Adult Health 1 (NR 324) Exam 2 Chamberlain UniversityAdult Health 1 (NR 324) Exam 2 Chamberlain Univ

Adult Health The nurse is planning care for a client with a hemoglobin of 6.0 g/dL. Which action should the nurse anticipate including in the plan of care? A Alternate periods of rest and activity. ✓ B Increase the client's dietary vitamin K intake.

C Place the client on neutropenic precautions. D Administer heparin subcutaneously.

The correct answer is A) Alternate periods of rest and activity.

The nurse is caring for a client with a tibial fracture. Which prescription does the nurse know is used to prevent complications of immobility? A Ondansetron 4mg IV push. B Fentanyl 25 mcg IV push. C Ibuprofen 600 mg PO. D Heparin 5,000 units subcutaneously. Answers: A -D The correct answer is D) Heparin 5,000 units subcutaneously.

The nurse is caring for a client being treated for primary polycythemia vera.

Which healthcare provider order should the nurse anticipate? Answers: A -D A Phlebotomy. B Fluid restriction C Iron supplementation D Platelet infusion The correct answer is A) Phlebotomy.

A nurse is caring for a client with a platelet level of 18,000/mcL. Which finding requires immediate action? Answers: A-D A Petechiae on the lower legs. B Lethargy on assessment. C Bruising around the IV site. D Oozing of blood from the nose.

The finding that requires immediate action due to the client's low platelet count is: D) Oozing of blood from the nose.

A nurse is caring for a client admitted with an exacerbation of ulcerative colitis.

Which nursing action should be included in the plan of care? Answers: A-D A Monitor stools for blood B Increase dietary fiber intake C Decrease fluid intake D Administer ibuprofen for pain The appropriate nursing action to include in the plan of care for a client admitted with an exacerbation of ulcerative colitis is: A) Monitor stools for blood.

The nurse has received handoff shift report at the human immunodeficiency virus (HIV) clinic. Which client should the nurse assess first? A A client reporting

having a cough, congestion, and chills for the last 24 hours. B A client whose rapid HIV antibody test is positive. C A client whose latest CD4+ count has dropped to 300 uL. D A client reporting having a headache from prescribed antiretroviral medications. Answers: A - D The client the nurse should assess first is: A) A client reporting having a cough, congestion, and chills for the last 24 hours.

A nurse is planning education for a client with rheumatoid arthritis about joint preservation strategies. Which activity should the nurse include in the teaching?

A Avoid activity and rest in bed as much as possible. B Perform all household chores in one day. C Stand during meal preparation to keep joints loose. D Use the strongest joint for any task or activity. Answers: A-D The activity the nurse should include in the teaching for joint preservation strategies for a client with rheumatoid arthritis is: C) Stand during meal preparation to keep joints loose.

The nurse is planning to educate a client with Crohn's disease about pernicious anemia. What should the nurse include in the education? Answers: A -D A Iron dextran infusions B Routine blood transfusions C Oral ferrous sulfate tablets D Cobalamin (B12) injections The nurse should include the following in the education about pernicious anemia for a client with Crohn's disease: D) Cobalamin (B12) injections.

A nurse is preparing to administer vancomycin 500 mg PO daily divided into four equal doses. The amount available is vancomycin 125 mg capsules. How many capsule(s) should the nurse administer with each dose? 1 capsule(s) (If needed, round the answer to the nearest whole number.)

To administer vancomycin 500 mg PO daily divided into four equal doses, you would divide the total daily dose (500 mg) by the number of doses (4).

500 mg / 4 doses = 125 mg per dose.

Since the available capsules are 125 mg each, the nurse would administer: 125 mg per dose / 125 mg per capsule = 1 capsule per dose.

So, the nurse should administer 1 capsule with each dose.

A nurse prepares to administer gentamycin 800 mg in 100 mL of dextrose 5% in water (D5W) to infuse over 1 hr. The drop factor of the tubing is 15 gtt/ml. At what rate will the nurse set the infusion? 1 gtt/min (If needed, round the answer to the nearest whole number.)

