345 Final Review

A nurse is monitoring a client who is receiving medication by peripheral IV infusion. The client reports pain at the insertion site, and the nurse noted fluid leaking around the catheter. Which of the following actions should the nurse take first?

• Take a photograph of the peripheral IV site

• Obtain and record the client's vital signs

• Stop the infusion

• Identify all medications administered through the IV site for the past 24 hours

A nurse is assessing a client who is postop following a TURP and has continuous bladder irrigation. The nurse notes no drainage in the client's drainage bag over 1 hour. Which of the following actions should the nurse take?

• Instruct the client to void around the indwelling catheter

• Assess the client for signs of distention

• Increase the rate of the irrigation solution

• Administer a diuretic

A nurse is providing discharge teaching to the family of the client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure?

• Reorient the client

• Protect the client's head

• Loosen constrictive clothing

• Turn the client onto his side

A nurse is checking lab values to determine if a client with diabetes mellitus is adhering to the treatment plan. Which of the following tests should the nurse use to make this determination?

• Hemoglobin A1C

• Urine sugar and ketone levels

• Glucose tolerance test

• Fasting serum glucose

A nurse is providing teaching to a client who has type 1 diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include in the teaching?

• Shakiness

• Urinary frequency

• Dry mucous membranes

• Excess thirst

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

• Urine negative for ketones

• Distended neck veins

• Kussmaul respirations

• Elevated blood pressure

A nurse is admitting a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurse's priority?

• Initiate airborne precautions

• Administer antimicrobial therapy

• Tell the client that the infection will be communicable for 2-3 weeks after therapy starts

• Teach the client about the manifestations of TB

A nurse is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism?

• Calf tenderness

• Stabbing chest pain

• Elevated temperature

• Bradycardia

A nurse is providing teaching to a client with cancer who is receiving external radiation therapy. Which of the following statements by the client indicates and understanding of the teaching?

• "I need to protect the area from sunlight"

• "I'm going to apply a heating pad to the area after each treatment"

• "I'll massage the area once per day"

• "I'll wash the markings off after each therapy treatment"

A nurse is assessing a client who has a bleeding duodenal ulcer. Which of the following findings should the nurse expect?

• Increased blood pressure

• Coffee ground emesis

• Decreased heart rate

• Bright green stools