1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
a. Bradycardia
b. Flushed skin
c. Frothy sputum – pg.198
d. Jugular vein distention
2. A nurse is assessing a client who is experiencing renal colic from a calculus in left renal pelvis. Identify the area where the nurse should expect the client to have referred pain. (Find “hot spots” in the artwork)
3. A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actions should the nurse take?
a. Monitor the access site for drainage.
b. Strip the catheter tubing
c. Measure the amount of the dialysate outflow
d. Raise the client to high fowlers position – pg.370: encourage client to lie Supine with head slightly elevated during CCPD and APD treatment.
e. Position the client to her other side.
4. A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?
a. Wash you’r perineal area two times each day with antimicrobial soap.
b. Change your pet’s litter box daily.
c. Change the water in your drinking glass every 4 hrs.
d. Wash your toothbrush in the dishwasher once each month.
5. A nurse is planning to insert an indwelling catheter for a female client. Which of the following actions should the nurse plan to take?
a. Collect urine specimen from the drainage bag 1 hr after insertion
b. Raise the head of the bed to 45 degrees prior to insertion
c. Secure the catheter to the client’s inner thigh
d. Attach the bag to the rail of the bed
6. A nurse is providing teaching for a client who has age-related macular degeneration. Which of the following information should the nurse include in the teaching?
a. A possible cause of this problem is long-term lack of dietary protein.
b. You probably have a Detachment of your retina.
c. You probably have noticed a decline in your central vision. – pg.63
d. The doctor can perform surgery to correct the start paying the folds in your retina.
7. A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report? – Expected Findings: fatigue, Wt loss, abdo.pain, abdo.distention, pruritus.
a. Platelets 70,000/mm3 – pg.357
b. Distended abdomen
c. Alkaline phosphatase 125 units/L
d. Clay colored stools
8. A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a client for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects?
a. Hyperglycemia – if unavailable, do not attempt to catch up by increasing the infusion rate because client can develop Hyperglycemia.
b. Diarrhea
c. Constipation
d. Hypoglycemia – pg.298 – sudden abruption of infusing rate can cause hypoglycemia.
9. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take? – CORRECT
a. Administer the unit of packed RBC’s over 1 hr.
b. Obtain the client’s first set of vital signs 1 hr after initiating the transfusion.
c. Initiate venous access with a 21-gauge needle.
d. Use Y tubing with 0.9% sodium chloride when administering the transfusion.
10. A nurse is caring for a female who has toxic shock syndrome. Which of the following findings should the nurse expect?
a. Elevated platelet count
b. Generalized rash
■ Whole body rash
c. Decreased total bilirubin
d. Hypertension
■ Hypotension
11. A nurse is providing discharge teaching to an older adult client who had an exacerbation of COPD. The client is to start fluticasone by metered-dose inhaler. Which of the following instructions should the nurse include?
a. Use fluticasone as needed for shortness of breath.
b. Limit fluid intake to 1 L per day.
c. Obtain a yearly influenza immunization.
d. Assist use of pursed-lip breathing.
12. A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
a. “You can cross your legs at the ankles when sitting down.”
b. “Clean the incision daily with hydrogen peroxide.”
c. “Install a raised toilet seat in your bathroom.”
d. “You should use an incentive spirometer every 8 hrs.”
13. Missing
14. A nurse is caring for a client who is postoperative following a femur fracture. Which of the following findings should the nurse report to the provider immediately?
a. The client reports shortness of breath – sign of surgical complication
b. The client has a temperature of 38.1 C (100.5F)
c. The client’s incision is red and warm
d. The client reports incision pain
15. A nurse is planning care for a client who Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?
a. Place the client in a protective environment
b. Obtain a stool specimen with gloves
c. Clean surfaces with chlorhexidine-bleach
d. Wash hands with alcohol-based hand rub.
16. A nurse is setting up a sterile field before performing a dressing change on client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all the apply.)
a. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap
b. Select a work surface at the nurse’s waist level
c. Apply sterile gloves before opening the pack
d. Open the first flap of the sterile package toward the nurse’s body
e. Place a surgical pack with a sterile drape on the work surface.