To calculate the infusion rate in drops per minute (gtt/min), we need to use the formula: Infusion rate (gtt/min) = (Volume to be infused × Drop factor) / Time of infusion (in minutes) First, let's convert the volume to be infused from mL to drops: Volume to be infused = 100 mL × 15 gtt/mL = 1500 gtt Now, we can calculate the infusion rate: Infusion rate (gtt/min) = (1500 gtt × 1 min) / 60 min = 25 gtt/min Therefore, the nurse should set the infusion rate to 25 gtt/min.

The nurse is planning care for a client after a Roux-en-Y gastric bypass (RYGB) surgery. For each potential healthcare provider order, indicate if it is anticipated or not anticipated in the care of this client. Action Not Anticipated Anticipated Place the client on a liquid diet. Maintain total bedrest for 24 hours. Provide 30 mL of fruit juice every two hours. Position the client with the head elevated 3045 degrees. Administer subcutaneous heparin. ●

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Place the client on a liquid diet. ● Anticipated. After Roux-en-Y gastric bypass surgery, clients typically start with a liquid diet and gradually progress to solid foods.

Maintain total bedrest for 24 hours. ● Not Anticipated. While the client may have restrictions on physical activity immediately after surgery, total bedrest for 24 hours is not typically required.

Provide 30 mL of fruit juice every two hours. ● Anticipated. Fluid intake is important after surgery to prevent dehydration and promote healing. Fruit juice can provide calories and hydration.

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Position the client with the head elevated 30-45 degrees. ● Anticipated. Elevating the head of the bed helps reduce the risk of aspiration and promotes respiratory function after surgery.

Administer subcutaneous heparin. ● Anticipated. Prophylactic administration of anticoagulants such as heparin is common after surgery to prevent deep vein thrombosis (DVT) and pulmonary embolism (PE).

The nurse is planning education for a client with gastroesophageal reflux disease (GERD). Which statement should the nurse include in the teaching regarding the treatment goal of GERD? A "Treatment is aimed to reduce acid production in the stomach." B "Treatment is focused on reducing the rate of gastric emptying." C "Treatment will relax the lower esophageal sphincter." D "Treatment will reduce the frequency of belching." Answers: A -D The statement that the nurse should include in the teaching regarding the treatment goal of GERD is: A) "Treatment is aimed to reduce acid production in the stomach."

A nurse is caring for a client with a stage IV pressure ulcer and a history of methicillin-resistant staphylococcus aureus (MRSA). Which finding should the nurse report to the healthcare provider immediately? Answers: A - D A Temperature of 100.9° F B Respiratory rate of 20 breaths per minute C Heart rate of 102 beats per minute D Blood pressure of 100/62 mmHg The finding that the nurse should report to the healthcare provider immediately is: A) Temperature of 100.9°F A nurse is caring for a client with suspected inflammatory bowel disease. Which finding would suggest ulcerative colitis, rather than Crohn's disease? Answers: A-D A Many episodes of bloody diarrhea B Decreased albumin level C Abdominal pain and cramping D Significant inflammation in the small intestine The finding that would suggest ulcerative colitis, rather than Crohn's disease, is: A) Many episodes of bloody diarrhea.

A client presents to the emergency department with pain and ankle swelling following a soccer injury. Which action should the nurse implement first? २ A

Provide morphine 2 mg IV push. B Contact the radiology department to arrange an ankle x-ray. C Administer ibuprofen PO. D Elevate the leg and apply an ice pack. Answers: A -D The action the nurse should implement first is: D) Elevate the leg and apply an ice pack.

A nurse is caring for a client with renal failure and a hemoglobin of 8.1 g/dL. Which medication should the nurse expect to administer? Answers: A - D A Erythropoietin B Vitamin B12 C Vitamin K D Folate supplement The medication the nurse should expect to administer for a client with renal failure and a hemoglobin of 8.1 g/dL is: A) Erythropoietin A client reports pain in the right foot one day after a right below-the-knee amputation. Which is the nurse's best action? A Contact the healthcare provider to inquire about mirror therapy. B Explain that the brain does not yet understand the limb is no longer there. C Remove and re-wrap the compression bandage. D Provide intravenous pain medication. Answers: A - D The nurse's best action in this situation is: C) Remove and re-wrap the compression bandage.

