1106

The nurse provides care for clients on an oncology floor. Which client does the nurse assess first after receiving report? 1.The client diagnosed with breast cancer with extensive bone metastasis and who is irritable and confused.2.The client who reports nausea and vomiting 6 hours after receiving chemotherapy.3.The client diagnosed with lung cancer and who reports fatigue and mild shortness of breath with ambulation.4.The client with a WBC of 1600/mm3 (1.6 × 109/L) and who reports burning with urination.

1

The home care nurse returns to the office to find four phone messages. Which message does the nurse return first? 1.The adult child of a client diagnosed with lung cancer stating that the client refuses chemotherapy today.2.A client asking when staples can be removed from an abdominal incision.3.A client with a colostomy reporting that the skin is raw around the stoma.4.The spouse of a client with a cerebrovascular accident stating that the client is refusing a bath.

1 then 2 This client is at risk for experiencing physical harm and this issue is time-sensitive. The nurse should assess whether the client is experiencing side effects and should ensure that the client is informed about the risks of refusing chemotherapy.

The nurse prepares to administer digoxin 0.25 mg PO to a client diagnosed with heart failure. The nurse recognizes that which factor increases the risk for digoxin toxicity? (Select all that apply.) 1.Serum potassium level of 3 mEq/L (3 mmol/L).2.Renal insufficiency.3.Total serum calcium level of 11.5 mg/dL (2.88 mmol/L).4.Diuretic therapy.5.Serum magnesium level of 1.9 mEq/L (0.95 mmol/L). View Explanation

1,2,3,4

A client with a history of congestive heart failure (CHF) reports shortness of breath and mid-abdominal pain. When auscultating the client's lungs, the nurse discovers crackles in the bases and an expiratory wheeze. Which intervention should the nurse perform to obtain essential information for the health care provider? (Select all that apply.) 1.Measure the client's intake and output.2.Assess the client's lower extremities.3.Assess the client's abdomen.4.Ask if the client is experiencing chest pain.5.Monitor the client's cardiac rate and rhythm.

1,2,3,4,5

The nurse assesses an older adult client for healthy sleep habits. Which statement, if made by the client, indicates further teaching is necessary? (Select all that apply.) 1."I drink a hot cup of caffeinated coffee at 6 p.m. every day."2."I typically finish up my computer work right before I go to bed."3."My nightly routine consists of dinner at 1830, vigorous exercise from 2100 to 2200, and I'm in bed by 2300."4."I recently installed sheer shades in my bedroom."5."I drink approximately two glasses of wine before bedtime."6."Doing deep breathing exercises before bedtime helps me to relax."

1,2,3,4,5

The nurse assesses a newborn and notes that the neonate is hypothermic. Which interventions are appropriate for the nurse to include in the newborn 's plan of care? (Select all that apply.) 1.Warm the newborn slowly to avoid potential apnea episodes.2.Wrap the newborn in a warm blanket.3.Place a hat on the newborn 's head.4.Bathe the newborn quickly and then place under a radiant warmer.5.Provide the newborn with skin-to-skin contact with the mother.

1,2,3,5

The nurse teaches a client how to obtain accurate blood pressure (BP) measurements at home. Which factors will the nurse include as causing a false high BP reading? (Select all that apply.) 1.Using a cuff that is too short.2.Repeating assessments too quickly.3.Positioning the brachial artery below the heart.4.Using a cuff that is too wide.5.Deflating the cuff too quickly.

1,2,3,5

The nurse admits a client with severe, persistent headaches. Which question is appropriate to ask when assessing the client's orientation? (Select all that apply.) 1."What is your health care provider's name?"2."What is the name of this health care facility?"3."Who was the mayor of Orlando in 2018?"4."What year and month is it currently?"5."What is your parent's current address?"

1,2,4 3,5 are incorrect. they assess memory rather than orientation. Time/place/Person

A client diagnosed with pancreatic cancer says to the nurse, "Why is this happening to me? It feels like God is punishing me." Which intervention represents appropriate nursing care for this client? (Select all that apply.) 1.Be physically present.2.Listen actively and seek clarification.3.Reassure the client that things will be all right.4.Use gentle touch to comfort and show concern.5.Provide protected privacy and quiet time.

