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A client being seen in a primary health care provider's office has just been scheduled for a barium swallow the next day. The nurse writes down which instructions for the client to follow before the test?
"Do not eat or drink after midnight tonight."2
The nurse is planning to administer an oral glucose tolerance test (OGTT) to a client to rule out or confirm diabetes mellitus. The nurse knows that the client needs more information when the client makes which statements? Select all that apply.
"I can at least drink fluids during the test." 3"I have 30 minutes to drink the glucose load. "I will have blood drawn every 5 minutes for the next 3 hours."
TThe nurse is assessing a client bladder cancer who has a cystectomy and creation of a ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?
"I empty the urinary collection bag when it is two-thirds full."4
The nurse has reinforced instructions to a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that there is a need for further teaching if the client makes which statement?
"I hope the incision from the test will heal quickly."
The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?
"I need to be sure to place my cup of coffee on the counter."4
The nurse is reinforcing instructions to a female client regarding the procedure for collecting a midstream urine sample. Which statement by the client indicates an understanding of the procedure?
"I need to collect the urine in the cup after I start to urinate."4
The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care?
"I should drink extra fluids for the remainder of the day."
The nurse has provided instructions to a client scheduled for a mammography regarding the procedure. Which statement by the client indicates an understanding of the procedure?
"I should not wear deodorant on the day of the test."
Which statement made by the nursing student indicates a need for further teaching by the nursing instructor on the concept of ethnocentrism?
"It is imposing one's beliefs on individuals from another culture."4
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?"
The nurse who is assisting in a weight loss program prepares to monitor a client's weight. The client receives education about caloric intake and weight reduction. In order to lose 2 pounds per week the caloric intake should be decreased by how many calories per day?
1000 calories4
A client has been admitted for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?
15 mg/dL3
The nurse volunteering at the health screening clinic reinforces instructions to a 22-year-old client that diet and exercise would be used as tools to keep the total cholesterol level under at least which level?
200 mg/dL3
The nurse is assigned to a hospitalized client with chronic pancreatitis. The nurse reviews the client's record and expects to note a serum amylase level that is most likely which value?
300 units/L
Which client is the safest one for a licensed practical nurse (LPN) to care for?
A client recovering from a scheduled cesarean delivery4
The nurse is caring for a group of clients. Which client is most likely to have a serum phosphorus level of 2.0 mg/dL (0.64 mmol/L)?
A client with a history of alcoholism4
The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply.
A client with a new burn injury A client diagnosed with acute kidney injury (AKI)
The nurse is preparing to provide mouth care to an unconscious client. The nurse collects which items to perform this procedure? Select all that apply.
A soft toothbrush Irrigation syringe Bite stick or a padded tongue blade Suction with oral suction catheter attached
The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action?
Activate the fire alarm.4
The nurse initiates a prescription from the primary health care provider and restrains a client who has a chest tube connected to suction. The client is confused and continues to remove the dressing around the tube and pulls at the tube. Which information would the nurse document in the client's medical record regarding restraints? Select all that apply.
Adequacy of circulation in the body area that is restrained Type of restraint and body area where the restraint was applied Communication with client and family member about need for restraint The alternative measures that were attempted before restraints were applied
The nurse is monitoring the fluid balance of a client with advanced human immunodeficiency virus (HIV) infection. Because the client has lost a great deal of weight and muscle mass, the nurse understands that which action will provide a reliable indicator of fluid balance?
Monitoring for decreased urine output and hypotension4
The nurse has assisted with obtaining a blood specimen for arterial blood gas (ABG) analysis. The nurse avoids doing which to properly obtain and send the specimen?
Obtain a 3-mL syringe that is used for parenteral medication.
An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory would be most concerned with which result?
Potassium 5.4 mEq/L4
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse would include which piece of information in discussions with the client?
The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.
The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing student would indicate a need for further teaching?
The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes.
A bone marrow aspiration is scheduled for a client suspected of having leukemia. What intervention does the nurse anticipate will be done to protect the aspiration site and client from becoming infected?
The site will be cleansed thoroughly with an antiseptic and allowed to air dry before the procedure.
The nurse would institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply.
Wear gloves and gown while in the room caring for the client. Use soap and water, not alcohol-based hand rub, for hand hygiene.
