Adaptive set 3

A nurse is caring for a client with diabetes insipidus. Which clinical manifestation should a nurse expect the client to exhibit? 1 Increased blood glucose 2 Decreased serum sodium 3 Increased specific gravity Correct4 Decreased urine osmolarity

4

The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin (SpO2). Which other parameter can be determined using this technique? Correct1 Arterial oxygen saturation Incorrect2 Partial pressure of oxygen in arterial blood 3 Partial pressure of arterial carbon dioxide 4 Partial pressure of oxygen in venous blood

2

A 3.5-year-old child with severe iron deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit? 1 Cold, clammy skin Correct2 Increased pulse rate 3 Increased blood pressure Incorrect4 Cyanosis of the nail beds

2

During chest examination in a healthy client, the APN percusses and hears a low-pitched sound over the lungs. Which sound should the nurse document in the medical record? Incorrect1 Dull 2 Flat 3 Tympany Correct4 Resonance

4

A client who has bone pain of insidious onset is suspected of having multiple myeloma. The nurse expects which diagnostic finding specific for multiple myeloma? 1 Occult blood in the stool 2 Low serum calcium levels Correct3 Bence Jones protein in the urine 4 Positive bacterial culture of sputum

3

A client is diagnosed with stage 3 of Parkinson disease. Which clinical manifestations are found in the client? Select all that apply. 1 Akinesia Incorrect2 Masklike face Correct3 Postural instability 4 Unilateral limb involvement Correct5 Increased gait disturbances

3,4

Which diagnostic test is performed under general anesthesia to detect non-Hodgkin lymphoma and requires the client to sign an informed consent form? 1 A thoracentesis 2 A bronchoscopy Correct3 A mediastinoscopy 4 Computed tomography (CT)

3

Which hormone aids in regulating intestinal calcium and phosphorous absorption? 1 Insulin 2 Thyroxine Correct3 Glucocorticoids Incorrect4 Parathyroid hormone

3

A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply. Correct1 Pallor Correct2 Agitation Correct3 Tachycardia Correct4 Narrow pulse pressure 5 Decreased respirations

1,2,3,4

When assessing the progress of a client being treated for myasthenia gravis, the nurse expects what change in muscle strength? 1 Partial improvement of muscle strength with mild exercise Correct2 Fluctuating weakness of muscles innervated by the cranial nerves 3 Little change regardless of the therapy initiated 4 Dramatic worsening with anticholinesterase drugs

2

An 11-year-old client is admitted with enlarged supraclavicular lymph nodes, fatigue, and low-grade fever. She also has a persistent nonproductive cough. In light of these findings, the nurse knows to gear education toward preparation for which therapies? 1 Intravenous (IV) fluids and nutritional therapy 2 Bloodwork and oxygenation therapy 3 IV fluids and antibiotic therapy Correct4 Computed tomography (CT) and lymph node biopsy

4

Which child is at the highest risk for blunt trauma associated with the indirect entry (hematogenous stage) of microorganisms? Correct1 8-year-old boy 2 10-year-old girl Incorrect3 13-year-old girl 4 14-year-old boy

1

A 19-year old client is diagnosed with a heavy and palpable hard mass on the anterior aspect of the testis. Which treatment would be appropriate? 1 Radiotherapy 2 Chemotherapy Incorrect3 Testicular biopsy Correct4 Radical inguinal orchiectomy

4

Which actions would the nurse describe as defining the role of a senior leader? Select all that apply. Correct1 Providing resources Incorrect2 Promoting evidence-based practice standards Incorrect3 Reporting quality and safety issues to the manager 4 Using data to measure effectiveness of improvement Correct5 Defining procedures for immediate response to errors

1,5

A client has a leaking thoracic duct following a radical neck surgery. What does the nurse expect the postoperative plan of care to include? 1 A gastrostomy tube, a high-fat diet, and bed rest Correct2 A chest tube, total parenteral nutrition (TPN), and bed rest 3 A rectal tube, a low-fat diet, and increased activity 4 A nasogastric tube, a moderate-fat diet, and increased activity

2

Which part of the respiratory system is referred to as Angle of Louis? 1 Hilum Correct2 Carina 3 Alveoli 4 Epiglottis

2

A client who sustained a head injury reports bland taste of food. Upon examination, the nurse finds that there is loss of taste perception from the anterior two-thirds region of the tongue. What is the origin of the involved nerve? Incorrect1 Medulla 2 Midbrain Correct3 Inferior pons 4 Cerebrum