A nurse is administering an antibiotic infusion. Ten minutes into the infusion, the client reports pruritis and dyspnea. What should the nurse do first? A Administer 2 L of oxygen via nasal cannula and administer diphenhydramine. B Auscultate lung sounds and count respiration rate. C Contact the health care provider and charge nurse. D Elevate the head of the bed and discontinue the infusion.

Answers: A-D\ The nurse's first action should be: D) Elevate the head of the bed and discontinue the infusion.

A nurse is caring for a client with a platelet count of 19,000/mcL. Which is the priority action by the nurse? Answers: A -D A Initiate bleeding precautions. B

Assess temperature every four hours. C Activate the rapid response team D Place the client in protective isolation.\ The priority action by the nurse for a client with a platelet count of 19,000/mcL is: A) Initiate bleeding precautions.

A client presents to the emergency department vomiting bright red blood.

Which action should the nurse perform first? Answers: A - D A Obtain vital signs. B Palpate the abdomen. C Listen to heart sounds. D Measure emesis output.

In this scenario, the nurse's first action should be to: A) Obtain vital signs.

A nurse is planning care for a client with thrombocytopenia. Which intervention should the nurse include in the plan of care? A Monitor for blood in the urine and stool. B Measure abdominal girth twice weekly. C Assess core temperatures using a rectal thermometer. D Monitor for the increase of white blood cells in the complete blood count results. Answers: A - D The intervention the nurse should include in the plan of care for a client with thrombocytopenia is: A) Monitor for blood in the urine and stool.

A nurse is providing discharge instructions to a client with neutropenia. Which information should the nurse include? Select all that apply. Answers: A - F G A Bathe daily to reduce microorganisms on the skin. B Avoid crowds and anyone with infectious symptoms. C Appoint another person to clean up after pets. D Do not eat undercooked meat or raw fish. E Take folic acid supplements every day. F Avoid sharing glasses and utensils with others.

For a client with neutropenia, the nurse should include the following information in the discharge instructions: B) Avoid crowds and anyone with infectious symptoms. ●

Neutropenic clients are at increased risk of infection due to a low neutrophil count. Avoiding crowds and individuals with infectious symptoms helps reduce the risk of exposure to pathogens.

D) Do not eat undercooked meat or raw fish.

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Neutropenic clients are more susceptible to foodborne infections.

Advising against consuming undercooked meat or raw fish helps minimize the risk of exposure to pathogens that could cause foodborne illness.

F) Avoid sharing glasses and utensils with others.

Sharing glasses and utensils can increase the risk of exposure to pathogens. Neutropenic clients should avoid sharing these items to reduce the risk of infection transmission.

The nurse is caring for a client with severe anemia who is receiving a transfusion of packed red blood cells (PRBCs). Which laboratory result indicates the transfusion was successful? Answers: A - D A Hemoglobin of 11.5 g/dL B Red blood cell count of 2.1 cells/mcL C Platelet count of 230,000 UL D Partial thromboplastin time of 30 seconds ●

The laboratory result that indicates the transfusion was successful for a client with severe anemia receiving packed red blood cells (PRBCs) is: A) Hemoglobin of 11.5 g/dL A nurse is educating a client diagnosed with the human immunodeficiency virus (HIV) about highly active antiretroviral therapy (HAART). Which statement made by the client requires immediate follow-up? A "I have a lot of questions about the adverse effects of these medications." B "I have been on my HIV medications for 10 years." C "I always use a condom when having intercourse." D "I have a hard time remembering to take my daily medications." Answers: A - D The statement made by the client that requires immediate follow-up is: D) "I have a hard time remembering to take my daily medications."

What method can relieve joint stiffness in the morning for a client with rheumatoid arthritis? A Ensure the use of a soft mattress for sleeping. B Take prescribed corticosteroids before bed. C Perform weight lifting exercises upon waking. D Use warm packs on the affected joints. Answers: A-D The method that can relieve joint stiffness in the morning for a client with rheumatoid arthritis is: D) Use warm packs on the affected joints.