The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse would tell the client that which food item is least likely to contain calcium?
butter
The client who is scheduled for an intravenous pyelogram has been instructed to take liquid magnesium citrate on the day before the scheduled procedure. The client asks the nurse about the administration procedure for this medication. Which instruction would the nurse provide to the client?
"Take the medication on ice."
A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse would respond by making which appropriate statement?
"Tell me what you know about complementary therapies."4
A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work, and they feel isolated and fearful. The nurse would suggest which to the mother?
"You should seek community after-school programs or activities for your children."4
A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client?
"You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."
The nurse determines that which clients are at high risk for metabolic acidosis? Select all that apply.
Clients with diabetes Clients with kidney failure Clients with malnourishment
The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions would the nurse perform before initiating the feeding? Select all that apply.
Explain the procedure to the client. Irrigate the NG tube with saline. Elevate the head of the bed to 45 degrees.
The nurse is caring for a postoperative client who is wearing an abdominal binder following abdominal surgery. Which interventions would the nurse include in relationship to prescribed dressing change? Select all that apply.
Sit up for coughing while splinting the incision.2 Remove the binder to change the abdominal dressing as prescribed and reapply.
Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L (2.7 mmol/L)?
U waves2
A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which?
Ulnar circulation2
The nurse is assigned to care for a client who has been diagnosed with human immunodeficiency virus (HIV). In planning care for the client, the nurse understands that educating staff concerning which instruction will have the greatest impact on minimizing the spread of the virus?
Using personal protective equipment appropriately2
The nurse is talking to students during their psychiatric mental health clinical rotation. The nurse informs the students that which physical illnesses occur more frequently with severe mental illness? Select all that apply.
Hypertension4 Metabolic syndrome Myocardial infarction
A hospitalized child with leukemia has received chemotherapy by the intravenous (IV) route, and a discharge to home is being planned. Laboratory values indicate that the child is neutropenic. The child is being treated daily by cleansing and the application of a topical antibiotic on an open area from an old IV site. The nurse reinforces instructions to the mother regarding the signs of infection at this affected site. Which statement by the mother indicates that the mother understands the instructions?
"I will clean the site and apply the topical ointment every day."3
A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action would the nurse plan to take?
Encourage the client to slow down breathing
The nurse is discussing intervention strategies with a parent of a child with a developmental disability. Which of the following describes a family system program as an intervention strategy?
Focuses on the parents' internal factors that affect the quality of parenting3
A client has been treated for dehydration and pneumonia. The nurse evaluates that the client has been successfully treated if the blood urea nitrogen (BUN) level is which value?
19 mg/dL3
The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply.
Frequent assessment of vital signs Coughing and deep breathing exercises Pain monitoring and medications to relieve pain
A client is having problems with blood clotting. Which food item would the nurse encourage the client to eat?
Green, leafy vegetables
The nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse would then examine the results of serum electrolytes to see whether which electrolyte imbalance is present?
Hypokalemia2
The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding would the nurse expect to note as a result of this long-term use?
Increased specific gravity of the urine
A client with diabetes mellitus has a blood glucose level of 596 mg/dL on admission. The nurse anticipates that this client is at risk for which type of acid-base imbalance?
Metabolic acidosis2
The metabolic panel of a client reveals a calcium level of 6.5 mg/dL (1.6 mmol/L). Based on this laboratory finding, which additional data specific to this calcium level would the nurse collect? Select all that apply.
Presence of Chvostek's sign Presence of electrocardiogram abnormalities5 Presence of tingling in the fingertips and around the mouth 6Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes
A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure?
Preventing and recognizing hyperglycemia
The nurse is preparing to care for a client following a lumbar puncture. The nurse plans to place the client in which position immediately after the procedure?
Prone with a pillow under the abdomen4
A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The mother asks the nurse about the purpose of the test and why the test needs to be done if it is already known that the child has HIV. The nurse would reinforce which information to the mother? Select all that apply.
The CD4+ count is used to determine the child's immune status. The CD4+ count is used to identify the risk for disease progression. The CD4+ count identifies the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age. The CD4+ count is measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered.
The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items would the nurse encourage? Select all that apply.
Tofu3 Broccoli Sardines Mustard greens
Following a cleft lip repair, the nurse reinforces instructions to the parents of the infant. Which of the instructions would be given to the parents of the infant? Select all that apply.
Monitor frequency of diaper changes. 2Cleanse the surgical site with normal saline. Apply prescribed antibiotic ointment to the surgical site.
A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance?