1,2,4,5

The security team activates a code pink (missing newborn) in the newborn nursery unit. Which procedure does the nurse follow to comply with the security plan? (Select all that apply.) 1.The nursing staff stands guard at all entry and exit doors.2.The nursing staff allows a health care provider carrying a large bag to exit the unit.3.The nursing staff continues to monitor exit and entryways while documenting at the computer.4.The nursing staff stops visitors and personnel carrying bags or wearing large lab coats.5.The nursing staff allows visitors to enter while the code pink is activated.

1,4

The nurse speaks to the spouse of a client who has concerns about the client's sleeping pattern. The spouse states, "I am having a hard time getting a good night's rest because of my spouse's noisy breathing." Which response by the nurse will help to further evaluate the problem? (Select all that apply.) 1."Does your spouse report feeling drowsy during the day?"2."Does your spouse exercise often?"3."Has your spouse been evaluated for a stroke?"4."How many times does your spouse awaken at night?"5."What is your spouse's current weight?"6."Describe the types of sounds your spouse makes at night."

1,4,5,6

A bilingual nurse is asked to interpret preoperative instructions for a client on another unit in the hospital. What action by the nurse is most important to do first before agreeing to do the interpretation? 1.Ask the client if another hospital nurse may interpret medical information.2.Check the hospital policy for staff providing medical interpretation.3.Ask the client's family if they will give permission for medical interpretation.4.Determine if the client is competent to give permission for the interpretation by the nurse.

2

The nurse provides care for a client who anticipates using a prosthesis after an above-the-knee amputation. Which action should the nurse take when caring for this client? 1.Encourage the client to sit in a chair for extended periods of time.2.Maintain the compression dressing to the amputation site.3.Provide range-of-motion exercises twice a day. 4.Elevate the residual limb for 72 hours.

2

The nurse provides care for a newborn who was circumcised 30 minutes ago. Assessment reveals a moderate amount of bright red bleeding on the dressing. Which action is the first action for the nurse to take? 1.Put a clean, loose-fitting diaper on the newborn .2.Apply gentle pressure to the penis.3.Notify the health care provider.4.Assess the newborn's pulse and blood pressure.

2

The psychiatric inpatient unit has four new admissions. Which client does the nurse see first? 1.A salesperson diagnosed with depression after the baby was born with Down syndrome and the spouse threatened to file for divorce.2.A police officer with a history of post-traumatic stress disorder (PTSD) who was admitted with agoraphobia after two of his co-officers were killed.3.A computer programmer admitted with a diagnosis of generalized anxiety disorder who has extensive debt and just filed for bankruptcy.4.A college student admitted for depression and anxiety after a sibling committed suicide and a parent was recently diagnosed with lung cancer.

2 This client has a high potential for violence to self and/or others. There is easy access to weapons and knowledge of how to use them. Agoraphobia particularly causes this client to be uneasy in the new surroundings and potentiates acting out in fear.

The nurse provides care for an older adult client who is receiving 24-hour total parenteral nutrition (TPN) via a central line. Which assessment finding requires the nurse to collaborate with the health care provider? (Select all that apply.) 1.Weight gain of less than 2.2 lb (1 kg)/day.2.Urine output of 100 mL/hr.3.Muscle cramps and spasms.4.Presence of clay-colored stools.5.Poor skin turgor on the client's hand.

2,3,4

The nurse provides care for a client with a family history of hypertension. The nurse prepares to teach the client about primary prevention measures. Which information does the nurse include in the teaching plan? (Select all that apply.) 1.Regularly measure the blood pressure.2.Maintain a healthy weight.3.Utilize stress reduction techniques.4.Take antihypertensive medication, as prescribed.5.Reduce salt intake. View Explanation

2,3,5

When providing care to a group of postoperative clients, which interventions does the charge nurse delegate to the LPN/LVN? (Select all that apply.) 1.Palpating the suprapubic area of a client who has not voided in 6 hours.2.Changing the gauze dressing for a client who had a hip pinning yesterday.3.Teaching the client how to self-administer enoxaparin injections.4.Titrating oxygen administration according to prescribed parameters.5.Following up on a report of a 100.6 o F (38.1 o C) temperature in a client after an appendectomy.6.Auscultating the abdomen of a client who is nauseated after eating broth.