3

After assessing the skin of a client, the primary healthcare provider concludes it is allergic contact dermatitis. Which clinical manifestation made by the primary healthcare provider helped reach that conclusion? Correct1 Appearance of red papules and plaques 2 Appearance of raised or irregulary shaped wheals Incorrect3 Appearance of red, macular, papular rash with abrupt onset 4 Appearance of bright erythema, oozing vesicles with extreme pruritus

1

A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care? Correct1 The disease process and breathing exercises Incorrect2 How to control or prevent respiratory infections 3 Using aerosol therapy, especially nebulizers 4 Priorities in carrying out everyday activities

1

A client who is receiving medication for an eye disorder reports bleeding in the eye. Which drug will the nurse most likely observe written in the medication administration record? Correct1 Ketorolac Incorrect2 Trifluridine 3 Natamycin 4 Ciprofloxacin

1

A 19-year old client is diagnosed with a heavy and palpable hard mass on the anterior aspect of the testis. Which treatment would be appropriate? 1 Radiotherapy 2 Chemotherapy Incorrect3 Testicular biopsy Correct4 Radical inguinal orchiectomy

1

It is determined that a client with heart block will require implantation of a permanent pacemaker to assist heart function. In explaining the pacemaker to the client, what does the nurse say it is necessary for? Correct1 Simulating a normal heartbeat 2 Shocking the atrioventricular (AV) node to contract 3 Slowing the heart to a more normal rate Incorrect4 Synchronizing the action of the heart valves

1

A nurse in the pediatric clinic is taking the health history of a toddler with an exacerbation of eczema. What are the nurse's priority assessments of the child? Select all that apply. 1 Increase in appetite Correct2 Wearing cotton clothes Correct3 Tolerance of new foods 4 Exposure to a viral infection 5 Recent contact with someone with eczema

2,3

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? Incorrect1 Perform the procedure once in the morning and once at night. 2 Move the trunk to an upright position and then exhale while bending over. Correct3 Inhale completely and then blow out as hard and as fast as possible through the mouthpiece. 4 Place the mouthpiece between the lips and in front of the teeth before starting the procedure.

3

In an organization, the leader is providing specific feedback regarding positive performance to his or her subordinate. Which leadership theory behavior is being displayed by the leader? Incorrect1 Trait theory 2 Two-factor theory Correct3 Expectancy theory 4 Situational-contingency theory

3

A 5-year-old child is brought to the child health clinic for a routine visit, and the nurse observes the child interacting with other children. What type of play does the nurse expect of the child? 1 Team Incorrect2 Parallel 3 Initiative Correct4 Cooperative

4

The nurse anticipates that a child born with a missing chromosome is most likely to have which condition? 1 Cretinism 2 Phenylketonuria 3 Down syndrome Correct4 Turner syndrome

4

A client comes for an annual physical examination. To provide appropriate nutritional counseling, the nurse calculates the client's body mass index (BMI). The client's weight is 65 kg, and the height is 1.7 meters. What is the client's BMI? Record your answer using one decimal place. ________ BMI

The formula for BMI is: weight in kg ÷ (height in meters)2. The square of the client's height is 1.7 × 1.7 = 2.89; 65 ÷ 2.89 = 22.5. The desirable BMI for adults is 18.5 to 24.9.

Which findings in a four-year-old indicates an appropriate development of socialization skills? Select all that apply. Correct1 The child tends to be selfish and impatient. Correct2 The child takes pride in his or her accomplishments. Correct3 The child tells family tales to others with no restraint. Incorrect4 The child is eager to do things correctly and please others. 5 The child tries to follow rules during an associative play, but cheats to avoid losing.

1,2,3

A nurse is planning to negotiate with the supervisor in order to achieve a better work environment. Which actions are appropriate in this context? Select all that apply. Correct1 Making tradeoffs Incorrect2 Valuing the efforts of nursing colleagues Correct3 Asking for a more desirable work schedule Incorrect4 Displaying a positive and professional attitude Incorrect5 Making an effort to effect change by working collectively

1,3

A nurse in the cardiovascular clinic reviews a client's ECG. What should the nurse do?(sinus rythm strip) Incorrect1 Recommend the Valsalva maneuver. Correct2 Document that the rhythm is normal. 3 Prepare to defibrillate the client at 200 joules. 4 Advise the client to reduce the intake of caffeine.