Metabolic acidosis2
The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological processes are occurring? Select all that apply.
"Water and electrolytes are lost in approximately the same proportion as they exist in the body."6"A client who has a large blood loss due to an accident will initially have an isotonic dehydration."
A lethargic, pale child is brought to the primary health care provider's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the mother if the child has had any recent infections, to which the mother responds that the child had a very sore throat a few weeks ago. The primary health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which laboratory test would rule out a past streptococcal infection in the child?
Antistreptolysin titer4
A seriously ill client in the hospital tells the nurse that he thinks he has lost some of his ability to hear over the past few days. The nurse reviews the medications the client is currently receiving. Which medications are known to be ototoxic? Select all that apply.
Aspirin Furosemide5 Gentamycin
The nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who underwent lumbar puncture. The nurse knows that a reported value of 0 is normal for which substance in CSF?
Red blood cells4
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 actions would the nurse take? Select all that apply.
Ask how the client feels and inquire about any feelings of dizziness.3 Review the client record to determine time and type of analgesia last received. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).
When checking a client's skin, the nurse notes the presence of multiple straight and wavy threadlike lines beneath the skin and suspects the presence of scabies. Which precaution would the nurse institute before making contact with the client?
Put on a gown and gloves.4
A client has been on total parenteral nutrition for 8 weeks. The primary health care provider prescribes that the total parenteral nutrition be weaned down by 50 mL/hr/day until discontinued. The client asks the nurse, "Why doesn't the doctor just stop the parenteral nutrition instead of dragging it on for 3 days?" The nursing response would be to explain that the primary health care provider is concerned about which phenomenon?
Rebound hypoglycemia
The nurse is caring for a client following an abdominal surgery performed 1 day ago. An intravenous (IV) line is infusing, and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse would perform which actions? Select all that apply.
Ask the client whether he has passed any flatus. Document the finding and continue to check for bowel sounds.
A client arrives to the surgical nursing unit after surgery. What would be the initial nursing action after surgery?
Assess patency of the airway.2
The nurse is assisting in developing a plan of action for the emergency department in the event of an internal fire. Which would the nurse include in the plan? Select all that apply.
Direct ambulating clients to walk to a safe location. Remove all clients from danger before attempting to extinguish the fire. Move bedridden clients away from the fire area by use of beds or stretchers.
A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the registered nurse with which action?
Drawing a sample for prothrombin time (PT) and international normalized ratio (INR)
The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?
It helps to make sure that the primary health care provider is aware of all of the medications the client is taking and has been taking at home.
The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that there is a need for further teaching if the client verbalized which statement?
Keep the oxygen concentrator as close to the room wall as possible.4
The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which is the immediate action of the nurse?
Remove the clients from the waiting room.
Following a surgical procedure, the nurse applies sequential compression devices to both lower extremities and turns the machine on. The nurse implements this intervention for which purpose?
To prevent thrombosis formation in the veins4
A client receiving total parenteral nutrition (TPN) asks the nurse if he has developed diabetes when the capillary blood glucose level is monitored and he is given insulin. The nurse explains that which is the reason for monitoring glucose levels and administering insulin?
TPN contains concentrated carbohydrates and raises blood glucose.
A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 150 mEq/L (150 mmol/L). Which interventions would the primary health care provider likely prescribe? Select all that apply.
Monitor vital signs. Monitor electrolyte levels. Monitor intake and output. Increase water intake orally. Maintain sodium-reduced diet.
A primary health care provider (PHCP) has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse is reinforcing teaching with the client and would include which instructions? Select all that apply.
Take the calcium carbonate with or just after meals. Avoid foods such as beets, spinach, and bran in the diet. Take the medication with a full glass of water (8 oz/240 mL).
The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000 mm3 (19 × 109/L). Based on this laboratory result, which actions would the nurse include in the plan of care? Select all that apply.
Testing stools and urine for blood Using a soft toothbrush for mouth care
A 70-year-old client who has been treated for cellulitis of the leg asks the nurse how to improve resistance to infection. Which measures would the nurse reinforce in the teaching plan? Select all that apply.
Balance activity and rest, and avoid stress. Keep skin on arms and legs well lubricated. 5Wash any breaks in the skin with soap and water. 6Receive recommended vaccines against influenza and pneumonia.
Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?
Being affected by Rh incompatibility
A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? Select all that apply.
