A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects?
A. Electrically generated feelings of heat
B. Cryotherapy for painful areas
C. Realignment of energy flow through meridians
D. A tingling sensation replacing the pain | Answer: D. A tingling sensation replacing the pain
- A TENS unit applies small electric currents to the painful area, with the client increasing the current until the "pins and needles" sensation overrides the pain.
Rationale:
A - A TENS unit does not create heat when applied to a painful area. Warm compresses, heating pads, and paraffin dips are examples of modalities that apply heat to painful areas.
B - Many over-the-counter gels and creams work by creating a sense of cold to help relieve muscles aches and pain. A TENS unit does not work by cryotherapy, or cold treatment.
C - Acupuncture is a therapy that works via the insertion of fine needles to help unblock any obstructed flow of energy in other parts of the body. A TENS unit does not clear obstructions in energy flow. |
A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first?
A. Obtain ABGs.
B. Administer propofol to the client.
C. Instruct the client to allow the machine to breathe for them.
D. Disconnect the machine and manually ventilate the client. | Answer: C. Instruct the client to allow the machine to breathe for them.
- When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator."
Rationale:
A - The nurse should monitor ABG results to determine the effectiveness of mechanical ventilation, but this is not the first action the nurse should take.
B - The nurse might need to administer propofol to provide sedation and increase the client's tolerance of mechanical ventilation, but this is not the first action the nurse should take.
D - Many factors can cause a high-pressure alarm to sound. The nurse might have to disconnect the machine and manually ventilate the client if the ventilator fails or the client experiences respiratory distress, but this is not the first action the nurse should take. |
A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients?
A. A client who is receiving preoperative teaching for
a right knee arthroplasty.
B. A client who states they will have difficulty obtaining a walker for home use.
C. A client who reports an increase in pain following a left hip arthroplasty.
D. A client who is having emotional difficulty accepting that they have a prosthetic leg. | Answer: A. A client who is receiving preoperative teaching for
a right knee arthroplasty.
- The nurse should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions.
Rationale:
B - The nurse should make a referral to a social worker for a client who reports difficulty obtaining a walker for home use.
C - The nurse should contact the provider for a client who is experiencing increased pain following a left hip arthroplasty.
D - The nurse should refer the client to a counselor to assist with coping with the adjustment to the need of a prosthetic leg. |
A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first?
A. Document the client's intake and output.
B. Scan the bladder with a portable ultrasound.
C. Pour warm water over the client's perineum.
D. Perform a straight catheterization. | Answer: B. Scan the bladder with a portable ultrasound.
- The first action the nurse should take using the nursing process is to assess the client. Scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder.
Rationale:
A - The nurse should document the client's intake and output to ensure adequate fluid balance. However, there is another action that the nurse should take first.
C - Pouring warm water over the client's perineum is a method for stimulating micturition. However, there is another action that the nurse should take first.
D - Performing a straight catheterization might prove necessary. However, there is another action that the nurse should take first. |
A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)? mL | Answer: 24 mL
Follow these steps for the Dimensional Analysis method of calculation:
Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.)
X mL =
Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.)
5 mLX mL = 125 mg
Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement.
5 mL600 mgX mL = × 125 mg1
Step 4: Solve for X.
X mL = 24 mL
Step 5: Round if necessary.
Step 6: Determine whether the amount to administer makes sense. If there are 125 mg/5 mL and the prescription reads 600 mg, it makes sense to administer 24 mL. The nurse should administer phenytoin oral solution 24 mL PO. |
A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching?
A. "I will need to take antibiotics for 1 year."
B. "My partner will need to take an antiviral medication."
C. "My joints ache because I have Lyme disease."
D. "I bruise easily because I have Lyme disease." | Answer: C. "My joints ache because I have Lyme disease."
- Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage II and, by stage III, become chronic. Other chronic complications include memory problems and fatigue.