A nurse is caring for a client on neutropenic precautions. Which action is most important for the nurse to take? A Remove fresh fruit from the lunch tray. B

Increase dietary iron intake. C Place a humidifier in the room. D Administer a transfusion of packed red blood cells. Answers: A-D The most important action for the nurse to take when caring for a client on neutropenic precautions is: A) Remove fresh fruit from the lunch tray.

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via a nasogastric (NG) tube. Which action should the nurse take when administering the tube feeding? A Verify tube placement by auscultating for air over the stomach. B Hold feeding if there is any residual gastric contents. C Elevate the head of the bed at least 30 degrees. D Obtain an x-ray prior to each use. G Answers: A - D The action the nurse should take when administering enteral feedings via a nasogastric (NG) tube is: C) Elevate the head of the bed at least 30 degrees.

A nurse is caring for a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which clinical finding should be reported to the healthcare provider immediately? Answers: A-D A Creatinine 2.4 mg/dL B Macular rash over the cheeks C Hemoglobin 11.8 g/dL D Positive antinuclear antibody (ANA) test The clinical finding that should be reported to the healthcare provider immediately for a client with an acute exacerbation of systemic lupus erythematosus (SLE) is: A) Creatinine 2.4 mg/dL A nurse is monitoring a client receiving a blood transfusion. Which finding indicates the client is experiencing an allergic transfusion reaction? Answers: A D A Generalized urticaria B Distended jugular veins C Blood pressure 184/92 mm Hg D Bilateral flank pain The finding that indicates the client is experiencing an allergic transfusion reaction is: A) Generalized urticaria

A client who was in a motorcycle accident presents with massive swelling to the left lower leg. Which action will the nurse take first? Answers: A-D A Apply a compression bandage B Place ice packs on the lower leg C Elevate the leg on two pillows D Check leg pulses and capillary refill The action the nurse will take first for a client presenting with massive swelling to the left lower leg after a motorcycle accident is: D) Check leg pulses and capillary refill.

The nurse is teaching a client with anemia about a new ferrous sulfate prescription. Which client statement indicates an understanding of the teaching?

A "I should expect my stools to be black or dark in color." B "I should expect the fatigue to lessen within 24 hours." C "I will expect the color of my urine to be amber." D "I will take this medication with milk or other dairy product." Answers: A-D The client statement that indicates an understanding of the teaching about ferrous sulfate prescription is: A) "I should expect my stools to be black or dark in color."

The nurse is planning care for a client vomiting "coffee-ground" emesis. What diagnostic test should the nurse anticipate including in the client's plan of care?

Answers: A - D A Endoscopy B Barium studies C Angiography D Gastric analysis The diagnostic test the nurse should anticipate including in the client's plan of care for vomiting "coffee-ground" emesis is: A) Endoscopy The nurse received hand-off shift report on a group of clients. Which client should the nurse see first? A A client with ulcerative colitis complaining of diarrhea. B A client with nausea and is scheduled to receive ondansetron. C A client post-gastric bypass surgery with a potassium level of 3.0 mEq/L. D A client admitted with Crohn's disease complaining of abdominal cramping.

Answers: A - D The client the nurse should see first is: C) A client post-gastric bypass surgery with a potassium level of 3.0 mEq/L.

The nurse is caring for a client with a history of short bowel syndrome who is receiving total parenteral nutrition (TPN) through a central line. The client has been receiving TPN for the past two weeks and is scheduled to be discharged home on TPN. The nurse should educate the client and family about which potential complication caused by abruptly discontinuing a client's total parenteral nutrition (TPN)? Answers: A - D A Infection B Hypoglycemia C Liver dysfunction D Hypernatremia The potential complication caused by abruptly discontinuing a client's total parenteral nutrition (TPN) that the nurse should educate the client and family about is: B) Hypoglycemia A nurse is caring for a team of clients on a medical-surgical unit. For which client would the nurse question an order for enteral feedings? A A 35-year-old client with Crohn's disease experiencing peritonitis related to bowel perforation B A 55-year-old client with a stroke who is unable to swallow and has a nasogastric tube in place C A 45-year-old client with anorexia related to cancer treatment D A 65-year-old client with extensive burns who is on mechanical ventilation Answers: A-D The client for whom the nurse would question an order for enteral feedings is: A) A 35-year-old client with Crohn's disease experiencing peritonitis related to bowel perforation.

