NCLEX: Respiratory, Neuro, GI, Ortho Cardio GI, Endocrine, Integumentary - €6,31   In winkelwagen

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NCLEX: Respiratory, Neuro, GI, Ortho Cardio GI, Endocrine, Integumentary

NCLEX: Respiratory, Neuro, GI, Ortho Cardio GI, Endocrine, Integumentary Integumentary NCLEX A client with dermatitis has been prescribed a topical corticosteroid for use on the affected areas, and the nurse has reinforced instructions about the use of this medication. Which statement by the client indicates a need for further teaching? Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication? Isotretinoin (Amnesteem, Clavaris) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the health care provider's prescription sheet to see if which therapy has been prescribed for site care A client with eczema has a prescription for a topical corticosteroid. The nurse cautions the client to use the product carefully in which area where the risk of systemic absorption is greater? The nurse is providing instructions to a client with a diagnosis of scabies regarding the administration of crotamiton (Eurax). Which statement by the client indicates an understanding regarding the application of this medication? The health care provider has prescribed silver sulfadiazine (Silvadene) for the client with a partial-thickness burn, which has cultured positive for gram-negative bacteria. The nurse is reinforcing information to the client about the medication. Which statement made by the client indicates a lack of understanding about the treatments? A client is seen in the clinic for complaints of skin itchiness that has been persistent over the past several weeks. Following data collection, it has been determined that the client has scabies. Lindane is prescribed, and the nurse is asked to provide instructions to the client regarding the use of the medication. How should the nurse teach the client to apply the cream? The nurse is applying a topical glucocorticoid on a client with eczema. The nurse monitors for systemic absorption of the medication if the medication is being applied to which body areas? Coal tar has been prescribed for a client with a diagnosis of psoriasis, and the nurse reinforces instructions to the client about the medication. Which statement by the client indicates a need for further teaching? Isotretinoin (Accutane) is prescribed for a client to treat severe cystic acne. The nurse tells the client that the length of the usual prescribed course of treatment is which? Mafenide acetate (Sulfamylon) is prescribed for the client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which is the most appropriate nursing action? The burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client knowing that which indicates a systemic effect has occurred? Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse is preparing to reinforce instructions to the client and spouse regarding the wound treatment. Which directions should the nurse include in the instructions? The nurse is assigned to care for a client with a leg ulcer. Sutilains (Travase) treatments are prescribed. The nurse should avoid which action when performing the treatment? A client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes that the chest and neck are red, and the client is complaining of pain at the radiation site. How should the nurse interpret this data? A client with severe acne is seen in the clinic, and the health care provider (HCP) prescribes isotretinoin (Amnesteem, Clavaris). The nurse reviews the client's medication record and should contact the HCP if the client is taking which medication? The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption of the medication if the medication is being applied to which body area? A client with a burn injury is applying mafenide acetate (Sulfamylon) to the wound. The client calls the health care provider's office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. Which instructions should the nurse reinforce to the client? The nurse reinforces instructions to a client regarding the use of tretinoin (Retin-A). Which statement by the client indicates the need for further teaching? The nurse is caring for a client with a burn injury to the lower legs. Silver sulfadiazine (Silvadene) is prescribed to be applied to the sites of injury. Which indicates the appropriate method to apply this medication? The nurse is caring for a client diagnosed with scabies who has just been prescribed crotamiton (Eurax). The nurse provides which instruction for application of this medication? Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? The nurse reviews the laboratory results for a client diagnosed with leukemia who is receiving chemotherapy. The nurse notes that the white blood cell (WBC) count is 2000 cells/mm3. The nurse identifies the finding as indicative of which? The nurse in a health care provider's office has scheduled a client with dermatitis to be seen in 1 week for a patch test. The nurse should reinforce instructions to the client to do which action before the procedure? The clinic nurse is collecting data on a client being admitted. The nurse notes that the client is taking azelaic acid (Azelex). Because of the medication prescription the nurse should suspect that the client is being treated for which condition? 1. An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank. 2. A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which describes a characteristic of this type of a lesion? 3. The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as malignant melanoma. The nurse should expect which characteristic of this type of lesion to be documented in the client's record? 4. The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching? 5. A client arrives at the emergency department and has experienced frostbite to the right hand. Which should the nurse expect to find when inspecting the client's hand? 6. The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which should the nurse expect to find when checking the client's sacral area? 7. The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present? 8. Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? 9. The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn? 10. The nurse is assigned to care for a client with herpes zoster. Which characteristics should the nurse expect to note when checking the lesions of this infection? 11. The nurse is caring for a client with a diagnosis of pemphigus vulgaris. The nurse understands that which is a characteristic of this condition? 12. A client asks the nurse about the causes of acne. The nurse should respond by making which statement to the client? 13. The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which? 14. The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position should the nurse anticipate being prescribed for the client? 15. The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further teaching? 16. The nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder? 17. The nurse is reinforcing discharge instructions to a client who had a skin biopsy. Which statement by the client indicates the need for further teaching? 18. The nurse prepares to assist a health care provider examine the client's skin with a Wood's light. Which action should be included in the plan for this procedure? 19. The nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritus. Which client statement indicates the need for further teaching? 20. A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse makes which statement to the client? 21. A client is being admitted to the hospital for the treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. Which response should the nurse give to the client's question? 22. The nurse prepares to care for a client with acute cellulitis of the lower leg. Which treatment should the nurse anticipate being prescribed for the client? 23. The health care provider suspects a client has herpes zoster. To confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equipment? 24. A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse should make which response to the client? 25. The nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area should provide the best information? 26. The nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further teaching? 27. The nurse prepares to assist in instructing a client about prevention of Lyme disease. Which should the nurse include in the instructions? 28. Following diagnostic evaluation, it has been determined that the client has Lyme disease, stage 2. The nurse understands that which is most indicative of this stage? 29. A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate? 30. A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been determined by which? 31. Which individual is least likely at risk for the development of Kaposi's sarcoma? 32. The nurse reviews a client's chart and notes that the health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which should the nurse expect to note during data collection? 33. The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition? 34. The nurse is checking her clients for skin breakdown. Which client should have the lowest priority for concern in the development of skin breakdown? 35. A client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes that the chest and neck are red, and the client is complaining of pain at the radiation site. How should the nurse interpret this data? 36. Sodium hypochlorite (Dakin's solution) is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which in the plan? 37. Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication? 38. The nurse inspects a pressure ulcer on a client's sacrum and notes that the ulcer has partial-thickness skin loss and the formation of a blister. The nurse should document the ulcer as which category? 39. A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the health care provider to prescribe which measure to maximize the effectiveness of this therapy? 40. Which individuals is least likely at risk for the development of psoriasis? 41. The nurse is assisting in caring for a client with a severe burn who has just received an autograft to the knee area of the right leg. The nurse plans to keep the right leg in which position? 42. A client with a burn injury is scheduled for a heterograft. The nurse is preparing the client for the skin grafting, and the client asks the nurse what "heterograft" means. Which is the most appropriate response to the client? 43. The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury would be which percentage? 44. A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The "stinger" is still visible in her arm. What should be the nurse's first action? 45. A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure, the nurse observes that the flap has a slightly blue hue. The nurse draws which conclusion? 46. A client has a non-infected pressure ulcer on the left heel. The nurse should use which sterile solutions to cleanse the wound as part of a dressing change procedure? 47. A client sustains a burn injury to the entire right and left arms, right leg, and anterior thorax. According to the rule of nines, the nurse should determine that this injury constitutes which body percentage? 48. The nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day after injury, the client's vital signs include an oral temperature of 102.8° F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially perform which action? 49. The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for further teaching about the measures that will prevent the spread of infection? 50. A client, admitted to the emergency department, is suspected of having frostbite of the hands. Which finding should the nurse note in this condition? a. White skin that is insensitive to touch 51. Which clients are at risk for developing skin breakdown? Select all that apply. 52. The nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to take which action next in the care of this client? 