2

Which criteria should the primary healthcare provider use for the prescription of long-term continuous oxygen therapy? 1 PaO2-72, SpO2- 96 Incorrect2 PaO2-60, SpO2- 90 Correct3 PaO2-55, SpO2- 88 4 PaO2-40, SpO2- 75

3

A nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is the most important intervention for the nurse to include in this plan? 1 Ensuring sufficient rest 2 Changing lifestyle routines 3 Breathing clean outdoor air Correct4 Taking medications as prescribed

4

What is the normal value of inspiratory reserve volume? 1 0.5 L 2 1.0 L 3 1.5 L Correct4 3.0 L

4

A client reports sustaining an insect bite. The initial symptoms were edema and itching at the site of the bite. Which immunological reaction may have occurred? Correct1 Anaphylaxis Incorrect2 Atopic reaction 3 Goodpasture syndrome 4 Systemic lupus erythematosus

1

A registered nurse (RN) is sent to a rehabilitation center because of chemical impairment issues. Which member of the healthcare team will be asked to provide feedback about the RN's progress? Correct1 Nurse manager Incorrect2 Healthcare provider 3 Patient care associate 4 Cross-trained technician

1

The nurse is preparing to discharge a 3-day-old infant who weighed 7 lb (3175 g) at birth. Which finding should be reported immediately to the healthcare provider? Correct1 Weight of 6 lb 4 oz (2835 g) 2 Hemoglobin of 16.2 g/dL (162 mmol/L) 3 Three wet diapers over the last 12 hours 4 Total serum bilirubin of 10 mg/dL (171 µmol/L)

1

Which is the priority nursing action to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiologic dispersal device (RDD)? Correct1 Covering the nose 2 Protecting the eyes Incorrect3 Decontaminating the skin 4 Administering prophylactic antibiotics

1

A client with heart disease is admitted to the birthing suite. Which nursing intervention may help prevent the development of cardiac decompensation during her labor? 1 Positioning her on the side with her head on a pillow Correct2 Positioning her on the side with her shoulders elevated 3 Administering the prescribed intravenous (IV) infusion of isotonic saline 4 Administering the prescribed IV piggyback infusion of oxytocin

2

A medical care facility is seeking to establish an orthopedic center of excellence. The nurse manager teaches direct care nurses about opportunities available to them in the process. Which task would a direct care nurse be eligible for? 1 Developing a budget Correct2 Conducting a literature review Incorrect3 Conducting a needs assessment 4 Forming an advisory committee

2

A nurse provides discharge teaching about ampicillin that is prescribed for a client. The nurse evaluates that the teaching is effective when the client makes which statement? Incorrect1 "I will miss eating grapefruit." Correct2 "I must increase my fluid intake." 3 "I can stop taking this medication any time." 4 "I should take this medication just after eating."

2

At 20 hours of age a newborn is found to have a bilirubin concentration of 13 mg/dL (274 mcmol/L). Which finding most likely contributed to this bilirubin level? 1 Clubfoot Correct2 Cephalhematoma 3 Caput succedaneum 4 Gestation of 41 weeks

2

Delegatee Task A "I will help you complete the task early" B "Check the client's blood pressure every morning" C "yes, you are doing it right..." D "yes you can us a digital sphygmomanometer..." The registered nurse is assigning work to four delegatees. Which delegatee most likely has a limited relationship with the delegator? Incorrect1 Delegatee A Correct2 Delegatee B 3 Delegatee C 4 Delegatee D

2

The healthcare unit reviews the evaluation report of a newly promoted nurse leader and rates the performance as excellent. At which qualities did the nurse excel? Select all that apply. 1 Enforcing contracts Correct2 Charting new paths that lead to progress Incorrect3 Interpreting established policies and procedures Correct4 Demonstrating positive feelings in the workplace Incorrect5 Demonstrating collaborative behaviors for client care

2,4

A nurse is assisting a client to plan a therapeutic diet that is high in vitamin C to help with healing. Which excellent sources of vitamin C should the nurse include in the plan? Select all that apply. 1 Lettuce Correct2 Oranges 3 Apricots Correct4 Cantaloupe Correct5 Strawberries

2,4,5

The nurse is providing emergency care to a client suffering from heat stroke. What should be the order of nursing interventions in this scenario? Incorrect 1. Remove the client from the hot environment. Incorrect 2. Ensure a patent airway. Correct 3. Remove the client's clothing. Correct 4. Pour or spray cold water on the client's body and scalp. Incorrect 5. Place ice in cloth or bags and position the packs on the client's scalp. Incorrect 6. Fan the client with newspapers or whatever is available.