The nurse is caring for a client with a pressure ulcer. Which laboratory finding best indicates the client may have poor wound healing? Answers: A-D A Serum albumin of 2.1 g/dL B White blood cell count of 9,000/mcL C Prothrombin time of 12 seconds D Red blood cell count of 7.1/mcL The laboratory finding that best indicates the client may have poor wound healing is: A) Serum albumin of 2.1 g/dL A nurse is caring for a client admitted with ulcerative colitis. Which assessment finding should the nurse interpret as a potential complication of ulcerative colitis? Answers: A-D A Low hemoglobin and hematocrit B Epigastric pain following a high-fat meal C Low platelet count D Presence of steatorrhea

The assessment finding that the nurse should interpret as a potential complication of ulcerative colitis is: A) Low hemoglobin and hematocrit A nurse is caring for a client who just received a cast for a fractured tibia. Which action is the priority immediately after the healthcare provider has applied the cast? A Having the client perform range of motion B Instructing the client about cast care C Managing pain D Checking capillary refill distal to the cast Answers: A-D The priority action immediately after the healthcare provider has applied the cast is: D) Checking capillary refill distal to the cast.

A client with a history of coronary artery disease and anemia is admitted to the hospital with fatigue and shortness of breath. The client's hemoglobin level is 6.8 g/dL. The healthcare provider prescribes one unit of packed red blood cells.

Which nursing action(s) should be included in the plan of care to support the safe administration of blood components? Select all that apply. A Set up the transfusion with a "Y-type" tubing set. B Obtain a baseline set of vital signs and assess the client's lung sounds. C Ensure the pump is set to deliver the transfusion in less than 4 hours. D Start the transfusion within 60 minutes of receiving the blood from the blood bank. E Assess the client's intravenous line for patency. Answers: A - E The nursing actions that should be included in the plan of care to support the safe administration of blood components are: A) Set up the transfusion with a "Y-type" tubing set.

B) Obtain a baseline set of vital signs and assess the client's lung sounds.

D) Start the transfusion within 60 minutes of receiving the blood from the blood bank.

E) Assess the client's intravenous line for patency.

A nurse is caring for a client taking a non-steroidal anti-inflammatory drug for osteoarthritis pain. Which finding is the priority for the nurse to report to the healthcare provider? Answers: A-D A Constipation B Vomiting C Abdominal discomfort D Melena

The finding that is the priority for the nurse to report to the healthcare provider when caring for a client taking a non-steroidal anti-inflammatory drug (NSAID) for osteoarthritis pain is: D) Melena A client with a post-operative colostomy refuses to look at the stoma four days after surgery and states, "It's so gross, I can't stand it." Which is the nurse's best response? A "It is understandable that you feel this way, as this is a huge change for you." B "It is really important for you to look at your stoma so we can get you discharged." C "I will obtain a psychology consult from the provider so you can speak with someone about this." D "Don't worry, this will get better as more time passes." Answers: A-D The nurse's best response to the client's refusal to look at the stoma four days after surgery is: A) "It is understandable that you feel this way, as this is a huge change for you."

The nurse is teaching a client how to prevent dumping syndrome after a Rouxen-Y gastric bypass (RYGB) surgery. Which statement by the client indicates understanding? Answers: A-D A "I will drink fluids before or after meals." B "I will call the provider if I start vomiting." C "I will increase my intake of carbohydrates." D "I will decrease my intake of protein."

The statement by the client that indicates understanding of how to prevent dumping syndrome after a Roux-en-Y gastric bypass (RYGB) surgery is: A) "I will drink fluids before or after meals."

The nurse is caring for a client following a total hip replacement. Which action(s) should the nurse include in the client's plan of care? Select all that apply. A Demonstrate how to bend at the waist to put on socks and shoes. B Provide a raised toilet seat for the client's restroom. C Educate the client to remain in bed for the first 24 hours. D Assess the client's pulses and capillary refill distal to the surgical site. E Teach the client to perform deep breathing and coughing exercises. Answers: A -E The actions the nurse should include in the client's plan of care following a total hip replacement are: B) Provide a raised toilet seat for the client's restroom.

