ca pc 1

The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?

Alternating air pad

The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action?

Apply a sterile dressing soaked with sterile normal saline to the wound. Submit

Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table?

Apply the safety strap 2 inches above the knees.3

The nurse is preparing a session regarding nutrition for a group of culturally diverse pregnant women. The nurse determines that the priority nursing intervention includes which action?

Identify the cultural food preferences of each client.

A 9-year-old child with leukemia is in remission and has returned to school. The school secretary calls the mother of the child and tells the mother that a classmate has just been diagnosed with varicella (chickenpox). The mother immediately calls the nurse at the primary health care provider's office because the leukemic child has never had chickenpox. The nurse would make which response to the mother?

"Bring the child to the office for an injection called immune globulin."4

A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions with the client regarding preparation for the surgical procedure. Which client statement indicates an understanding of the preoperative instructions?

"I cannot drink or eat anything after midnight on the night before surgery."2

The nurse evaluates that the older client has a need for further teaching on how to promote sleep when the client makes which statements? Select all that apply.

"I drink hot chocolate before bedtime."4 "I plan out my goals for work for the next day" Submit

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 calories

Which laboratory results indicate a therapeutic drug level? Refer to chart. Select all that apply.

135

The nurse is reviewing the laboratory studies of a client receiving epoetin alfa. When would the nurse expect to note a therapeutic effect of this medication on the hemoglobin and hematocrit?

2 months after therapy

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the client's white blood cell count was which value?

2000 mm3 (2.0 × 109/L)

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 alcoholism

The nurse is reinforcing teaching with a client who is having difficulty sleeping. Which bedtime snacks will help the client achieve a restful night's sleep? Select all that apply.

A glass of warm milk A cube of Swiss cheese A cup of caffeine-free tea

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?

Butter3

A client states that he has removed all dairy foods from his diet because he is lactose intolerant. The nurse plans care for the client knowing which information?

Calcium and protein are valuable nutrients and need to be supplemented in some form.

The nurse is preparing to initiate a tube feeding for a client, and the primary health care provider has prescribed that the feeding be infused at 50 mL per hour. The nurse brings an electronic feeding pump to the bedside and discovers that there is no available outlet in the wall socket to plug the pump into. Which action would the nurse implement?

Contact the electrical maintenance department for assistance.

A licensed practical nurse (LPN) is providing follow-up teaching after a client underwent an upper gastrointestinal (GI) series with diatrizoate used for contrast. The nurse instructs the client that which may occur from the diatrizoate?

Diarrhea

A client is scheduled for an oral cholecystography. The nurse would plan to obtain what type of diet for the evening meal before the test?

Fat-free3

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

The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which findings would indicate a sign of a potential complication? Select all that apply.

Increasing restlessness A pulse rate of 108 beats per minute A blood pressure (BP) of 88/58 mm Hg Increasing pain unrelieved by analgesics

The nurse is preparing a client for the administration of a tuberculin skin test. The nurse determines that which body areas are appropriate for intradermal injections? Select all that apply.

Inner aspect of the forearm2\ Dorsal aspect of the upper arm Away from heavy pigmentation

A client with Crohn's disease is seen by the primary health care provider, and a complete blood count (CBC) has been prescribed. The nurse reinforces instructions to the client who will be reporting to the laboratory in the morning to have the blood test drawn. The nurse gives the client which information about this test?

No special preparation is necessary.3

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.

The nurse has a prescription to obtain a sample for urinalysis from a client with an indwelling urinary catheter. To prevent contamination of the specimen, the nurse would avoid which action?

Obtaining the specimen from the urinary drainage bag3

The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The primary health care provider visits and prescribes restraints if needed. Which actions are appropriate to delegate to the assistive personnel (AP), who has completed the facility's education about care of the restrained client? Select all that apply.

Socialize with the restrained client. Remove the restraint and perform range of motion activity.5Reapply the restraint after assisting the client to the bathroom.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse would plan to place the client in which position?

Supine, with the residual limb supported with pillows

The nurse reinforces instructions to a client who is to return to the primary health care provider's office in 1 week for a patch test to identify the allergen causing the dermatitis. The nurse provides which instruction to the client?

"Discontinue the prescribed antihistamine 2 days before the test."

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

A child is diagnosed with bacterial conjunctivitis, and antibiotic eye drops are prescribed for the child. The parent asks the nurse when the child can return to school. The nurse would make which response to the parent?

"The child should be kept home until the antibiotic eye drops have been administered for 24 hours."

A client with a history of seizure disorder is having a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client's blood level of the medication is within the normal range if which value is reported?

15 mcg/mL3

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/dL

The nurse is assigned to reinforce instructions to a client and the family about the management of home intravenous (IV) infusion therapy. The nurse begins the process by teaching the client and family principles related to what actions first?

Proper hand-washing technique4

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse would perform?

Aim at the base of the fire.2

The nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for which data first?