21,3,4,6,5 Emergency care should be provided to the client with heat stroke to restore thermoregulation. First the nurse should ensure a patent airway. Then the nurse should remove the client from the hot environment into air conditioning or shade and remove his or her clothing. Then the nurse should pour or spray cold water on the client's body and scalp. The client should be fanned with newspapers or whatever is available. This should be followed by placing ice in cloth or bags and positioning the packs on the client's scalp.

A nursing instructor asks a student to describe Betty Neuman's theory. Which statement by the student indicates the need for further education? 1 "Betty Neuman's theory is based on five concepts that interact with one another." 2 "Betty Neuman's theory is based on stress and the client's reaction to the stressor." 3 "Betty Neuman's theory places the client as an individual, group, family, or community." Correct4 "Betty Neuman's theory outlines that the external environmental factors act as stressor."

4

A primary health care provider prescribes total parenteral nutrition for a client with cancer of the pancreas. A central venous access device is inserted. What does the nurse identify as the most important reason for using this type of access? Incorrect1 Infection is uncommon. 2 It permits free use of the hands. 3 The chance of the infusion infiltrating is decreased. Correct4 The amount of blood in a major vein helps to dilute the solution.

4

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). Which outcome would the nurse anticipate? Incorrect1 Increased blood urea nitrogen (BUN) 2 Increased serum sodium level 3 Decreased specific gravity Correct4 Decreased urine output

4

Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. What should the nurse instruct the client about the purpose of pursed-lip breathing? 1 Decreases chest pain Incorrect2 Conserves energy 3 Increases oxygen saturation Correct4 Promotes elimination of CO2

4

A client at 42 weeks' gestation is scheduled for induction of labor. The nurse begins the induction with a piggyback infusion of 15 units of oxytocin. Which clinical finding requires the nurse to discontinue the oxytocin infusion? 1 Contractions that occur every 3 minutes and lasting 60 seconds 2 Elevation of blood pressure from 110/70 to 135/85 mm Hg during the last 30 minutes 3 Rupture of membranes with amniotic fluid that contains threads of blood and mucus Correct4 Several late fetal heart rate decelerations that return to baseline after the contraction is over

4

A 78-year-old client comes to the health clinic presenting with fatigue. The client's laboratory results indicate a hematocrit of 32.1% and a hemoglobin of 10.5 g/dL (105 mmol/L). Which is the most appropriate nursing intervention in response to these laboratory results? Correct1 Conduct a complete nutritional assessment of the client 2 Nothing, because these are expected values for this client's age 3 Advise the client to come back to the clinic to have the test repeated in three months Incorrect4 Investigate the cause of the anemia while understanding that mild anemia is an expected response to the aging process

1

A client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. What should the nurse do to prepare the client for the procedure? Correct1 Instruct the client to void. 2 Tell the client not to eat for four hours. Incorrect3 Give the client the prescribed analgesic. 4 Have the client turn to the lateral position.

1

A newborn has an Apgar score of 3 at 1 minute after birth. What is the immediate nursing action in response to this Apgar score? Correct1 Start resuscitation 2 Administer oxygen 3 Place in a heated crib 4 Stimulate by tapping the toes

1

Which surgical procedure is appropriate for the removal of a vocal cord due to laryngeal cancer? Correct1 Cordectomy 2 Tracheotomy Incorrect3 Total laryngectomy 4 Oropharyngeal resections

1

A nurse is completing the admission assessment of a client with peripheral arterial disease. Which assessments will the nurse expect to observe? Select all that apply. Correct1 Absence of hair on the toes Incorrect2 Superficial ulcer with irregular edges 3 Pitting edema of the lower extremities Correct4 Reports of pain associated with exercising 5 Increased pigmentation of the medial malleolus area

1,4

A client is admitted to the hospital with an altered level of consciousness. When assessing this client the nurse understands that level of consciousness extends along a continuum. Place the following words that describe level of consciousness in order from the most alert to the least alert. Correct 1. Alert Correct 2. Confused Incorrect 3. Obtunded Incorrect 4. Lethargic

1,2

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse? Select all that apply. Correct1 Respiratory rate of 14 breaths/minute Correct2 Blood pressure of 120/80 mmHg Correct3 Oxygen saturation of 95% 4 Temporal temperature of 37.4 °C Incorrect5 Radial pulse rate of 72 and irregular

1,2,3

Which questions should be asked by the nurse of an adolescent client before a pregnancy test is performed? Select all that apply. Correct1 "Are you sexually active?" Correct2 "When was your last period?" Correct3 "Are you having any nausea?" 4 "Do you have a history of pregnancy?" 5 "How will you tell your parents if the test result is positive?"