D) Assess the client's pulses and capillary refill distal to the surgical site.

E) Teach the client to perform deep breathing and coughing exercises.

The nurse has received handoff shift report on a group of clients. Which client should the nurse see first? A A client with neutropenia reporting a sore throat and chills. B A client with sickle cell anemia reporting nausea for the last 24 hours. C A client with a hemoglobin of 9 g/dL reporting fatigue. D A client with thrombocytopenia who has petechiae on the arms. Answers: A-D The client the nurse should see first is: A) A client with neutropenia reporting a sore throat and chills.

Which client exposure is most likely to require the nurse to have post-exposure prophylaxis if the client is HIV positive? A Sputum splash from coughing onto intact skin. B Splash into the eye while emptying the client's urinary catheter drainage bag. C Contamination of an open skin lesion with stool. D Skin puncture with the needle used to start the intravenous line. Answers: A - D The client exposure most likely to require the nurse to have post-exposure prophylaxis if the client is HIV positive is: D) Skin puncture with the needle used to start the intravenous line.

A nurse is providing education to a client with a new ankle sprain. Which instruction(s) should the nurse provide? Select all that apply. A Bear weight on the ankle as much as possible. B Wrap the ankle with a compression wrap: C Use ibuprofen or naproxen for pain and inflammation. D Apply ice to the ankle for 15-20 minutes at a time. E Elevate the ankle above the level of the heart.

Answers: A -E The instructions the nurse should provide to a client with a new ankle sprain are: B) Wrap the ankle with a compression wrap.

C) Use ibuprofen or naproxen for pain and inflammation.

D) Apply ice to the ankle for 15-20 minutes at a time.

E) Elevate the ankle above the level of the heart.

A nurse is providing discharge teaching about facilitating optimal healing to a client with diabetes who has a large abdominal wound. Which statement by the

client indicates an understanding of the teaching? Answers: A-D A "I should decrease my intake of fluids." B "I should increase my intake of simple carbohydrates." C "I should decrease my intake of green leafy vegetables." D "I should increase my intake of B-complex vitamins."

The statement by the client that indicates an understanding of facilitating optimal healing for a large abdominal wound with diabetes is: D) "I should increase my intake of B-complex vitamins."

A newly licensed nurse is caring for a client admitted to the unit with a diagnosis of failure to thrive and central total parenteral nutrition (TPN) has been prescribed. The charge nurse is observing the newly licensed nurse administer the TPN. Which action by the newly licensed nurse requires the charge nurse to immediately intervene? A The newly licensed nurse is about to administer the TPN through a peripheral IV line. B The newly licensed nurse labels the filtered tubing and TPN container. C The newly licensed nurse checks the label and ingredients in the solution against the prescription. D The newly licensed nurse assesses the catheter site for redness, warmth, and exudate. Answers: A - D The action by the newly licensed nurse that requires the charge nurse to immediately intervene is: A) The newly licensed nurse is about to administer the TPN through a peripheral IV line.

The nurse is assessing a client with anemia due to excess blood loss during surgery. Which finding will the nurse anticipate A Respiratory rate of 12 breaths per minute B 3+ pitting edema C Blood pressure of 148/92 mm Hg D Heart rate of 122 beats per minute Answers: A - D The finding the nurse will anticipate in a client with anemia due to excess blood loss during surgery is: D) Heart rate of 122 beats per minute A nurse is caring for a client with a low neutrophil count and a temperature of 101° F. After contacting the healthcare provider, the nurse should first 1 collect blood and throat cultures then 2 administer intravenous antibiotics. The nurse understands these orders should be completed within (3. ideally as soon as possible

The nurse is caring for a client who underwent surgery for ulcerative colitis and has a new ileostomy. The client reports pain at the surgical site and is receiving pain medication. What is the priority nursing diagnosis when planning care for this client with a newly placed ileostomy? A Deficient fluid volume related to increased intestinal output B Risk for ineffective coping related to body image changes C Impaired skin integrity related to exposure to fecal material D Risk for falls related to postoperative weakness Answers: A -D The priority nursing diagnosis when planning care for a client with a newly placed ileostomy is: C) Impaired skin integrity related to exposure to fecal material A nurse is providing discharge education to a client with a new ileostomy.