Rationale:
A - A client who has severe stage II Lyme disease will be prescribed a 30-day course of antibiotics. The nurse should emphasize to the client that, like with other types of infection, the full course of antibiotics should be completed.
B - Lyme disease is a vector-borne illness that is treated with antibiotics. Other vector-borne illnesses, such as West Nile Virus, are treated with antiviral medications. Lyme disease is not transmitted to others via human contact.
D - Lyme disease is an infectious disease that affects the body systemically, involving the neurologic, musculoskeletal, and cardiac systems. Cardiac manifestations include carditis and dysrhythmias. However, a client who has stage II Lyme disease does not typically experience bruising. |
A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching?
A. "I should clean my toothbrush in the dishwasher once a month."
B. "I should eat more fresh fruit and vegetables."
C. "I will avoid drinking a glass of cold liquid that has been standing for 30 minutes."
D. "I will take my temperature once a day." | Answer: D. "I will take my temperature once a day."
- A client who has AIDS is immunocompromised and is at risk for infection. The client should check their temperature daily to identify a temperature greater than 37.8° C (100° F), which is an early manifestation of an infection.
Rationale:
A - A client who has AIDS is immunocompromised and is at risk for infection. Therefore, the client should clean their toothbrush weekly in the dishwasher or in a bleach solution to destroy micro-organisms.
B - A client who has AIDS is immunocompromised and is at risk for infection. Therefore, the client should avoid eating raw fruits and vegetables that can contain bacteria and cause infection. The nurse should advise the client to eat a low-bacteria diet.
C - A client who has AIDS is immunocompromised and is at risk for infection. Therefore, the client should avoid drinking a glass of liquid that stands for 60 min or more to reduce the risk of drinking contaminated liquids. |
A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will take my iron with a glass of milk."
B. "I will take an antacid with my iron."
C. "I will limit my intake of red meat."
D. "I will eat more high-fiber foods." | Answer: D. "I will eat more high-fiber foods."
- The client should eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements.
Rationale:
A - Although oral iron supplements can cause gastrointestinal disturbances, the client should not consume dairy products at the same time as taking iron because dairy products inhibit the absorption of iron.
B - Although oral iron supplements can cause gastrointestinal disturbances, the client should not take antacids at the same time as taking iron because antacids inhibit the absorption of iron.
C - The client should increase intake of red meat because red meat is high in iron and will supplement this medication. |
A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider?
A. Hydrocodone
B. Bupropion
C. Lactulose
D. Warfarin | Answer: D. Warfarin
- Warfarin is an anticoagulant, which increases the client's risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery.
Rationale:
A - Hydrocodone is an opioid analgesic and is not contraindicated for a client scheduled for eye surgery. However, long-term opioid use can alter the client's response to analgesic agents.
B - Bupropion is an antidepressant and is not contraindicated for a client scheduled for eye surgery.
C - Lactulose is a laxative to treat constipation and is not contraindicated for a client scheduled for eye surgery. |
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take?
A. Remove the client's indwelling urinary catheter.
B. Irrigate the indwelling urinary catheter.
C. Clamp the indwelling urinary catheter.
D. Apply traction to the indwelling urinary catheter. | Answer: B. Irrigate the indwelling urinary catheter.
- The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow.
Rationale:
A - The nurse should not remove the client's indwelling urinary catheter as it ensures adequate urine flow.
C - Clamping the urinary catheter can increase pressure inside the client's bladder and cause internal bleeding.
D - The nurse should apply traction to the catheter to reduce the risk for bleeding, but this action will not clear the tubing of an obstruction. |
A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings?