17. A nurse is caring for a client who has acute appendicitis. Which of the findings is the priority to the provider?
a. Nausea
b. Flank pain
c. Fever
d. Rigid abdomen
18. A nurse is caring for a client who is receiving radiation. The client reports nauseas since the therapy was initiated. Which of the following considerations should the nurse include when planning the client’s meals?
a. Offer frequent, high-carbohydrate meals
b. Offer highly seasoned foods
c. Offer a snack prior to radiation therapy
d. Offer hot beverages with meals
19. A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement?
a. Empty water from the ventilator tubing daily.
b. Suction the client’s airway every 4 hr.
c. Maintain the client in supine position.
d. Perform oral care every 2 hr.
20. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding?
a. Palmar erythema
b. Spider angiomas
c. Yellow Sclera
d. Mental Confusion
21. A nurse is preparing to administer bumetanide to a client who has heart failure. Which of the following assessment findings should indicate effectiveness of the medication?
a. Bowel sounds present in 4 quadrants on auscultation
b. Alert and oriented to time place and person
c. Lung sounds clear
d. Apical pulse 80/min and regular
22. A nurse is caring for a client who has active tuberculosis. Which of the following interventions should the nurse include in the plan of care?
a. Perform chest percussion twice daily
b. Wear a high-efficiency particulate air mask
c. Initiate droplet precautions
d. Obtain daily sputum specimen
23. A nurse is caring for a client who has hypertension and has a new prescription for lisinopril. The nurse should consult with the provider about which of the following medication in the client’s medication administration record?
a. Potassium chloride
b. Levothyroxine
c. Acetaminophen
d. Metformin
24. A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan or care?
a. Avoid use of anticoagulants
b. Place pillow under client knees
c. Discourage leg exercises while in bed
d. Apply compression stocking in lower extremities
25. What interferes with warfarin therapy?
a. Potatoes
b. Oranges
c.Cauliflower
d.Bananas
26. A nurse is administering furosemide 80 to a client with pulmonary edema. Which of the following assessment findings indicates the nurse that the medication is effective?
a. Elevation in BP
b. Adventitious breath sounds
c. Weight loss of 1.8 kg (4lb) in the past 24 hr
d. Respiratory rate of 24/min
27. A nurse is caring for a client who has Cushing’s disease. Which of the following findings should the nurse expect?
a. Weight loss
b. Hyponatremia
c. Hyperglycemia
d. Hypercalcemia
28. A nurse is monitoring a client who has receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? (MS RM 10.0 Ch.40
a. Back pain
b. Bradycardia
■ tachy
c. Hypertension
■ Hypotension
d. Chills
29. 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. 75 mL of greenish yellow drainage
b. 100 mL of red drainage
c. 200 mL of brown drainage – purulent
d. 150 mL of serosanguineous drainage
30. A nurse is performing an admission assessment on a client who has severe chronic kidney disease. Which of the following findings should the nurse expect?
a. Lethargy – pg.382
b. Potassium 4.0 mEq/L
c. Hypotension
d. Serum creatinine 0.9 mg/dL
31. A nurse is teaching a client who has hypothyroidism. Which of the following information should the nurse include in the teaching? (Select all the apply.)
a. You will take medication for this condition for several months
b. You will need to eat a high-fiber diet to prevent complications of this condition
c. You might notice that you perspire more with this condition
d. We will perform laboratory tests to monitor the effect of your medication
e. This condition can cause you to gain weight.
