| A | B |
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| The nurse understands that collecting data about which body structures can provide information about fluid status in the older adult client? | Hair, skin, nails, and mucous membranes |
| The nurse should consider which factor when administering medication to the older adult client? | There is an increased risk for toxicity |
| The nurse is reinforcing teaching to a client with diabetes mellitus about differentiating between hypoglycemia and hyperglycemia. The client indicates an understanding by stating that which findings are signs/symptoms of hyperglycemia? | Increased thirst, fruity breath odor, increased urination. |
| The client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/min range. The client is also complaining of nausea. The nurse interprets that these symptoms are due to stimulation of which cranial nerve (CN)? | Vagus (CN X) |
| The nurse caring for an older client understands that which finding is abnormal related to the integumentary system? | Tearing of the skin. |
| A client has undergone colectomy with a colostomy for a bowel tumor. The nurse determines that the client's colostomy is beginning to function if which finding is noted? | Passage of flatus. |
| A client being seen in an ambulatory clinic for an unrelated complaint has a dry, scaly, raised rash on the face and upper body and erythema of the palms. The nurse interprets this finding as consistent with early manifestations of which disorder? | Sickle Cell Anemia |
| A client is diagnosed with left ventricular heart faillure. The nurse should monitor the client for which manifestation characteristic of this disorder? | Lung congestion |
| The nurse educator is preparing a teaching session on factors that affect malnutrition in older adult population. Which physiologic risk factors should be included in the presentation? | Medications, sensory changes, chronic health factors, problems with swallowing. |
| The nurse is reinforcing teaching to the family of a client who is newly diagnosed with diabetes mellitus about the disorder. The nurse evaluates that the family understands the reason for having glucagon on hand for emergency home use if the family indicates that the purpose of the medication is to treat which disorder? | Hypoglycemia from insulin overdose |
| The nurse is reinforcing teaching to a client who has diabetes mellitus and diabetic ketoacidosis (DKA) to develop a plan to prevent recurrence. Which instructions should be in the plan? | Monitor blood glucose levels 2 to 4 times daily, and notify the health care provider (HCP) when illness occurs. |
| A client complains of chronic pruritus. The nurse investigating this complaint would review the medical record for documentation of which disorder that would support this client's complaint? | Chronic kidney disease (CKD) |
| A client has mild carbon monoxide poisoning. The nurse should monitor the client for which expected sign or symptom? | headache |
| The nurse is caring for a client with deep vein thrombophlebitis (DVT) of the left leg. The nurse intervenes if the client is noted performing which action? | Wearing sequential compression devices (SCDs) |
| The nurse is monitoring a client after removal of an endotracheal tube. Which sign, if experienced by the client, should the nurse report immediately to the health care provider? | High-pitched, coarse breath sounds. |
| The nurse should reinforce which instruction about proper foot care to a client with diabetes mellitus? | Cut the toenails straight across, inspect the feet daily for any skin problems, and apply a moisturizing lotion to the feet, avoiding application between the toes. |
| A client with pancreatitis is being weaned from parenteral nutrition and asks the nurse why the parenteral nutrition cannot just be stopped. The nurse's response is based on the fact that sudden termination could result in which problem? | Rebound hypoglycemia |
| The nurse is caring for an older client with Alzheimer's disease who is exhibiting agitation. Which nursing intervention will most likely calm the client? | Asking the client to take a walk around the nursing unit. |
| A client is receiving parenteral nutrition via a central line. The nurse should monitor which item to detect the development of the most common complication of parenteral nutrition? | Temperature |
| The nurse is assisting in the care of a client who was experiencing hypermagnesemia. The nurse determines that the client's status is returning to normal if the client no longer exhibits which manifestation? | Areflexia |
| The nurse plans to monitor which client for signs of hyperkalemia? | A client with a severe burn injury |
| A client arrives at the emergency department and a sprained ankle is suspected. The nurse understands that which findings are consistent with a sprain? | Limited joint motion, tenderness on palpation,swelling of the affected area, client description of feeling looseness in the joint. |
| The nurse is reinforcing teaching for dietary modifications to a hypertensive client. The nurse encourages which snack foods that will be acceptable for this client? | Radishes, raw carrots,cucumber slices. |
| The nurse educator is conducting a teaching session on dry suction chest tube systems. Which statement, if made by a student, indicates an accurate understanding of this system? | " when the orange floater valve is in the window, the correct amount of suction has been applied." |
| The nurse is caring for a client who is newly diagnosed with asthma. The nurse is reinforcing instructions to the client and tells the client to avoid which triggers of acute asthma attacks? | Beer, molds, perfumes, animal dander. |
| The nurse would plan to monitor a client with heart failure for hypokalemia as a side effect of pharmacologic therapy if the client was receiving which medication? | Furosemide (Lasix) |