53. A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse reinforces instructions to the client regarding preparation for the test. Which statement by the client indicates an understanding regarding the preparation for this procedure? 54. The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse should question which prescription? 55. The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure ulcer in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure ulcer? Select all that apply. 56. A client with a burn injury begins to cry and states to the nurse, "I don't want anyone seeing me. I look awful." The nurse determines that the client is experiencing which associated problem? 57. An older client is transferred to the nursing unit following a graft to a stage 4 pressure ulcer. Which combination of dietary items should the nurse encourage the client to eat to promote wound healing? 58. The nurse is preparing a client for skin grafting and identifies that the health care provider has documented that the client is scheduled for a heterograft. The nurse understands that a heterograft used for the burn client is skin from which source? 59. During the inspection of a client's skin, the nurse notes redness and an abrasion type wound on the sacrum area. The nurse determines that this finding is indicative of which stage of pressure ulcer? 60. After 7 days of wound care, a client who has a well-granulated pressure ulcer reports to the nurse, "I'm feeling better overall." Which nursing intervention most likely contributed to the client's feelings? 61. Using the rule of nines, calculate the burn percentage for the client. Refer to the figure; the burned area is the darkly shaded area. Fill in the blank. Refer to figure. 62. A client comes to a health care provider's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick? 63. A client with jaundice is complaining of pruritus. Which strategy should the nurse institute to help control the problem and prevent injury? 64. The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse understands that moist desquamation is best described as which? 65. The nurse is discussing skin biopsy with a client scheduled for the procedure. The nurse tells the client to expect which amount of discomfort during the procedure? 66. The nurse in a health care provider's office has scheduled a client with dermatitis to be seen in 1 week for a patch test. The nurse should reinforce instructions to the client to do which action before the procedure? 67. An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage? 68. A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client should monitor for which sign/symptom during the first 24 hours after the burn injury? 69. An older client is complaining of chronic dry skin and occasional pruritus. The nurse reinforces instructions for the client to avoid which skin care regimen that will aggravate the condition? 70. A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the health care provider's prescription sheet to see if which therapy has been prescribed for site care? 71. The nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse should include on the poster instructions to avoid which activities? 72. A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In reinforcing instructions to the client about the medication, the nurse incorporates which aspect of this medication? 73. The nurse is caring for a client on transmission-based precautions who has herpes zoster or shingles. Which are some of the most important skin issues associated with this condition? Select all that apply. 74. The nurse is conducting a focused evaluation on a postoperative client's integumentary system. Which priority objective physical examination assessments are related to inspection? Select all that apply. 75. The nurse is caring for a postoperative client. The nurse knows that the primary processes of normal wound healing include which phases? Select all that apply. 76. The nurse is working on a surgical unit. Which surgical clients are most at risk for wound infection? Select all that apply. 77. An African-American client has been admitted for a skin rash on his lower back. Which should the nurse rely on when assessing the skin rash? Select all that apply. 1. After a liver biopsy, the nurse should place the client in which position? 2. The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion? 3. The nurse is checking a client for the correct placement of a nasogastric (NG) tube. The nurse aspirates the client's stomach contents and checks its pH level. Which pH value indicates the correct placement of the tube? 4. A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. The LPN should reinforce instructing the client to perform which action? 5. The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency? 6. The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. On review of the postoperative prescriptions, which should the nurse clarify? 7. The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse include in client teaching to help prevent dumping syndrome? 8. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence? 9. The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to see documented in the record? 10. The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to note? Select all that apply. Encourage coughing and deep breathing. Administer anticholinergics, as prescribed. 11. It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing? 12. The nurse is reviewing the health care provider's prescriptions written for a client admitted with acute pancreatitis. Which health care provider prescription should the nurse verify if noted in the client's chart? 13. A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid? 14. The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred? 15. Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding? 16. The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa? 17. A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse tells the client to avoid which position that could aggravate the pain? 18. The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse determines that the client understands the instructions given if the client states that which food item is acceptable to include in the diet? 19. A client is admitted to the hospital with acute viral hepatitis. Which sign/symptom should the nurse expect to note based on this diagnosis? 20. Which infection control method should be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure? 21. A client is admitted to the hospital with viral hepatitis and is complaining of a loss of appetite. In order to provide adequate nutrition, which action does the nurse encourage the client to take? 22. The nurse is caring for a client with acute pancreatitis and a history of alcoholism and is monitoring the client for complications. Which data should be indicative of paralytic ileus? 23. A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention should be appropriate? 24. The nurse is participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse plans to include which risk factor for colorectal cancer in the material? 25. A client has undergone esophagogastroduodenoscopy (EGD). The nurse places highest priority on which action as part of the client's care plan? 26. The nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement made by the client supports the diagnosis of gastric ulcer? 27. A client has been diagnosed with acute gastroenteritis. Which diet should the nurse anticipate to be prescribed for the client 28. A client has asymptomatic diverticular disease. Which type of diet should the nurse anticipate being prescribed? 29. The nurse is caring for a client suspected of having appendicitis. Which should the nurse anticipate will be prescribed for this client? 30. The nurse has given the client with hepatitis instructions about postdischarge management during convalescence. The nurse determines that the client needs further teaching if the client makes which statement? 31. The nurse is assigned to care for a client who had a Sengstaken-Blakemore tube inserted when more conservative treatment failed to alleviate the condition. The nurse should suspect that the client has which diagnosis? 32. The nurse has been caring for a client with a Sengstaken-Blakemore tube. The health care provider arrives on the nursing unit and deflates the esophageal balloon. Following deflation of the balloon, the nurse should monitor the client closely for which? 33. A health care provider places a Miller-Abbott tube in a client who has a bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next? 34. The nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which history is least likely associated with this disease? 35. A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which finding would indicate adequate location of the tube? 36. The nurse is caring for a client with a nasogastric tube. Which observation is most reliable in determining that the tube is correctly placed? 37. A client is admitted to the hospital with a bowel obstruction secondary to a recurrent malignancy, and the health care provider plans to insert a Miller-Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, "I don't want to hear about that. Just let the doctor do it." Based on the client's statement, which is the nurse's best action? 38. The nurse is assisting in planning stress management strategies for the client with irritable bowel syndrome. Which suggestion should the nurse give to the client? 39. A calcium supplement is prescribed for a client with hypoparathyroidism in the management of hypocalcemia. The client arrives at the clinic for a follow-up visit and complains of chronic constipation, and the nurse reinforces instructions to the client about measures to alleviate the constipation. Which comment by the client would indicate a need for further teaching? 40. A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures are most likely to promote coping? Select all that apply. 41. Which statement by the spouse of a client with end-stage liver failure indicates the need for further teaching by the multidisciplinary team regarding the management of pain? 42. After the deflation of the balloon of a client's Sengstaken-Blakemore tube, the nurse monitors the client closely for which esophageal complication? 43. The nurse is collecting data on a client admitted to the hospital with hepatitis. Which data indicate that the client may have liver damage? 44. The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of liver disease. Which medication prescription should the nurse question? 45. A nurse planning care for a client with hepatitis plans to meet the client's safety needs by performing which action? 46. The nurse is collecting admission data on the client with hepatitis. Which finding would be a direct result of this client's condition? 47. The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. Which data noted in the record indicate poor absorption of dietary fats? 48. A client is admitted to an acute care facility with complications of celiac disease. Which question should be helpful initially in obtaining information for the nursing care plan? 49. A client is seen in the ambulatory care office for a routine examination. Which statement by the client would be important for the nurse to follow up? 50. A client with a possible hiatal hernia complains of difficulty swallowing. Which other sign/symptom is associated with a hiatal hernia? 51. The nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent recurrence of symptoms. Which statement should be included in the teaching? 52. The nurse documents that a client with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which action? 53. Treatment measures have been implemented for a client with bleeding esophageal varices and have been unsuccessful. The health care provider states that a Sengstaken-Blakemore tube will be used to control the resulting hemorrhage. The nurse prepares for insertion via which route? 