RN
Adult
MedSurg
Practice
B
Multiple
Choice
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
will
bruise
easily
because
I
have
Lyme
disease"
C
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.
A
nurse
is
caring
for
a
client
who
is
on
bed
rest
and
has
a
new
prescription
for
enoxaparin
subcutaneous.
Which
of
the
following
actions
should
the
nurse
take?
A.
monitor
the
clients'
INR
daily.
B.
expel
air
bubbles
when
using
a
prefilled
syringe.
C.
inject
the
medication
into
the
anterolateral
abdominal
wall.
D.
massage
the
injection
site
after
administration.
C
The
nurse
should
inject
the
medication
into
the
anterolateral
or
posterolateral
abdominal
wall
to
enhance
medication
absorption
and
prevent
hematoma
formation.
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A
nurse
is
caring
for
a
client
who
is
receiving
mechanical
ventilation
via
a
tracheostomy
tube.
The
nurse
should
recognize
that
which
of
the
following
complications
is
associated
with
long-term
mechanical
ventilation?
A.
Elevated
blood
pressure
B.
Dehydration
C.
Stress
ulcers
D.
Hypernatremia
C
Stress
ulcers
in
clients
who
are
receiving
long-term
mechanical
ventilation
are
caused
by
elevated
levels
of
hydrochloric
acid
in
the
stomach.
Stress
ulcers
increase
the
risk
for
systemic
infection
and
require
pharmacological
treatment.
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
A
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.
The
nurse
caring
for
a
client
with
diabetic
ketoacidosis
(DKA)
can
expect
to
implement
which
intervention?
A.
Intravenous
administration
of
regular
insulin
B.
Administer
insulin
glargine
subcutaneously
at
hour
of
sleep
C.
Maintain
nothing
prescribed
orally
(NPO)
status
D.
Intravenous
administration
of
10%
dextrose
A DKA
is
a
complication
of
diabetes
mellitus
that
results
in
dehydration,
ketosis,
metabolic
acidosis,
and
elevated
blood
glucose
levels.
Management
of
DKA
involves
providing
hydration,
correcting
acid-base
imbalances,
and
decreasing
blood
glucose
levels.
Regular
insulin
is
a
fast-acting
insulin
that
can
be
effective
within
10
min
when
administered
intravenously.
A
nurse
is
teaching
a
client
who
has
a
cardiac
dysrhythmia
about
the
purpose
of
undergoing
continuous
telemetry
monitoring.
Which
of
the
following
statements
by
the
client
reflects
an
understand
of
the
teaching?
A.
this
measures
how
much
blood
my
heart
is
pumping
B.
this
identifies
if
i
have
a
defective
heart
valve
C.
this
identifies
if
the
pacemaker
cells
of
my
heart
are
working
properly
D.
this
measures
the
blood
circulating
to
my
heart
muscle
C
Telemetry
detects
the
ability
of
cardiac
cells
to
generate
a
spontaneous
and
repetitive
electrical
impulse
through
the
heart
muscle.
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?
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."
A
nurse
is
teaching
a
client
who
has
venous
insufficiency
about
self-care.
Which
of
the
following
statements
should
the
nurse
identify
as
an
indication
that
the
client
understands
the
teaching?
"I
will
wear
clean
graduated
compression
stockings
every
day."
The
client
should
apply
a
clean
pair
of
graduated
compression
stockings
each
day
and
clean
soiled
stockings
with
mild
detergent
and
warm
water
by
hand.
A
nurse
is
caring
for
client
who
is
experiencing
supraventricular
tachycardia.
Upon
assessing
the
client,
the
nurse
observes
the
following
findings:
heart
rate
200/min,
blood
pressure
78/40
mm
Hg,
and
respiratory
rate
30/min.
Which
of
the
following
actions
should
then
nurse
take?
A.
Defibrillate
the
client's
heart. B.
Perform
synchronized
cardioversion.
C.
Begin
cardiopulmonary
resuscitation.
D.
Administer
lidocaine
IV
bolus.
B
The
nurse
should
perform
synchronized
cardioversion
for
a
client
who
has
supraventricular
tachycardia.
A
nurse
is
planning
care
for
a
client
who
is
having
modified
radical
mastectomy
of
the
right
breast.
Which
of
the
following
interventions
should
the
nurse
include
in
the
plan
of
care?
A.
Instruct
the
client
that
the
drain
will
be
removed
when
there
is
25
mL
of
output
or
less
over
a
24-hr
period.
B.
Assist
the
client
to
start
arm
exercises
48
hr
after
surgery.
C.
Maintain
the
right
arm
in
an
extended
position
at
the
client's
side
when
in
bed.
D.
Place
the
client
in
a
supine
position
for
the
first
24
hr
after
surgery.
A
The
nurse
should
instruct
the
client
that
the
drain
will
remain
in
place
for
1
to
3
weeks
after
surgery
and
will
be
removed
when
there
is
25
mL
of
output
or
less
in
a
24-hr
period.
We
have
an
expert-written
solution
to
this
problem!
A
nurse
in
an
ICY
is
assessing
a
client
who
has
a
traumatic
brain
injury.
Which
of
the
following
findings
should
the
nurse
identify
as
a
component
of
Cushing's
triad?
Bradycardia
A
client
who
has
increased
intracranial
pressure
from
a
traumatic
brain
injury
can
develop
bradycardia,
which
is
one
component
of
Cushing's
triad.
The
other
components
of
Cushing's
triad
are
severe
hypertension
and
a
widened
pulse
pressure.
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
one
month
after
my
radiation
treatments
are
over
D.
I
will
use
a
heating
pad
on
my
neck
if
it
becomes
sore
during
radiation
therapy
B
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