A nurse is reinforcing discharge teaching about wound care with a family member of a client
who is postoperative. Which of the following should the nurse include in the teaching?
a.Administer an analgesic following wound care
b.Irrigate the wound with povidone iodine.
c.Cleanse the wound with a cotton tipped applicator.
d.Report purulent drainage to the provider. - ANS d.Report purulent drainage to the provider.
A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of
the following findings should the nurse expect?
a.Flaccid neck
b.Stooped posture with shuffling gait
c.Red macular rash
d.Masklike facial expression - ANS c.Red macular rash
A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis.
Which of the following interventions should the nurse include to prevent bone loss?
a. Increase fluid intake.
b. Encourage range-of-motion exercises.
c. Massage bony prominences.
d. Encourage weight-bearing exercises. - ANS d. Encourage weight-bearing exercises.
A nurse is collecting data from a client and notices several skin lesions. Which of the following
findings should the nurse report as possible melanoma?
a. Scaly patches
b. Silvery white plaques
c. Irregular borders
d. Raised edges - ANS c. Irregular borders
A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a
partial gastrectomy for ulcers. Which of the following information should the nurse include in the
teaching?
a.Avoid liquids at mealtimes
b.Exclude eating starchy vegetables
c.Avoid eating high-protein meals
d.Plan to increase intake of sweetened fruits - ANS a.Avoid liquids at mealtimes
,A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of
the following laboratory levels should the nurse review prior to the procedure?
a.Albumin
b.phosphorus
c.TSH
d.BUN - ANS d.BUN
A nurse is reinforcing glycosylated hemoglobin (HbA1c) testing with a client who has diabetes
mellitus. Which of the following statements indicates that the client understands the teaching?
a. "The HbA1c test should be performed 2 hr after I eat a meal that is high in carbohydrates."
b. "The HbA1c test can help detect the presence of ketones in my body."
c. "I will have my HbA1c checked twice per year."
d. "I will plan to fast before I have my HbA1c tested." - ANS c. "I will have my HbA1c checked
twice per year."
A nurse is examining a client's IV site and notes a red line up his arm. The client reports a
throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations
indicate which of the following complications of IV therapy?
a.Thrombophlebitis
b.Infiltration
c.Hematoma
d.Venous spasms - ANS a.Thrombophlebitis
A nurse is reinforcing teaching about management of constipation with a client who has
hypothyroidism. Which of the following should the nurse include in the teaching?
a. Increase intake of fiber-rich foods
b. Take a laxative every morning
c. Maintain a fluid intake of 1200 mL per day.
d. Limit activity to preserve energy - ANS a. Increase intake of fiber-rich foods
A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following
actions should the nurse take?
a. Position pillows between the bony prominences.
b. Check for incontinence every 3 hr.
c. Massage reddened areas of the skin.
d. Elevate the head of the bed to 45°. - ANS a. Position pillows between the bony prominences.
, A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD)
of the lower extremities. Which of the following interventions should the nurse include?
a. Place moist heat pads on the extremities.
b. Perform manual massage of the affected extremities
c. Dangle the extremities off the side of the bed.
d. Apply support stockings before getting out of bed - ANS c. Dangle the extremities off the side
of the bed.
A nurse is caring for a client who has meningococcal pneumonia. Which of the following
personal protective equipment should the nurse use?
a.gown
b.mask
c.sterile gloves
d.protective eyewear - ANS b.mask
A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client.
Which of the understanding of the teaching?
a. "I Should wait at least 2 hours after eating before going to bed."
b. "I should eat three meals a day without eating snacks between meals."
c. "I should season my food with garlic."
d. "I should drink my liquids through a straw." - ANS a. "I Should wait at least 2 hours after
eating before going to bed."
A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the
following findings should the nurse recognize as the priority?
a.pruritis
b.nausea
c.urinary retention
d.dyspnea - ANS d.dyspnea
A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following
information should the nurse include in the teaching?
a. "This type of insulin should be given at the same time every day."
b. "This insulin can be mixed with short-acting insulin in a single syringe."
c. "This type of insulin can be used in a pump."
d. "This insulin has an increased risk for hypoglycemia." - ANS a. "This type of insulin should be
given at the same time every day."
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