Which statement by the client indicates the teaching is effective? A "I should empty the collection bag when it is two-thirds full." B "I should change the collection pouch every two to three weeks." C "I should avoid gas-forming foods such as onions and cheese." D "I should limit fluid intake to 1 L per day to avoid excessive output." Answers: A-D The statement by the client that indicates the teaching is effective is: A) "I should empty the collection bag when it is two-thirds full."

The nurse cares for a client diagnosed with gastroesophageal reflux. Which information should the nurse include in the teaching plan? Answers: A -D A Increase whole grain intake. B Increase fat in meals. C Eat a bedtime snack. D Eat three large meals each day.

The information the nurse should include in the teaching plan for a client diagnosed with gastroesophageal reflux is: A) Increase whole grain intake.

A nurse is caring for a client with a platelet count of 20,000 platelets/mcL. Which action(s) should the nurse take? Select all that apply. A Instruct the client not to strain with a bowel movement. B Teach the client to use an electric razor for shaving. C Avoid obtaining rectal temperatures. D Remove fresh flowers from the client's room. E Apply firm pressure to any area of bleeding for 5-10 minutes. Answers: A - E

The actions the nurse should take for a client with a platelet count of 20,000 platelets/mcL are: A) Instruct the client not to strain with a bowel movement.

B) Teach the client to use an electric razor for shaving.

C) Avoid obtaining rectal temperatures.

E) Apply firm pressure to any area of bleeding for 5-10 minutes.

A nurse is caring for a client with advanced human immunodeficiency virus (HIV). Which laboratory value should the nurse report to the primary healthcare provider? Answers: A - D A White blood cell count 5,000/mm3 B CD4-T-cell count 160 cells/mm3 C Platelets 150,000/mm3 D Positive Western blot test The laboratory value that the nurse should report to the primary healthcare provider for a client with advanced human immunodeficiency virus (HIV) is: B) CD4-T-cell count 160 cells/mm3 A nurse is assessing a client in a primary care clinic. The client reports having pain in their joints that is worse in the morning, improves after they move around, and gets worse if they sit for long periods. The nurse should recognize these clinical manifestations as consistent with which condition? Answers: A - D A Osteoarthritis B Peripheral vascular disease C Bursitis D Rheumatoid arthritis The clinical manifestations described by the client are consistent with: D) Rheumatoid arthritis A nurse is caring for a client one day postoperatively after a total hip replacement. Drag the priority actions the nurse should take before ambulating the client to ensure safe and successful ambulation to the box on the right.

Potential Nuring Actions Priority Nursing Actions Sit the client upright with legs dangling prior to standing. Teach the client to use an incentive spirometer.

Assess if the client has had a bowel movement. Administer prescribed pain medication. Assess the client's pain level.

Priority Nursing Actions: 1. Assess the client's pain level.

2. Administer prescribed pain medication.

3. Sit the client upright with legs dangling prior to standing.

4. Teach the client to use an incentive spirometer.

The nurse is assessing the joints of a client who has a familial history of osteoarthritis. Which finding(s) are consistent with the nurse's suspicion of osteoarthritis? Select all that apply. Answers: A -E A Affected joints have hard, bony protuberances B Pain with motion of affected joints C Small joints in the hands are affected D Reduced range of motion E Symmetric joint involvement The findings consistent with the nurse's suspicion of osteoarthritis are: A) Affected joints have hard, bony protuberances B) Pain with motion of affected joints D) Reduced range of motion E) Symmetric joint involvement The nurse is providing discharge education to a client with a latex allergy about foods that may trigger an allergic response. Which food(s) stated by the client indicate the teaching was effective? Select all that apply. Answers: A-E A Broccoli B Avocados C Spinach D Guavas E Chestnuts The foods that may trigger an allergic response in a client with a latex allergy are: B) Avocados D) Guavas E) Chestnuts