54. The nurse is caring for a client with a Sengstaken-Blakemore tube. To prevent ulceration and necrosis of oral and nasal mucosa, the nurse should plan to perform which action? 55. A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. Which data would further support this diagnosis? 56. The nurse should include which information when reinforcing home care instructions for a client who has peptic ulcer disease? 57. The nurse is reinforcing dietary instructions for a client with peptic ulcer disease. Which action does the nurse encourage the client to do? 58. The nurse has been reinforcing dietary teaching for a client with gastroesophageal reflux disease (GERD) who has a routine follow-up visit. Which behavior is the best indicator of a successful outcome for this client? 59. A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which items concerning ongoing self-management should the nurse reinforce to the client? Select all that apply. 60. The nurse who is reinforcing instructions to a client following gastric resection should include which suggestions? Select all that apply. 61. The nurse reinforces instructions to a client following a gastrectomy about the signs and symptoms of pernicious anemia, knowing what information? 62. The nurse who is assisting in the care of a client within the first 24 hours following a total gastrectomy for gastric cancer should avoid which intervention? 63. The nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to absorb food. While carrying out this function, the nurse recalls that absorption is defined as which? 64. A health care provider asks the nurse to obtain a Salem Sump tube for gastric intubation. The nurse should correctly select which tube from the unit storage area? 65. The nurse has assisted in the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse plans to set the suction to which pressure? 66. A client has had a partial gastrectomy and the nurse is reinforcing discharge instructions. The nurse should tell the client about the need for which? Select all that apply. 67. A client in the emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply. 68. The nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse should place the client in which position during and after the feedings? 69. The nurse is reinforcing discharge instructions to a client who has had a total gastrectomy. The nurse tells the client about the importance of returning to the health care clinic as scheduled for which priority assessment? 70. The nurse assigned to care for a client with cirrhosis reviews the medical record and notes that the client has difficulty maintaining an effective breathing pattern due to pressure on the diaphragm. The nurse plans care knowing that which client position will best assist in facilitating breathing? 71. A client arrives at the emergency department and complains of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the health care provider's prescriptions. Which prescription should the nurse question if written on the health care provider's prescription form? 72. The nurse is caring for a client with a nasogastric (NG) tube and tests the pH of the aspirate to determine correct placement. The nurse notes that the pH is 5. Which information does this indicate? 73. A generally healthy 63-year-old man is seen in the health care provider's office for a routine examination. Which statement made by the client is important for the nurse to follow up on? 74. A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse should gather further information about the presence of which sign or symptom? 75. The nurse is teaching a client who is newly diagnosed with a hiatal hernia about measures to prevent recurrence of symptoms. The nurse should make which accurate statement to the client? 76. The nurse is reinforcing discharge instructions to a client with a hiatal hernia. Which should the nurse include in the teaching session? Select all that apply. 77. The nurse is reinforcing instructions to a client about insertion of a Sengstaken-Blakemore tube. Which statement by the client indicates an understanding of the teaching? 78. The nurse is assisting in caring for a client with a Sengstaken-Blakemore tube. Which article should the nurse place at the bedside? 79. A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting, and a gastric ulcer is suspected. The nurse should gather which additional supportive data from the client for this diagnosis? 80. The nurse should include which instruction in a teaching plan for a client who has peptic ulcer disease? 81. The nurse is reinforcing dietary instructions for a client with peptic ulcer disease. Which statement made by the client indicates a need for further teaching? 82. A client has undergone subtotal gastrectomy and the nurse is preparing the client for discharge. Which item should be included when reinforcing instructions to the client about ongoing self-management? 83. The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse should include which instruction? 84. The nurse provides information to a client following a gastrectomy who is now diagnosed with pernicious anemia. Which instructions about pernicious anemia should the nurse reinforce? Select all that apply. 85. The nurse is caring for a client within the first 24 hours following a total gastrectomy for gastric cancer. During this time frame, on which intervention should the nurse focus? 86. The nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to digest food. Which processes are involved in the complete digestive process? Select all that apply. 87. A licensed practical nurse (LPN) is helping a registered nurse (RN) conduct an abdominal assessment. The LPN assists the client into which position? 88. A health care provider asks the nurse to obtain a Salem Sump tube for gastric intubation. The nurse selects which tube from the unit storage area? 89. The nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression. Which settings will the health care provider prescribe? Select all that apply. 