32. A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?
a. Empty water from the client’s ventilator tubing
b. Evaluate the client for a cuff leak
c. Suction the client’s airway
d. Increase the client’s ventilator flow rate
33. A nurse is reviewing laboratory results for four client who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon?
a. INR of 1.6
b. Platelets 95,000/mm3
c. Hct 42%
d. WBC 8,000/mm3
34. 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 potassium level
b. Decreased blood pressure
c. Increased heart rate
d. Decreased urinary output
35. A nurse is providing teaching to a client following a liver biopsy 1 hour ago. Which of the following positions should the nurse instruct the client to maintain after the procedure?
a. Prone
b. Supine
c. Right lateral
d. Left lateral
36. 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 have to wait 2 months before additional saline can be added to my breast expander”
b. “I will perform strength building arm exercises using a 15-pound weight”
c. “I should expect less than 25 ml of secretions per day in the drainage devices”
d. “I will keep my left arm flexed at the elbow as much as possible”
37. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?
a. “Wash your feet twice per day with antibacterial soap and hot water”
b. “Wear loose fitting slippers around the house”
c. “Wear cotton rather than nylon sock” – pg/532
d. “Use a heating pad to keep your feet warm at night”
38. A nurse is caring for a client following the placement of a transverse colostomy. Which of the following findings indicates a possible complication?
a. Client reports pain of 6 on scale from 0 to 10
b. Heart rate 110/min
c. Bowel sounds hypoactive
d. Stoma appears dry -pg.602
39. A nurse is counseling a client who has a family history of hypertension about reducing high risk for high blood pressure. Which of the following strategies should the nurse recommend?
a. Engage is isometric exercises for 15 min daily
b. Maintain a body mass index between 31 and 34
■ less than 30
c. Lower total cholesterol level <200 mg/dL d. Increase dietary potassium intake 40. A nurse in the PACU is assessing a client who is postoperative following general anesthesia. Which of the following findings is the priority to address? a. Piloerection of the skin b. Vomiting upon arousal c. Decreased body temperature d. Indistinct, rambling speech 41. A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include? a. Change the dressing four times per day b. Use sterile gloves when performing the dressing change c. Clean from the incision to the surrounding skin d. Apply tincture of benzoin prior to removing the dressing 42. A nurse is preparing to administer vancomycin IV bolus to a client who has pneumonia. Which of the following clinical manifestations should the nurse instruct the client to monitor for and report? a. Pallor of the extremities b. Taste of metal in the mouth c. Halo of light around objects d. Ringing in the ears 43. A nurse is caring for a client who has pancreatitis and has been receiving total parenteral nutrition. Which of the following laboratory tests should the nurse monitor for overall nutritional status? a. Prealbumin b. C reactive protein c. Creatinine d. Lipase 44. A charge nurse is called to a client’s room after a staff nurse reports a client has had a wound evisceration. Which of the following actions should the charge nurse take? a. Attempt to reinsert the protruding viscera b. Obtain bottles of warm, sterile 0.9% sodium chloride solution c. Place the client in left lateral recumbent position- low fowlers hips knees bent d. Apply a firm pressure dressing across the client’s abdomen 45. A nurse is caring for four clients. Which of the following clients is at risk for developing metabolic alkalosis? a. A client who is receiving continuous gastric suctioning b. A client who has aspiration pneumonia c. A client who is experiencing an opioid overdose d. A client who has uncontrolled diabetes mellitus 46. 47. A nurse is caring for a client who is taking digoxin 0.125 mg 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 for digoxin toxicity? a. Calcium b. Potassium c. Magnesium d. Phosphatase 47. A nurse is assessing the abdominal wound of a client who is 3 days postoperative following a colon resection. Which of the following findings should the nurse report to the provider? a.Erythema b. Ecchymotic skin c. Drainage d. Edema 48. A nurse is completing an admission assessment for a client. The nurse should expect the provider to prescribe which of the following medications for the client? EXHIBIT: Temperature (98.3 F), HR (100/min), RR (20/min), BP (152/94mmHg) a. Atorvastatin b. Allopurinol c. Metoprolol d. levothyroxine 