Broth2Coffee3Gelatin
A client has a prescription to take sodium polystyrene sulfonate for several days. The client also needs to make some dietary changes. Which foods would the client avoid? Select all that apply.
Cabbage Mushrooms Strawberries
The nurse is assigned to care for a client who has a nasogastric (NG) tube and is receiving tube feedings. When implementing nursing care for the client, the nurse remembers which information? Select all that apply.
That aspiration as a complication is a primary concern To determine correct placement by aspirating contents from the tube to observe characteristics and check pH Submit
A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dL. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. How would the nurse interpret the data?
The blood glucose level is slightly higher than the normal value.4
The nurse is assigned to the care of a client who is being admitted to a facility. The nurse notes which observations as indications the client likely has a hearing deficit? Select all that apply.
The client answers questions incorrectly. 3The client states she quit attending social events. The client does not respond to a person unless facing the speaker.
The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition?
The client with the syndrome of inappropriate secretion of antidiuretic hormone Submit
The nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which data will be needed by the laboratory for adequate evaluation of the specimen? Select all that apply.
The client's temperature The date the specimen was drawn The time the specimen was drawn Any supplemental oxygen the client is receiving
The nurse considers the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Which are correct about this protocol? Select all that apply.
The surgeon is the person that marks the area of the operative procedure. The site marking is done before the client is brought to the surgical suite in the operating room.
The nurse determines that which herbal therapies can be prescribed for use as an antispasmodic? Select all that apply.
Chamomile5 Peppermint oil
A client is admitted to the hospital with a diagnosis of neutropenia. Which interventions would the nurse include in planning care for this client? Select all that apply.
Check temperature at least every 4 hours.2Monitor white blood cell count daily as prescribed. Remove fresh flowers or plants from the client's room.
The nurse administers scopolamine as prescribed to a client in preparation for surgery. The nurse monitors the client for adverse/side effects related to the administration of this medication. Which would the nurse determine is an expected side effect of this medication?
Client complaints of a dry mouth2
A client's preoperative vital signs are temperature 98.6°F (37°C) orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action would the nurse take first?
Compare these values to those recorded previously.4
A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?
Informing the surgeon of the situation
A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take?
Obtain orthostatic vital signs.2
The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are: temperature: 37.9° C (100.2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem?
Pneumonia
A nurse is about to give a daily dose of digoxin and notes that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL. The nurse would take which actions? Select all that apply.
Report the finding to the registered nurse. Gather data from the client related to signs of toxicity.
Arterial blood gases (ABGs) are obtained on a client with pneumonia. The ABG results are pH, 7.50; Pco2, 30 mm Hg; HCO3-, 20 mEq/L; and Po2, 75 mm Hg. The nurse interprets these results and determines that which acid-base condition exists?
Respiratory alkalosis
The nurse prepares a client for the lumbar puncture procedure by which interventions? Select all that apply.
Review the coagulation laboratory studies. Observe the lower lumbar area for skin infections. Check to see the client has a signed consent for the procedure.
A client is seen in the clinic for a physical examination. Laboratory studies are performed and reveal that the hemoglobin and hematocrit are low, indicating the need for further diagnostic studies and possibly a blood transfusion. The client is a Jehovah's Witness and states he will never have a blood transfusion. Which would be an appropriate action by the clinic nurse?
Support the client's decision not to receive a blood transfusion.3
A child is receiving edetate calcium disodium (calcium EDTA) for the treatment of lead poisoning. Which laboratory result would be important to monitor during treatment?
Blood urea nitrogen (BUN) level
The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom would the nurse expect to note in this client?
An increase in blood pressure
A 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which are characteristics of this type of solution? Select all that apply.
Is the same solution as sodium chloride 0.9% Is used to administer red blood cell transfusion Is used to treat hypotension due to fluid volume deficit
The nurse is caring for a client with a nasogastric tube in place for gastric decompression. The gastroenterologist prescribes to have the tube irrigated once every 8 hours. Select the correct interventions the nurse would utilize in performing this procedure. Select all that apply.
Utilize 30 mL of 0.9% normal saline for the irrigating solution. After injecting the irrigating solution, pull back on the irrigation syringe.5
The nurse is observing a nursing student preparing to obtain a throat culture on a client suspected of having a beta-hemolytic Streptococcus infection. Which actions indicate the need for further teaching regarding collecting this specimen? Select all that apply.
The student asks the client to tilt the head forward and to open the mouth. The student places the collection swab initially at the back of the client's tongue.