90. The nurse is working with a client diagnosed with anorexia nervosa. The nurse plans care, focusing on which as the primary problem? 91. A client has been diagnosed with chronic gastritis and has been told that there is too little intrinsic factor being produced. The nurse tells the client that which therapy will be prescribed to treat the problem? 92. The nurse is caring for a client in the emergency department who has right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescription? 93. The nurse is performing an abdominal assessment on a client. The nurse interprets that which finding is abnormal and should be reported to the registered nurse (RN) or health care provider? 94. The nurse is interpreting the laboratory results of a client who has a history of chronic ulcerative colitis. Which result indicates a complication of ulcerative colitis? 95. A client diagnosed with pernicious anemia asks the nurse what caused the deficiency. The nurse replies that it is likely a result of which condition that is part of the client's health history? 96. The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning and all connections are snug. The tube is secured properly and does not appear to have been dislodged. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. The nurse analyzes this problem as which? 97. The nurse is preparing to administer a soapsuds enema to a client. Into which position does the nurse place the client to administer the enema? Refer to figure. 98. A postgastrectomy client is at high risk for hyperglycemia related to uncontrolled gastric emptying of fluid and food into the small intestine (dumping syndrome). Because of this risk, the nurse plans to monitor which data? 99. The nurse is caring for a client with pneumonia with a history of bleeding esophageal varices. Based on this information, the nurse plans care, knowing that which could result in a potential complication? 100. A client is admitted to the hospital with a diagnosis of acute pancreatitis. The nurse plans care, knowing that which problem occurs with this disorder? 101. A postgastrectomy client who is being discharged from the hospital tells the nurse, "I hope my stomach problems are over. I need to get back to work right away. I've missed a lot of work, and I'm really behind. If I don't get my act together, I may lose my job." Based on the client's statement, the nurse determines that at this time, it is appropriate to discuss which topic? 102. The nurse gathers data from a client admitted to the hospital with gastroesophageal reflux disease (GERD) who is scheduled for a Nissen fundoplication. Based on an understanding of this disease, the nurse determines that the client may be at risk for which complication? 103. The nurse analyzes the results of laboratory studies performed on a client with peptic ulcer disease (PUD). Which laboratory value would indicate a complication associated with the disease? 104. The nurse is admitting a client to the hospital for the treatment of dehydration. The client reports nausea, vomiting, diarrhea, and cramping for the past week. The nurse asks the client about medications he is taking. The client denies taking prescription medications but states he has been taking some herbs given to him by his cousin. The nurse alerts the health care provider when the client states he has been taking which herb? 105. The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed the nasogastric tube to be discontinued. To determine the client's readiness for discontinuation of the nasogastric tube, which measure should the nurse check? 106. A sexually active 20-year-old client has developed viral hepatitis. Which statement made by the client would indicate a need for teaching? 107. A client is admitted to the hospital with severe jaundice and is having diagnostic testing. Because the client has no complaints of fatigue, the client is encouraged to ambulate in the hall to maintain muscle strength. The client paces around the room but will not enter the hall. Which problem most likely is the reason for the client's reluctance to walk in the hall? 108. A client with viral hepatitis states to the nurse, "I am so yellow." The nurse should take which action? 109. The nurse is reviewing the medication record of a client with acute gastritis. Which medication noted on the client's record should the nurse question? 110. A client with peptic ulcer disease is scheduled for a pyloroplasty, and the client asks the nurse about the procedure. The nurse bases the response on which information? 111. A client with a peptic ulcer is scheduled for a vagotomy, and the client asks the nurse about the purpose of this procedure. The nurse tells the client that a vagotomy serves which purpose? 112. The nurse is instructing a client who had a herniorrhaphy about how to reduce postoperative swelling following the procedure. Which should the nurse suggest to the client to prevent swelling? 113. The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. Which is the appropriate nursing action? 114. A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse should time the medication so that each dose is taken at which time? 115. A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. To aid the client in symptom management, the nurse suggests which diet? 116. A client is resuming a diet after partial gastrectomy. To minimize complications, the nurse should tell the client to avoid which practice 117. The nurse has assisted the health care provider with a liver biopsy, which was done at the bedside. Upon completion of the procedure, the nurse assists the client into which position? 118. A licensed practical nurse (LPN) is assisting in the insertion of a nasogastric (NG) tube for an adult client. The LPN helps determine the correct length to insert the tube by performing which measurement? 119. A postoperative client has regained bowel sounds and is ready to start a clear liquid diet. The nurse is told that the health care provider has written a prescription to remove the nasogastric (NG) tube. The nurse assists in the procedure and asks the client to do which during tube removal? 