A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? (Select all that apply.) - correct answer Poripheral edema
Hepatomegaly
Abdominal distention
A nurse is caring for a client who has heart failure and a new pre...
A nurse is collecting data from a client who has right-sided heart failure. Which of the
following findings should the nurse expect? (Select all that apply.) - correct answer
Poripheral edema
Hepatomegaly
Abdominal distention
A nurse is caring for a client who has heart failure and a new prescription for
furosemide. The nurse should monitor the client for which of the following adverse
effects of the medication? - correct answer Tinnitus
The nurse should monitor clients who take furosemide for tinnitus and hearing loss.
Audiometry is recommended for clients recelving prolonged IV furosemide.
A nurse is reinforcing teaching with a client who is recovering from severe diarrhea
and is ready to resume eating solid foods. Which of the following food items should
the nurse recommend? - correct answer Yogurt
The nurse should recommend adding yogurt to the diet to provide probiotics and add
substance to the stool, making it more formed. A client who is recovering from
diarrhea should consume a diet that is low in fiber. Taking probiotics can also help
restore the natural gastrointestinal flora.
A nurse is monitoring a client who has a new prescription for furosemide for
peripheral edema. For which of the following adverse effects should the nurse
monitor? - correct answer Muscle weakness
Furosemide is a loop diuretic, which is used to treat hypertension and edema.
Furosemide can cause excess excretion of potassium. The nurse should monitor the
client for manifestations of hypokalemia such as nausea, muscle weakness, and
spasms.
A nurse is contacting the provider of a client who has heart failure and a potassium
level of 3.4 mEq/L. Which of the following client medications should the nurse expect
the provider to withhold? - correct answer Digoxin
The nurse should expect the provider to withhold digoxin when the client's potassium
level is low to decrease the client's risk of dysrhythrmias due to digoxin toxicity.
Potassium assists in displacing digoxin, because digoxin binds to potassiurm, and
reduces the risk for digoxin toxicity.
,VATI Med surg proctored graded A+
2024 exam
A nurse is assisting with the care of a client who has cellulitis and is receiving IV
ceftriaxone. During data collection, the nurse notes the client is flushed and the client
reports urticaria. After stopping the IV infusion, which of the following actions should
the nurse take first? - correct answer Check the client's respirations.
After stopping the IV infusion, the first action the nurse should take when using the
airway, breathing, circulation approach to client care is to count the client's
respirations and monitor for dyspnea because a client experiencing an allergic
reaction can progress to anaphylactic shock and death.
A registered nurse (RN) in an acute care facility is caring for a group of clients with
the assistance of a licensed practical nurse (LPN). Which of the following tasks
should the RN delegate to the LPN? (Select all that apply.) - correct answer Inserting
an NG tube
Monitoring an IV infusion
Administering IM medications
A nurse is reinforcing teaching with a young adult client about testicular self-
examination. Which of the following instructions should the nurse include? - correct
answer "Examine your testicles after a warm shower."
After exposure to warm water in a shower or bath, the scrotum relaxes and becomes
easy to palpate. The testicle should feel smooth and round, and the client should
report any lumps to his provider.
A nurse is assisting in the planning of a health education class for a group of older
adult clients. Which of the following recommendations should the nurse include? -
correct answer Obtain a pneumococcal immunization
The pneumococcal immunization should be obtained to prevent pneumonia and is
generally given at or near the age of 65, One dose provides lifelong immunity
A nurse is preparing to administer eardrops to an adult client who has otitis media.
Which of the following actions should the nurse plan to take? - correct answer Warm
the bottle by holding it in the palm for 5 min before administration.
, VATI Med surg proctored graded A+
2024 exam
The nurse should plan to warm the bottle of drops slightly by holding it in the palm of
the hand or putting the bottle in a pocket for about 5 min. Administering cold ear
drops can cause the client to experience discomfort or dizziness.
A nurse is reinforcing teaching about the use of an oxygen concentrator in the home
for a client who has end-stage emphysema. Which of the following instructions
should the nurse include to promote client safety? - correct answer Maintain an
electrical backup system.
medical services and the electric company of the The nurse should remind the client
to maintain an electrical backup system to ensure continuity of oxygen therapy. This
includes notifying local emergency use of home oxygen equipment. In the event of
power loss, the client should notify 911, the provider, and the home health care
agency.
A nurse is caring for a client who is receiving continuous bladder irrigation following a
transurethral resection of the prostate. The client has reduced urinary output, red
urine, and reports bladder pain. Which of the following actions should the nurse take
first? - correct answer Increase the flow rate of the irrigation
When providing client care, the nurse should use the least restrictive intervention
first; therefore, the nurse should first increase the flow rate of continuous bladder
irrigation to keep the urinary output light pink or yellow.
A nurse is reinforcing teaching with a newly licensed nurse about enoxaparin. The
nurse should include in the teaching that which of the following medications can
interact with enoxaparin? (Select all that apply.) - correct answer Clopidogrel
Aspirin
Ginkgo biloba
A nurse is collecting data from a client who has hypokalemia. Which of the following
findings should the nurse expect? - correct answer Cardiac dysrhythmias
The nurse should monitor the client who has hypokalemia, an electrolyte imbalance,
for life-threatening cardlac dysrhythmilas, abdominal pain, and distention.
A nurse is collecting data from a client who reports dizziness and vertigo and is
performing the Romberg test. Which of the following instructions should the nurse
give the client about this test? - correct answer "Open your eyes."
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