H/P: Gouty arthritis for 3 years
Hypertension diagnosed 5 years ago1 pack per day cigarette use for 15 yearsFamily history of prostate cancer
Lab Results:
Blood glucose (fasting) 102 mg/dL (74 to 106 mg/dL)BUN 15 mg/dL (10 to 20 mg/dL)Creatinine 1 mg/dL (0.5 to 1.1 mg/dL)Prostate Specific Antigen (PSA) 1.5 ng/mL (0 to 2.5 ng/mL)
Prescriptions: Ibuprofen PRN for headaches
Olmesartan 20 mg PO daily Prednisone 5 mg PO daily
A. Disease processes
B. Laboratory findings
C. Current medications
D. Family history | Answer: C. Current medications
- The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing.
Rationale: A - A history of gout and hypertension will not affect the results of the allergy skin testing. When reviewing a client's health record, the nurse should identify a history of diseases that alter the immune response as an interfering factor that can cause false negative results. B - The client's laboratory values are within the expected reference ranges and are not an indication for postponing allergy skin testing. D - Allergy skin testing results can be affected by age; infants and older adult clients can have decreased reactivity to allergens. However, family history is not a factor in consideration for postponing allergy skin testing. |
A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy?
A. Shellfish
B. Peanuts
C. Eggs
D. Avocados | Answer: D. Avocados
- Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity.
Rationale:
A - Clients who have a shellfish allergy might have an allergic reaction to povidone-iodine.
B - Clients who have a peanut allergy might have an allergic reaction to propofol.
C - Clients who have an egg allergy might have an allergic reaction to propofol. |
A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)?
A. Total cortisol 0.9 mcg/dL (5 to 23 mcg/dL)
B. Amylase 440 units/L (30 to 220 unit/L)
C. Calcium 7.5 mg/dL (9 to 10.5 mg/dL)
D. Troponin I 8 ng/mL (less than 0.03 ng/mL) | Answer: D. Troponin I 8 ng/mL (less than 0.03 ng/mL)
- Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury. The client's laboratory value is above the expected reference range for troponin I, indicating an MI has occurred.
Rationale:
A - A total cortisol level of 0.9 mcg/dL is less than the expected range. However, a decreased level of cortisol indicates a deficiency of the adrenal, pituitary, or thyroid glands, not an MI.
B - An amylase level of 440 units/L is above the expected range. However, an increased amylase level indicates pancreatitis, not an MI.
C - A calcium level of 7.5 mg/dL is below the expected range. However, a decreased calcium level indicates a condition such as renal failure, hypoparathyroidism, or vitamin D deficiency, not an MI. |
A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority?
A. Anorexia
B. Abdominal pain radiating to the right shoulder
C. Rebound abdominal tenderness
D. Tachycardia | Answer: D. Tachycardia
- When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately to the provider.
Rationale:
A - Anorexia is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse's priority.
B - Abdominal pain radiating to the right shoulder is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse's priority.
C - Rebound abdominal tenderness is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse's priority. |
A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
A. "I will wash the ink markings off the radiation area after each treatment."
B. "I will use my hands rather than a washcloth to clean the radiation area."
C. "I will be able to be out in the sun 1 month after my radiation treatments are over."
D. "I will use a heating pad on my neck if it becomes sore during the radiation therapy." | Answer: B. "I will use my hands rather than a washcloth to clean the radiation area."
- The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation.
Rationale:
A - The ink markings designate the exact radiation area. The client should not remove these markings until they complete the entire radiation treatment.
C - Radiation therapy causes skin to become sensitive to the effects of sun exposure and increases the risk for developing skin cancer. The client should avoid direct sunlight during the radiation treatments and for at least 1 year following the conclusion of the therapy.
D - The client should avoid exposing the treatment area to heat as this can cause further irritation to the skin. |
A nurse is caring for a client who is 4 hr postoperative following a total vaginal hysterectomy.
Click to highlight the findings the nurse should report to the provider immediately.
A. Client sleeping, arouses to verbal stimuli
B. Respiratory rate 14/min
C. Oxygen saturation 95% on room air, breath sounds clear
D. Reports pain as 2 on scale of 0 to 10
E. Perineal pad saturated with blood, large clots present
F. Change of blood pressure, heart rate of 102/min | Answer: E, F
- The client has manifestations of vaginal hemorrhage, including vaginal bleeding, blood clots, reduced blood pressure, and tachycardia. The nurse should report these findings to the provider.