1,2,3

The nurse is assessing an older adult client with suspected hearing loss. Which observations made by the nurse in the client indicates a decrease in hearing acuity? Select all that apply. Correct1 Frequent usage of words such as "what" Correct2 Postural changes while listening to the speaker Correct3 Bending towards the other person while talking Correct4 Mismatch in the questions asked and the responses given Incorrect5 Startled expression when there is any unexpected sound in the environment

1,2,3,4

A health care organization is planning to implement differentiated nursing practice. What should be prepared prior to implementing this care delivery system? Select all that apply. Correct1 Salary ranges 2 Client caseloads Correct3 Position descriptions Correct4 Expected competencies Correct5 Degree of participation in decision-making

1,3,5

A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply. Correct1 Significant life stress 2 Severe anxiety 3 Generalized pain Correct4 Excessive caffeine 5 Chronic depression Correct6 Environmental noise/distractors

1,4,6

A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion? 1 History of hypertensive disease Correct2 Emboli associated with atrial fibrillation 3 Developmental defect of the arterial wall 4 Inappropriate paroxysmal neural discharge

2

Before a male client signs an operative consent for an abdominoperineal resection, the nurse verifies that the client understands that surgery likely will result in which outcome? 1 Permanent ileostomy in the jejunum Correct2 Permanent colostomy and impotence 3 Temporary ileostomy and diminished libido Incorrect4 Temporary colostomy in the descending colon

2

Nurse Behavior A Guiding and directing B Observing and monitoring C Explaining and persuading D Encouraging and problem solving The behavior of four nurses in different situations is given below. Which nurse exhibits a behavior that can be characterized as delegation according to Hersey's model? Incorrect1 Nurse A Correct2 Nurse B 3 Nurse C 4 Nurse D

2

The clinic nurse is providing home care instructions for a client with pelvic inflammatory disease. Which optimal resting position should be recommended by the nurse? 1 Sims Correct2 Fowler Incorrect3 Supine with knees flexed 4 Lithotomy with head elevated

2

Which client should be treated first according to the National Institutes of Health Stroke Scale (NIHSS)? 1 Client with score of 0 for dysarthria 2 Client with score of 1 for limb ataxia Correct3 Client with score of 3 for facial palsy 4 Client with score of 0 for level of consciousness

3

Which factor is essential to consider when the nurse determines whether a unit's environment is conducive to psychologic safety for a confused client with dementia? 1 Nursing care is flexible. Incorrect2 The client's needs are met entirely. Correct3 Realistic limits and controls are set. 4 The physical surroundings are clean and orderly.

3

A school-aged child is admitted to the pediatric unit with the diagnosis of a brain tumor. During breakfast the child vomits. What are the priority nursing interventions? Select all that apply. 1 Refeeding breakfast Correct2 Notifying the practitioner Correct3 Requesting a reevaluation Incorrect4 Administering the prescribed antiemetic 5 Increasing the intravenous infusion rate

2,3

A 9-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia (ALL). What early signs and symptoms of leukemia does the nurse expect to identify? Select all that apply. 1 Flushing Correct2 Anorexia Correct3 Limb pain Correct4 Splenomegaly Incorrect5 Mouth lesions

2,3,4

A nurse is caring for a client who is learning how to take care of a newly created colostomy. When observing a return demonstration of the colostomy irrigation, the nurse evaluates that more teaching is required when the client carries out what procedure? 1 Clamps off the flow of fluid when feeling uncomfortable 2 Lubricates the tip of the catheter before inserting it into the stoma 3 Discontinues the insertion of fluid after only a half a liter of fluid is instilled Correct4 Hangs the irrigation bag on the door clothes hook during fluid insertion

4

A nurse is caring for an infant with a cleft lip and palate. What information should the nurse include when teaching the parents about this diagnosis? 1 Anticipation that these children will have psychological problems Incorrect2 Emphasis that the two defects follow the laws of Mendelian genetics 3 Assurance that the defect is rare and probably will not occur twice in the same family Correct4 Expectation that these children will have no other defect and otherwise will be healthy

4

What are the similarities between the teaching methods for a toddler compared to a preschooler? Select all that apply. 1 In both cases, independent learning is encouraged. 2 In both cases, teaching is used as a collaborative activity. Correct3 In both cases, play is used to teach a method or procedure. Correct4 In both cases, learning is accompanied with pictures and short stories. 5 In both cases, individuals are encouraged to participate in the teaching plan.

