood. D. The nurse should expect the client to have an increased hemoglobin level as blood volume is reduced by vascular dehydration. Anurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? A. Narrower than usual QRS complexes B. Much greater amplitude than the usual QRS complexes C. Same polarity as the usual QRS complexes D. Immediate resumption of the usual rhythm - correct answers-B. Much greater amplitude than the usual QRS complexes The QRS complexes unusually have greater amplitude in height and depth in clients with PVCs. A nurse is caring for a client who is experiencing autonamic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next? A. Administer nifedipine B. Place the client in a high-Fowler's position C. Check for urinary retention D. Check for a fecal impaction - correct answers-B. Place the client in a high-Fowler's position According to evidence-based practice, the nurse should first place the client in a high-Fowler's position to decrease the client's blood pressure and reduce the risk of end-organ damage from the sudden rise in blood pressure. According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately. A nurse is teaching a client who has polycythemia vera about self-care measures. Which of the following interventions should the nurse include? A. "Drink at least 1 liter of fluid each day." B. "Continuously wear support hose." C. "Elevate your legs when sitting.” D. "Use dental floss daily." - correct answers-C. "Elevate your legs when sitting." Clients who have polycythemia vera should elevate their legs when seated to avoid venous pooling with subsequent clot formation. Anurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care? A. Restrict fluids to 1,000 mL per day B. Measure the client's abdominal girth daily C. Check IV sites every 4 hr for bleeding D. Administer an enema as needed for constipation - correct answers-B. Measure the client's abdominal girth daily The nurse should measure the client's abdominal girth daily to monitor for manifestations of internal bleeding. A client who has a reduced platelet count is at risk of bleeding due to delayed clotting. A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on the chest and arms D. Flushed, dry skin E. Abdominal distension - correct answers-B C E The formation of large amounts of microemboli in the circulation depletes the body's platelets and clotting factors. As a result, uncontrollable bleeding can occur, as manifested by bleeding at the venipuncture site, petechiae on the chest and arms, and bleeding in the abdominal cavity resulting in abdominal distension due to internal bleeding. A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply.) A. Auscultate injected air B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Check the aspirated fluid for glucose - correct answers-B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouthpiece with an alcohol swab after each use D. Use the spirometer every 8 hr - correct answers-B. Cough deeply after each use For a bronchoscopy, clients typically receive premedication with a benzodiazepine or an opioid to ensure sedation and amnesia. The client will have signed a consent form, so the nurse should verify that the provider explained the procedure and that the client understands it. A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? A. Absent pedal pulses B. Ankle swelling C. Hair loss D. Skin atrophy - correct answers-B. Ankle swelling The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. Other manifestations can include brown pigmentations and cellulitis. A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. Depressed fracture of the forehead B. Clear fluid coming from the nares C. Motor loss on one side of the body D. Bleeding from the top of the scalp - correct answers-B. Clear fluid coming from the nares Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture. A nurse is caring for a client who has diabetes insipidus. For which of the following findings should the nurse monitor? A. Proteinuria B. Oliguria C. Polyuria D. Glycosuria - correct answers-C. Polyuria Aclient is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members? A. Use battery-operated equipment for personal care. B. Apply mineral oil to protect the facial skin from irritation. C. Remove the television set from the client's bedroom. D. Wear cotton clothing to avoid static electricity. - correct answers-D. Wear cotton clothing to avoid static electricity. The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark. A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? A. Gloves B. Gown C. Eyewear D. Mask - correct answers- Anurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest X-ray. The nurse should instruct the newly licensed nurse to take which of the following actions? A. Have the client wear a surgical mask. B. Wear a gown for protection from the client's infection. 