Rationale:
ABCD - These are expected findings. Therefore, the nurse does not need to report these findings to the provider. |
A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy.
A nurse is providing teaching for the client. Which of the following instructions should the nurse include?
Select all that apply.
A. Avoid highly seasoned foods.
B. Eat five servings of fresh fruit per day.
C. Consume high-protein snacks.
D. Avoid drinking fluids with meals.
E. Eat several small meals per day.
F. Maintain a high carbohydrate intake. | Answer: A, C, D, E
A - The nurse should instruct the client to avoid excessive amounts of spices and salt.
C - The client should eat snacks that are high in protein and low in carbohydrates to prevent the gastric food boluses and reactive hypoglycemia in dumping syndrome.
D - The nurse should instruct the client to drink fluids 30 min before or after meals.
E - The nurse should instruct the client to eat several small, frequent meals instead of three large meals per day.
Rationale:
B - The client should limit intake to three servings of unsweetened cooked or canned fruit per day.
F - Dumping syndrome requires a low carbohydrate diet because of reactive hypoglycemia. |
A nurse is caring for a client who is scheduled for a right knee arthroplasty.
The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching?
Select all that apply.
A. "I will be sure to ask for pain medication before my knee starts to hurt too bad."
B. "Well, I guess there's no changing my mind about having surgery now."
C. "I will need to do the breathing exercises every 1 to 2 hours after the surgery."
D. "I will probably be going home with a walker."
E. "My physical therapy will start after I leave the hospital." | Answer: A, C, D
A - For optimal control of postoperative pain, the client should request analgesic medication before the pain becomes severe.
C - The client should cough and deep breathe and use the incentive spirometer every 1 to 2 hr to reduce the risk of postoperative complications, such as pneumonia.
D - It can take 6 weeks for complete recovery from knee arthroplasty. Clients are often discharged with the use of a walker and will advance to a cane or crutch 4 to 6 weeks following surgery.
Rationale:
B - The nurse and the client reviewed the consents; therefore, the nurse has instructed the client that they have the right to refuse surgery at any time.
E - Early ambulation leads to improved postoperative outcomes and reduces the risk of complications of immobility, such as pneumonia and atelectasis. The client should be informed that physical therapy will begin the day of, or the day following, surgery. |
A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care?
A. Keep a lead-lined container in the client's room.
B. Limit each visitor to 1 hr per day.
C. Place a dosimeter badge on the client.
D. Remove soiled linens from the client's room each day. | Answer: A. Keep a lead-lined container in the client's room.
- The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant.
Rationale:
B - The nurse should restrict each visitor to 30 min per day to limit exposure to radiation.
C - The nurse and other facility staff should wear a dosimeter badge when in the client's room to monitor their exposure to radiation.
D - The nurse should keep all soiled linens in the client's room until the client has had the radiation implant removed. |
A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority?
A. Report of sore throat
B. Report of memory loss
C. Alopecia
D. Mucositis | Answer: A. Report of sore throat
- When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis.
Rationale:
B - Report of memory loss is nonurgent because it is an expected finding for a client who is receiving chemotherapy; therefore, there is another finding that is the nurse's priority. The nurse should provide the client with cognitive training strategies to reduce memory loss.
C - Alopecia is nonurgent because it is an expected finding for a client who is receiving chemotherapy; therefore, there is another finding that is nurse's the priority. The nurse should instruct the client to cover their head to protect from injury due to sunburn or loss of heat.
D - Mucositis is nonurgent because it is an expected finding for a client who is receiving chemotherapy; therefore, there is another finding that is the nurse's priority. The nurse should instruct the client to increase water intake and use a soft toothbrush to reduce mucositis. |