49. A nurse is assessing a client who is near the end of life following a head injury. The client has alternating periods of rapid breathing and apnea. The nurse should document this finding as which of the following respiratory patterns? a. Biot’s respirations b. Hypoventilatory respirations c. Kussmaul respirations d. Cheyne-Stokes respirations 50. A nurse is administering a unit of packed RBCs to a client and notes that there are several small clots floating in the IV bag. Which of the following actions should the nurse take? a. Inject 5,000 units of heparin into the unit of packed RBCs b. Place the unit of packed RBCs in a warming unit for 5 min c. Return the unit of packed RBCs to the blood bank d. Dilute the unit of packed RBCs using 50 mL of Lactated Ringer’s 51. A nurse in a provider’s office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include? a. “Eat a light meal 1 hour before bedtime” b. “Lie down for 30 minutes after each meal” c. “Increase your caloric intake by 250 calories per day” d. “Sleep with the head of your bed elevated 6 inches” 52. A nurse is reviewing a client’s ECG rhythm strip. Which of the following components should the nurse use to measure impulse conduction from the SA node through the AV node? a. ST segment b. QRS complex c. PP interval d. PR interval 53. A nurse is caring for a client who has pulmonary edema. The client’s ABGs are pH 7.22, PaCO2 60mm Hg, and HCO3 26 mEq/L. The nurse should identify that the client is experiencing which of the following acid-base imbalances? a. Respiratory acidosis b. Metabolic alkalosis c. Respiratory alkalosis d. Metabolic acidosis 54. A nurse is teaching a client about self-administration of nitroglycerin sublingual for the treatment of angina pectoris. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. I should avoid repeating the dose if I get a headache b. I should lie down when I take this medication c. I should store the medication in a pill box d. I should take the medication 1 hour before exercise 55. A nurse is caring for a client who has had a subtotal thyroidectomy? Which of the following findings is the highest priority finding? a. Hemorrhage b. Decreased urine output c. Stridor d. Hypoglycemia 56. A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? a. Generalized abdominal pain b. Cloudy effluent c. Fever d. Increased heart rate 57. A nurse is caring for a client who is receiving enteral nutrition. Which of the following interventions by the nurse will prevent aspiration? a. Check the gastric pH following bolus feedings b. Place the client in supine position before initiating feedings c. Instruct the client to perform the Valsalva maneuver after feedings d. Measure residual volume prior to bolus feedings 58. A nurse is admitting a patient to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse plan to take to help prevent of acute kidney failure? a. Administer 0.9% sodium chloride IV at 25 mL/hr. b. Administer a calcium chanel blocker c. Administer 500 mL IV fluid bonus d. Administer oral rehydration solution 59. A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? a. I rest in my recliner with my feet elevated for about an hour every afternoon b. I use my heating pad on a low setting to keep my feet warm c. I soak my feet in hot water before trimming my toenails d. I apply a lubricating lotion to the cracked areas on the soles of my feet every morning 60. A nurse is caring for client who has COPD and reports dyspnea. The nurse should place the client in which of the following positions a. Lithotomy b. Prone c. Fowler’s d. Trendelenburg 61. Client has a pressure ulcer. Which indicates wound healing? a. Light yellow exudate b. Wound tissue firm to palpation c. Dry brown eschar d. Dark red granulation tissue 62. STEPS to use of a peak flow meter (order form 1-5) a. “Stand upright” 1 b. “Seal your lips around the mouth piece”3 c. “Fill your lungs with a deep breath”2 d. “Exhale forcefully and quickly”4 e. “Record the highest of three consecutive readings”5 63. A nurse is caring for a client who has a PICC line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12hr. Which of the following actions should the nurse take in managing the client’s PICC line? a. Maintain a continuous IV infusion through the PICC line b. Access the catheter using a non-coring needle c. Change the transparent membrane dressing daily ■ Usually q7days d. Flush the catheter with a 0.9% sodium chloride solution after each use 64. A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching? a. Use peroxide to clean the mouthpiece of your inhaler b. Exhale fully before bringing the inhaler to your lips c. Depress the chatheter after you inhale d. Do not shake your inhaler