2,4

A client returns to the care area following abdominal exploratory surgery. Once the nurse measures vital signs, which action will the nurse perform next? 1.Position on left side, supported with pillows.2.Check the medical record and determine the status of the fluid balance from surgery.3.Check the abdominal dressing for any evidence of bleeding.4.Monitor the incision and pulmonary status for the presence of infection. View Explanation

3

The nurse performs an initial assessment of a client in the outpatient clinic with a diagnosis of myxedema. For which symptoms does the nurse carefully assess the client? 1.Tachycardia, fatigue, and intolerance to heat.2.Polyphagia, nervousness, and dry hair.3.Lethargy, weight gain, and intolerance to cold.4.Tachycardia, hypertension, and tachypnea.

3

The nurse prepares a client for an intravenous pyelogram (IVP). Which statement by the client indicates to the nurse teaching is effective? 1."I may feel a fluttery sensation when the catheter is inserted. "2."The test may cause spasms and shooting pains in my back. "3."I may experience a hot feeling and my skin may become flushed. "4."I may become lightheaded and have a desire to cough. "

3

The nurse provides care to a client who is scheduled to undergo lumbar puncture during a workup for suspected multiple sclerosis (MS). Which information does the nurse include when preparing the client for lumbar puncture? 1."You will receive general anesthesia for this procedure."2."You cannot eat or drink for 8 hours immediately before having the procedure."3."You will need to remain very still during the procedure."4."You will wear a compression dressing at the puncture site for 24 hours after the procedure."

3 Food and fluids are not restricted prior to lumbar puncture.

The nurse provides care for a client with a colostomy. Which nursing intervention is an essential part of the plan of care for this client? (Select all that apply.) 1.Wash the pouch with water and detergent.2.Drain the pouch when it is one-half full.3.Empty the pouch six or more times daily.4.Remove the pouch by pushing the skin away from the barrier.5.Advise the client to use a straw when drinking.6.Apply powder to the skin around the stoma.

3,4

A nurse from the emergency department (ED) is floated to the surgical unit. Which clients will the charge nurse appropriately assign to the ED nurse? (Select all that apply.) 1.A client with a new diagnosis of heart failure to be discharged in 24 hours.2.A client who had a cholecystectomy 6 hours ago.3.A client who had a stroke 3 days ago and requires total care and enteral feedings.4.A client admitted with pneumonia requiring IV antibiotics.5.A client admitted with anemia requiring a blood transfusion.

3,4,5

The adult child of an older adult client calls the home health nurse, reports that the client has become resistant to bathing, and asks the nurse to help. Which action is most important for the nurse to take when addressing concerns regarding the client's hygiene? 1.Ask the client about any sores or rashes.2.Create a bathing schedule for the client.3.Switch to sponge bathing for this client.4.Explore hygiene concerns with the client.

4

The nurse assesses a group of clients for risk of skin breakdown. The nurse identifies which client as being lowest risk for developing skin breakdown? 1.A client who is incontinent of feces.2.A client with nutritional deficiencies.3.A client who is confined to bed.4.A client with mental illness.

4

The nurse reviews antenatal testing results for several clients. Which result will prompt the nurse to notify the health care provider? 1.A term client anticipating induction with a biophysical profile of 9.2.A primigravida client reporting fetal movement 10 times in 1.5 hours.3.A multigravida client with three fetal heart rate accelerations on a nonstress test.4.A client at 40 weeks gestation with a positive contraction stress test.

4

A nurse interviews a South Asian client. The nurse observes that the client and the young child with the client are wearing long skirts and cloth coverings over their heads, even though it is very warm. The client speaks in short responses and in a soft tone of voice. Which conclusion does the nurse draw? 1.The client requires further assessment for abuse.2.The client exhibits expected practices from the client's religion.3.The client needs help with cultural adaptation.4.The client exhibits expected cultural characteristics from the client's background.

4 Clients from a South Asian culture (e.g., India, Pakistan, Bangladesh, Nepal, Sri Lanka, Fiji, and East Africa) usually speak in a soft tone of voice, as speaking in a more direct and louder manner may be perceived as disrespectful. Their traditional clothing often consists of long pieces of clothing, with or without a head cover. Such attire and speaking in a soft tone are part of the shared practices of people from that area. Sharing common beliefs and practices is one of the characteristics of culture.