3,4

A nurse provides dietary teaching for a client with an acute exacerbation of ulcerative colitis, and afterward the client makes a list of foods that can be included on the diet. Which food choices indicate that the teaching by the nurse is effective? Select all that apply. 1 Orange juice 2 Creamed soup Correct3 Jelly sandwich Correct4 Lean roast beef Correct5 Scrambled eggs

3,4,5

The nurse is making rounds on a client who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? Select all that apply. 1 Monitor for signs of alopecia. 2 Encourage an increase in fluids. Correct3 Wash hands before entering the client's room. Correct4 Advise use of a soft toothbrush for oral hygiene. Correct5 Report an elevation in temperature immediately. 6 Encourage the client to eat raw, fresh fruits and vegetables.

3,4,5

What growth changes are observed in a male client during adolescence? Select all that apply. 1 Development of broader hips 2 Development of deep and fuller voice Correct3 Increase in length of vocal cords by 0.4 inch (1 cm) 4 Increase in length of vocal cords by 0.17 inch (0.4 cm) Correct5 Uncontrollable shifting of the voice from deep to high tones

3,5

A 3-month-old infant has a ventriculoperitoneal shunt inserted. What should the nurse include in the infant's plan of care? 1 Keeping the infant in the prone position 2 Applying moist sterile dressings to the incision Incorrect3 Watching for signs of cerebrospinal fluid leakage Correct4 Teaching the parents signs of increased intracranial pressure

4

A client with acute kidney failure becomes lethargic and fatigued. Upon reviewing the client's medical record, which finding does the nurse determine is the most likely cause of this behavior? Incorrect1 Hyperkalemia 2 Hypernatremia 3 A limited fluid intake Correct4 An increased blood urea nitrogen level

4

A father worries about the effects that an imaginary playmate will have over his 5-year-old child. What should the nurse inform the father? Select all that apply. Incorrect1 "Your child will achieve what the imaginary playmate attempts." 2 "Your child will have an inferiority complex because of imaginary playmates." 3 "Imaginary playmates will confuse your child's grasp of reality." Correct4 "Imaginary playmates will experience what your child wants to remember." Correct5 "Your child's imagination of a playmate means that your child is healthy."

4,5

An adolescent is hospitalized for dehydration. An intravenous infusion of 1000 mL of 0.9% sodium chloride with 20 mEq/L of potassium chloride is prescribed. Hospital policy states that potassium should be mixed in a 500-mL bag of 0.9% sodium chloride. The potassium chloride label reads "2 mEq/mL." How many milliliters of potassium chloride should the nurse add to the 500-mL bag? Record your answer using a whole number. ___ mL

5ml

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? 1 Serum sodium of 139 mEq/L (139 mmol/L) 2 Serum chloride of 100 mEq/L (100 mmol/L) 3 Serum calcium of 10.2 mg/dL (2.55 mmol/L) Correct4 Serum potassium of 7.2 mEq/L (7.2 mmol/L

4

While providing feedback to nurse practitioners, the registered nurse uses the extinction approach to handle negative behaviors. Which theory of leadership is the registered nurse applying in this scenario? 1 Hierarchy of needs 2 Transactional theories Incorrect3 Transformational theories Correct4 Organizational behavior modification (OB Mod) theory

4

In a healthcare unit, there are 30 clients and the charge nurse delegates the healthcare team for providing client care. Which statements made by the delegator would indicate care responsibilities are assigned to unlicensed assistive personnel (UAP)? Select all that apply. Correct1 "Note the oxygen saturation reading." 2 "Administer oral antibiotic medications." Correct3 "Check whether the client is taking fluids." 4 "Admit the client to the intensive care unit."

1,3,5

Which care activities would be involved in a correct delegation process? Select all that apply. Correct1 Licensed practical nurse (LPN) cleans the client's body. 2 Unlicensed assistive personnel (UAP) provides medication to the client. Correct3 Unlicensed assistive personnel (UAP) assist the client with oral feedings. Incorrect4 Licensed practical nurse(LPN) evaluates the client's temperature condition. Correct5 Registered nurse (RN) guides the unlicensed assistive personnel (UAP) while recording client's temperature.