120. The nurse has a prescription to give 30 mL of an antacid to a client through a nasogastric (NG) tube that is connected to wall suction. The nurse should do which action to perform this procedure correctly? 121. The nurse is caring for a client with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times? 122. The nurse will be providing postprocedure care to a client who has undergone esophagogastroduodenoscopy (EGD). The nurse should plan to do which action first? 123. A health care provider asks the licensed practical nurse (LPN) to reinforce preprocedure instructions to a client who will undergo a barium swallow (esophagography) in a few days. The LPN should include which instruction in this discussion? 124. The nurse notes that the medical record of a client with cirrhosis states that the client has asterixis. To verify this information the nurse should take which action? 125. A health care provider is about to perform a paracentesis on a client with abdominal ascites. The nurse should assist the client to assume which position? 126. A client is receiving bolus feedings via a nasogastric tube. The nurse plans to place the client's head of the bed (HOB) in which optimal position once the feeding is completed? 127. A client receiving a high cleansing enema complains of pain and cramping. The nurse should take which corrective action? 128. The nurse is getting a client who underwent umbilical hernia repair ready for discharge. The nurse tells the client that it is important to continue to do which action after discharge? 129. A client presents to the urgent care center with complaints of abdominal pain. Suddenly the client vomits bright red blood. The nurse takes which immediate action? 130. The nurse is reinforcing medication instructions to a client with peptic ulcer disease. Which represents correct information given by the nurse? 131. A client with acute pancreatitis is experiencing severe pain. After noting an absence of an analgesic prescription on the health care provider prescription sheet, the nurse should suggest contacting the health care provider to request a prescription for which medication? 132. An acutely ill looking client arrives at the emergency department. The client complains of "the worst pain I ever felt in my belly. I can't get comfortable." The client is quiet but with each movement the client cries out in pain. The nurse suspects the client has peritonitis. Which data should the nurse collect to assist in validating this suspicion? Select all that apply. 133. A client arrives at the emergency department complaining of severe abdominal pain and is placed on NPO status. During a quick assessment the nurse observes that the client has both Cullen's sign and Grey Turner's sign and pancreatitis is suspected. The nurse should perform the following actions/prescriptions in which priority order? Arrange the actions in the order they should be performed. All options must be used. 134. A morbidly obese client, 3 days postoperative gastric bypass surgery, comes to the clinic complaining of pain. The nurse suspects that the client has an anastomotic leak requiring hospitalization. Which findings validate this suspicion? Select all that apply. 135. The nurse is reinforcing instructions to a client and his family about alcohol abuse and chronic cirrhosis. The nurse knows to include which essential elements in the discharge teaching guide? Select all that apply. ORTHOPEDIC NCLEX 1. The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? 2. A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings? 3. A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? 4. The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place? 5. The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? 6. The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? 7. The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item? 8. A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? 9. The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately? 10. The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? 11. A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? 12. The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 13. The nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. Which action should alleviate the client's fears and misconceptions about surgery? 14. The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the health care provider and anticipates that the provider will prescribe which? 15. The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which nursing action should be performed? 16. A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery? 17. The nurse is monitoring an adult client for postoperative complications. Which is mostindicative of a potential postoperative complication that requires further observation? 18. The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem? 19. The nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which action should the nurse avoid in the care of the drain? 20. The nurse checks the client's surgical incision for signs of infection. Which is indicative of a potential infection? 21. The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which should be the initial action by the nurse? 22. The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 23. The nurse is assisting with caring for a client with abruptio placenta. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first? 24. A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action? 25. The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item? 26. The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action? 27. The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action? 28. The nurse assists in planning care for a child who sustained a burn injury. The nurse plans care based on which accurate statement? 