before use 65. A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the followig assessment findings supports this suspicion? a. Cool, clammy skin b. Increased urine output c. Kussmaul respirations d. Acetone breath 66. Client, who is 6 hr postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? a. Palpate the dorsalis pedis pulse. b. Maintain the affected extremity in a dependent position c. Wrap sterile gauze on the shart point of the pins d. Adjust the clamps on the fixator flame 67. A nurse is preparing an in-service presentation about the use of automated external defibrillators (AEDs). Which of the following instructions should the nurse include in the teaching? a. “Perform CPR while the AED is analyzing” b. “Position the client on a flat surface” c. “Set the AED to 80 joules” d. “Use an AED for a client who has A-fib” 68. Serum sodium level of 120 mEq/L. Which of the followings findings should the nurse expect? a. Hyperreflexia b. Decreased bowel sounds c. Confusion d. Increase CVP 69. A nurse in an emergency dept is caring for a client who has abdominal pain. The client reports a 3-day history of low-grade fever with the chest congestion. Which of the following prescriptions should the nurse initiate first? (exhibit) a. Sputum for culture and sensitivity b. Regular insulin at 0.1 unit/kg/hr by continuous IV infusion c. Ceftriaxone 1g by intermittent IV bolus every 12 hr d. 0.9% sodium chloride at 500 mL/hr by continuous IV infusion 70. Pt. taking isoniazid and rifampin, which understands? a. “I will be finished with this medication regimen in 3 months” b. “I should check the whites of my eyes while taking these medications” – hepatotoxicity c. “I should take my mediation with an antacid if it upsets my stomach” d. “I will no longer be infectious after two consecutive negative sputum specimens” 71. The use of incentive spirometer. a. Position the mouthpiece 2.5cm (1 in) from the mouth b. Place hands on the upper abdomen during inhalation c. Hold breaths about 3-5 secs before exhaling d. Exhale slowly through purse lips 72. Pt. who is in septic shock. Which lab findings indicate the patient is developing “multiple organ dysfunction syndrome”? a. Arterial hypoxemia – MODS Complication b. Decreased liver enzymes c. Decreased BUN d. Hypoglycemia 73. A nurse is reviewing a client’s laboratory values and notes a potassium level of 2.8 mEq/L. Which of the following findings should the nurse expect? a. Hyperactive bowel sounds ■ Hypoactive Bowel sounds b. Increased blood pressure ■ Decreased BP c. Irregular pulse d. Exaggerated reflexes 74. A nurse is caring for a client who is admitted to the medical-surgical unit with a seizure disorder. Which of the following interventions should the nurse include in the plan of care? a. Teach assistive personnel how to apply restraints b. Keep the side rails in a down position c. Keep a padded tongue blade at the client’s bedside d. Maintain peripheral IV access. 75. A nurse is collecting a medical history from an older adult client who has hypertension and new prescription of nadolol Which of the following findings should the nurse report to the provider? a. cataracts b. GERD c. Asthma d. Hypothyroidism 76. A nurse is preparing a client for a Lumbar puncture. Which of the following images indicates the position the nurse should assess the client into for this procedure? 77. A nurse is caring for a client who has diabetes mellitus. The client’s ABG are ph 7.14, PaO2 90 mmHg, PaCO2 35 mmHg, and HCO3-4 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? a. Respiratory acidosis b. Metabolic alkalosis c. Respiratory alkalosis d. Metabolic acidosis 78. A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include? a. Increased Phosphorus intake b. Increased Potassium intake c. Decrease protein intake d. Decreased carbohydrate intake. 79. A nurse is planning care for a client who has new diagnosis of acute pancreatitis. Which of the ff interventions should the nurse include in the plan of care? a. Administer antihypertensive meds b. Maintain the client on NPO status c. Place client in supine position d. Monitor the client for hypercalcemia 80. A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status? a. Altered level of consciousness b. Pupillary constriction c. Decorticate posturing d. Cheyne-stokes respirations 81. A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding? a. Captopril b. Ibuprofen – no NSAIDS c. Digoxin d. Phenytoin 82. A nurse is caring for an older adult client who is suspected of having septicemia. Which of the following actions is the nurse’s priority? a. Obtain a WBC count with differential b. Obtain a history to determine recent injuries. c. Obtain a blood specimen of culture and sensitivity testing d. Obtain a broad-spectrum antibiotic for rapid administration. 