1,3,5

A person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestations of hypothermia does the nurse expect? Select all that apply. Correct1 Stupor 2 Erythema 3 Increased anxiety 4 Rapid respirations Correct5 Paresthesia in affected body parts

1,5

A nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are important to include in this client's diet? Select all that apply. 1 High fat Correct2 Low sodium Correct3 High vitamins Correct4 Moderate protein 5 Low carbohydrates

2,3,4

A nurse is discussing informed consent with a client who is scheduled for a hysterectomy. What components should the informed consent include? Select all that apply. 1 Duplicate of the Patient's Bill of Rights Correct2 Explanation of available alternative treatments Correct3 Answers to questions and concerns about the procedure Correct4 Complete description of the possible dangers and discomforts 5 Countersignature by the person designated in the client's living will

2,3,4

A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. Which locations on the client's body should the nurse assess? Select all that apply. 1 Sclera Correct2 Nail beds Correct3 Conjunctivae Correct4 Palms of hands 5 Bony prominences

2,3,4

A newly promoted registered nurse (RN) is about to start delegation for the first time in her career. Which experiences foster professional self-confidence in the early career stage for an RN? Select all that apply. 1 Inability to comprehend Correct2 Experience in clinical delegation Correct3 Application of theory to practice Correct4 Development of clinical judgment Correct5 Engagement with a nursing mentor

2,3,4,5

When monitoring a client for hyponatremia, which assessment findings should the nurse consider significant? Select all that apply. Incorrect1 Thirst Correct2 Seizures 3 Erythema Correct4 Confusion 5 Constipation

2,4

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply. 1 Anorexia Correct2 Vomiting 3 Constipation Correct4 Muscle weakness Correct5 Irregular heart rate

2,4,5

A client with a history of Crohn disease develops an intestinal obstruction. A nasogastric tube is inserted and connected to low continuous suction. The nurse monitors the client for fluid volume deficit. What clinical finding does the nurse expect if the client becomes dehydrated? Incorrect1 Restlessness 2 Constipation Correct3 Inelastic skin turgor 4 Increased blood pressure

3

What would the nurse state is true about the sleep pattern of preschoolers? 1 They sleep at least 15 hours during the day. 2 It is uncommon for them to wake up during night. Correct3 It is difficult for them to relax after they have had long and active days. Incorrect4 About 50% of their sleep is under random eye movement (REM) sleep.

3

Which statement is true regarding the Hering-Breuer reflex? 1 Increases tidal volume 2 Decreases respiratory rate Correct3 Prevents overdistension of the lungs 4 Reduces the number of functional alveoli

3

What should the nurse include in the discharge instructions for a client who will be receiving total parenteral nutrition (TPN) at home? 1 Changing the TPN access device daily Incorrect2 Contacting and scheduling professionals to administer the TPN 3 Listing the schedule of the days the client is to receive the TPN Correct4 Administering the TPN while working around the client's normal activities

4

Which antiinfective agent may lead to blindness if not used correctly by the client in prescribed amounts? 1 Bromfenac 2 Natamycin Incorrect3 Trifluridine Correct4 Gentamicin

4

A woman who was sexually assaulted by a stranger in the elevator of her apartment building is brought by her husband to the emergency department. What is the priority nursing intervention? Correct1 Obtaining information about her perception of the incident 2 Notifying legal authorities that a sexual assault has occurred 3 Talking with the husband about his feelings concerning sexual assault 4 Teaching the client how to obtain a midstream clean-catch urine specimen

1

The nurse notes that the client's ECG rhythm strips show more P waves than QRS complexes. When there are PR intervals, they are all consistent. How should the nurse interpret this strip? Correct1 Second degree AV block Mobitz II 2 First degree atrioventricular (AV) block 3 Third degree AV block (complete heart block) 4 Second degree AV block Mobitz I (Wenckebach)

1

A client is admitted to the hospital for a needle biopsy of the liver. A diagnosis of cancer of the liver is suspected. What should the nurse include in the client's preoperative teaching plan? 1 Midline abdominal incision will be used. Correct2 Bed rest must be maintained after the procedure. Incorrect3 General anesthesia will be used during the biopsy. 4 Supine position will be maintained after the procedure.