29. The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Which interventions should the nurse perform? Select all that apply. 30. The client arrives at the emergency department after a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client? 31. The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless, and his color is becoming dusky. The nurse should interpret this data as indicating which? 32. The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation? 33. A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? 34. The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action? 35. The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? 36. A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function? 37. The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? Serous drainage 38. The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first? Check the client's alignment in bed. 39. The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity? Performing active range of motion (ROM) to the right ankle and knee 40. The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection? Presence of a "hot spot" on the cast 41. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition? Impaired tissue perfusion 42. The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention? Elevate the leg on pillows continuously for 24 to 48 hours. 43. A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention? Petaling the cast edges with adhesive tape 44. The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply. Keep the cast and extremity elevated. The cast needs to be kept clean and dry. Allow the wet cast 24 to 72 hours to dry. 45. The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position? 8 inches to the front and side of the client's toes 46. The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action? Moves the cane when the right leg is moved 47. The nurse is caring for a client with fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? Elevating the limb and applying ice to the affected leg 48. A client is being discharged home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement? "I need to avoid getting the cast wet." 49. The client is brought to the emergency department and is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action? Maintaining a patent airway 50. The nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client's bedside? Suction equipment 51. The nurse notes the appearance of skin breakdown on a client's hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure. Extravasation 52. A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate? "You are concerned that you don't feel any better after surgery?" 53. A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further skin care instructions are required if the client makes which statement? "I need to scrub the skin vigorously with soap and water." 54. A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which as a high-risk area for pressure and breakdown? Left heel 55. A client has been placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction? Slightly elevating the foot of the bed 56. A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy? Fluid overload 57. The health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood contains 250 mL, and the drop factor is 10 gtt/1 mL. Although an infusion pump will be used, the registered nurse asks the licensed practical nurse (LPN) to assist with monitoring the flow rate during the infusion. The LPN monitors the flow rate, knowing that how many gtt/min should infuse? Fill in the blank. Round the answer to the nearest whole number. 10 gtt/min 58. The nurse monitors a postoperative client for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication? Increasing restlessness 59. The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out? To allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure, and the site 60. The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action? The surgeon marking the area of the operative procedure 61. A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. Notify the registered nurse. Document the client's complaint. Instruct the client to remain quiet. Prepare the client for wound closure. 62. A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. Which nursing action should be the priority for this client? Determine vital signs. 63. The nurse is assisting in monitoring the condition of a client after pericardiocentesis for cardiac tamponade. Which observation indicates that the procedure was unsuccessful? Distant and muffled heart sounds 64. The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is non-reddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 cells/mm3. Which interpretation does the nurse make of these findings? The incision line is slightly edematous but shows no active signs of infection. 65. A client is receiving thrombolytic therapy by continuous infusion. The client suddenly becomes extremely anxious and complains of itching. The nurse hears stridor, and on examination of the client, notes generalized urticaria and hypotension. Which should be the priority action of the nurse? Stop the infusion, and notify the registered nurse. 66. A family of a spinal cord–injured client rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic, with a flushed face and neck, and complains of a severe headache. The pulse is 40 beats per minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, knowing that the client is experiencing which? Autonomic dysreflexia 67. A client with diabetes mellitus has had a right below-knee amputation. The nurse should be especially vigilant in monitoring for which complication related to the client's history? Separation of wound edges 68. A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How does the nurse correctly interpret the client's statement? "It is a normal response and indicates the presence of phantom limb sensation." 69. The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other

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