83. A nurse is assessing a client following a kidney biopsy. Which of the following findings should the nurse identify as an indication that the client is experiencing internal bleeding? a. Bradycardia b. Polyuria c. Flank Pain d. Increase Blood Pressure 84. 86. A nurse is caring for a client who has diabetes insipidus and has had a urinary output of 3,000 ml in the past 12 hr. which of the following medications should the nurse expect to administer to the client? a. Dopamine b. Desmopressin acetate c. Furosemide d. Spironolactone 85. A nurse is admitting a client to a medical unit following placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse? a. Sneezing b. Presence of a sharp spike prior to the QRS complex on the ECG c. Hiccups d. Presence of intrinsic P waves following a QRS complex on the ECG 86. A nurse is caring for a client receiving TPN who weighs 160Lb. If the RDA of protein is 0.8g/kg of body weight. How many g of protein should the client receive? 87. A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft? a. Dilated appearance of the graft b. Normotensive blood pressure c. Absence of a bruit d. Palpable thrill 88. A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following indicates effective of the teaching? a. I should expect my lesions to resolve in 6 weeks b. I should expect to take my medication for 3 weeks c. I should use natural skin condoms during sex. d. I should apply antibiotic ointment to lesions. 89. A nurse is caring for a client who has a history of chemotherapy-included nauseas and vomiting. Which of the following medications should the nurse administer prior to chemotherapy? a. Ondansetron – pg.581 b. Sertraline c. Diphenhydramine d. Methylprednisolone 90. A nurse is preparing to administer daily medications to a client who is undergoing procedure at 1000 that req IV contrast dye. Which of the following routine meds to give at 0800 should the nurse withhold? a. Metoprolol b. Metformin – pg. 364: risk for lactic acidosis from contrast dye with iodine c. Fluticasone d. Valproic Acid 91. A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take? a. Confirm the correct position of the line by obtaining a blood sample. – Xray confirms placement. b. Instruct the client to cough as the catheter is inserted. – cough may shift vessels. DANGER c. Place the head of the client’s bed lower than the foot. d. Cleanse the site with a hydrogen peroxide solution. – must clean with chlorhexidine 92. A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding? a. Hypotension b. Weight gain - S/S: weight gain, hypertension, tachycardia c. Bradycardia d. Loss of skin turgor 93. A nurse is reviewing discharge teaching with a client with a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching? a. “I know the medication increases my risk for blood clots.” b. “I should avoid taking ibuprofen while taking this medication.” – pg.143 c. “I will increase green leafy vegetables in my diet.” d. “I will return in 1 month to have my blood tested.” 94. A nurse is caring for a client who has glaucoma. Which of the following findings should the nurse expect? a. The client reports loss of peripheral vision. – pg.65 b. The client’s eyes are watery c. The client’s pupils are constricted. d. The client reports dark floaters in the affected eye. 95. A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care? a. Remind the client to use a cane on his left side while ambulating. b. Provide the client with a short-handled reacher. c. Position the bedside table on the client’s left side. d. Place a plate guard on the client’s meal tray. 96. A nurse in the emergency department is evaluating a young client for bacterial meningitis. Which of the following actions should the nurse take as a part of the focused assessment? a. Run a tongue blade on the outside of the client’s sole and note any flaring of the toes b. Tap the client’s facial nerve and note any fecal twitching c. Strike the client’s patellar tendon with a percussion hammer and note any increase in response d. Gently elevate the client’s head and note any nuchal rigidity – pg.31 97. A nurse is planning to flush an implanted port for a client who is receiving chemotherapy. Which of the following supplies should the nurse plan to use? a. A short peripheral catheter b. A winged infusion needle c. A non-coring needle -pg.166 d. A large-bore needle 98. A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching? a. “I can have mayonnaise on my sandwiches.” b. “I can drink vegetable juice with a meal.” c. “I can season my foods with garlic and onion salts.” d. “I can have a frozen fruit juice bar for dessert.”