2

A person sustains severe burns of the arms and is waiting for emergency services to arrive. A nurse bystander responds to the scene. Another bystander is getting ready to apply butter to the burns, stating that it will provide soothing relief. Which response by the nurse is best? 1 "Let's focus on sitting quietly with the victim while waiting for the ambulance." Correct2 "Let's cover up the victim with one of those tablecloths instead." 3 "Let's apply first aid cream to the burns rather than the butter." 4 "Let's get that butter on quickly."

2

The nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation? 1 Measure other vital signs. Correct2 Stop administering the medication. 3 Elevate the head of the client's bed. 4 Report to the primary healthcare provider.

2

A client who has been experiencing chest pain and vomiting for several hours is admitted to the hospital with a diagnosis of myocardial infarction. The client is transferred immediately to the cardiac intensive care unit. The client's potassium level is below the expected range. Considering this laboratory result, what should the nurse monitor the client's electrocardiogram (ECG) for? 1 Tall, peaked P waves 2 Increased P-R intervals Correct3 Elevated U and flattened T waves 4 Multiple trigeminy and bigeminy runs

3

A client is experiencing hallucinations. What therapeutic intervention should the nurse plan to help the client cope with the hallucinations? Incorrect1 Reinforcing the perceptual distortions until the client develops new defenses 2 Providing an unstructured environment and assigning the client to a private room 3 Avoiding helping the client make connections between anxiety-producing situations and hallucinations Correct4 Distracting the client's attention by providing a competing stimulus that is stronger than the hallucinations

4

A client with hepatitis B (HBV) develops cirrhosis and is hospitalized. One potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse determines that this may be attributed to a decrease in serum albumin level. Which of these conditions results from this imbalance? 1 Hemorrhage with subsequent anemia 2 Diminished resistance to bacterial insult Incorrect3 Malnutrition of cells, especially hepatic cells Correct4 Reduction of colloidal osmotic pressure in the blood

4

After assessing a client who is in cardiac arrest, a primary healthcare provider prescribes a dose of medication that is much higher than is recommended for the clinical situation and directs the nurse to give the medication immediately. Which response by the nurse is most appropriate? 1 "You're wrong. I do not feel comfortable administering this high of a dose." 2 "Please tell me how you arrived at this dose. I think your calculations are incorrect." 3 "You're probably thinking of another drug. This is beyond the safe dosage limits indicated for this drug." Correct4 "That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself."

4

A client with extensive gastric carcinoma is admitted to the hospital for an esophagojejunostomy. What information should the nurse include in the teaching plan when preparing this client for surgery? Correct1 Postoperative chest tube Incorrect2 A clear liquid diet the day of surgery 3 Trendelenburg position for the first 24 hours after surgery 4 Complete bed rest for 48 hours after surgery

1

A nurse is preparing a pregnant 39-year-old client for an amniocentesis. Which factor increases the risk of problems after an amniocentesis? 1 The client's blood type is known to be Rh positive. 2 Ultrasonography is done before the amniocentesis. Incorrect3 The procedure is done at the twenty-second week of gestation. Correct4 Several punctures are needed to obtain amniotic fluid.

4

Upon assessment of the client, the nurse observed the following condition (see image). What is the cause for the condition of the client represented in the image? (Picture of an obese man who can close his mount) 1 Decreased cardiac output 2 Decreased erythropoietin levels 3 Accumulation of mucopolysaccharides in blood vessel wall Correct4 Accumulation of hydrophilic mucopolysaccharides in tissues

4

The care delivery committee is considering client-focused care units for a 300-bed community hospital. What cost information should the committee prepare to help the hospital's board of directors make this decision? Select all that apply. Incorrect1 Training charge nurses Correct2 Redesigning all care areas Correct3 Cross-training support personnel Incorrect4 Hiring additional nurse managers 5 Hiring an all registered nurse staff

2,3

The primary healthcare provider prescribes medication to prevent transplant rejection from increased concentration of interleukin-2. Which drugs could the nurse most likely administer? Select all that apply. 1 Sirolimus Correct2 Tacrolimus Correct3 Cyclosporine Incorrect4 Azathioprine 5 Mycophenolate

2,3

A nurse is assessing a client with multiple sclerosis. Which common initial clinical effects should the nurse expect to find? Select all that apply. 1 Headaches Correct2 Nystagmus 3 Skin infections Correct4 Scanning speech Correct5 Intention tremors

2,4,5