A patent airway2

A client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which medication that would be prescribed to treat this acid-base disorder?

Acetazolamide3

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 restrained4Type of restraint and body area where the restraint was applied5Communication with client and family member about need for restraint6The alternative measures that were attempted before restraints were applied

The nurse is reviewing the results of a client's serum laboratory studies. Which result indicates a deficiency of protein intake?

Albumin, 2.6 mg/dL2

The nurse is assisting in performing an arterial blood gas (ABG) analysis on a client. The nurse initially implements which intervention after the blood gas is drawn to minimize the risk for uncontrolled bleeding?

Applying direct pressure to the site3

The correctional nurse is assisting in developing an in-service for new correctional nurses. The nurse would suggest to include which at-risk health disparities that occur in the prisoner population, when compared to the general population? Select all that apply.

Asthma Hepatitis C Hypertension Drug dependence

A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, which instruction would the nurse provide the client?

Avoid eating or drinking after midnight before the test.2

The nurse has reinforced instructions to a client with tuberculosis about proper handling and disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes to take which measure?

Discard used tissues in a plastic bag.2

A client on the medical unit tells the nurse of back discomfort but does not want any pain medication. Which nonpharmacological interventions would the nurse offer the client to help reduce the pain? Select all that apply.

Distraction3\ Back massage5Relaxation breathing

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which would the nurse wear to perform these tasks?

Gown and gloves

The nurse is assisting in the care of a client with a new ileostomy on the clinical nursing unit. Which observations indicate to the nurse that the client is at risk for fluid volume deficit? Select all that apply.

Ileostomy output of 650 mL in 4 hours3 Blood pressure (BP) 104/66 mmHg, temperature 98.4° F, pulse 106 beats per minute, respirations 20 breaths per minute Submit

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. Submit

The nurse in the hospital is assisting in developing a plan of care for an older client to prevent a fall. Which actions would be least likely to prevent a fall? Select all that apply.

Keeping the bathroom light off at nighttime4 Placing the client in the quiet area of the nursing unit in a room away from the nurse's station Submit

The nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which sign/symptom would be noted in the client if hyperkalemia is present?

Muscle weakness4

The nurse working in a human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) clinic is reviewing modes of transmission for HIV for a new nurse to the clinic. Which potential modes of HIV transmission would the nurse review? Select all that apply.

Needle-stick injuries Transmission by breast milk4 Inconsistent use of protective equipment Submit

A pulmonary angiography is scheduled for a client suspected of having a pulmonary embolism. The nurse understands that which actions are an appropriate preprocedure care intervention? Select all that apply.

Obtain a signed informed consent form. Prepare the anticipated entry site for local anesthesia. Inquire whether the client has any allergies to shellfish. Ask whether client has ever experienced an allergy to any contrast media. Submit

The nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which is an expected measurement determined by the pulse oximeter?

Oxygen saturation 95% to 100%; blood pressure 120/80 to 130/80 mm Hg

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions would the nurse use to perform this procedure? Select all that apply.

Put on a mask. Don gown and gloves. Wear a pair of protective goggles.

The nurse is changing the neck ties on a tracheostomy tube. Which method is appropriate for the nurse to take?

Remove the old ties, clean the site, and then apply the new ties while a second health care team member holds the tracheostomy tube.

A client who has undergone a barium enema is being readied for discharge from the ambulatory care unit. Which instruction would the nurse include in instructions to the client?

The barium will cause the stools to be clay colored, but then the stool becomes normal colored.

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. Neutropenic precautions have been implemented. Which activity would the nurse question if observed while caring for this client?

The client orders lunch of soup, salad with tomatoes and cucumbers, and an apple.

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?

The client with a fast respiratory rate

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 appropriately

++The nurse is developing a teaching session for a group of older adults at a local senior center. Regarding sensory changes, which information would the nurse include in the session?

Visual impairment can lead to disability.2

The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. The nurse inserts a new IV. Which intervention would the nurse institute next for the client?

Wrap a light roll of gauze to cover the IV site.2

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)

A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that a client with an ileostomy is at risk for developing?

Metabolic acidosis

The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal, how would the nurse position the client?

Upright in a chair2

The nurse is reinforcing instructions about home safety measures regarding medications and toxic substances to a parent. Which parent statements indicate a need for further teaching? Select all that apply.

"I need to refer to medication as 'candy' only when really necessary." "I can place several medications in the same bottle if I am going for an overnight trip."

The nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further teaching if the client makes which statement?

"I should use disposable plates, forks, and knives."2

The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery?

Pain2

The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery later in the day. When asking the client whether the client has taken any scheduled or over-the-counter medications in the past 24 hours, which statements would concern the nurse? Select all that apply.

"Yes, I take a full-strength aspirin every day."\ "I have taken my medication for my blood pressure this morning."5

A client is in respiratory alkalosis induced by gram-negative sepsis. The nurse assists in implementing which measure as the effective means to treat the problem?

Administer prescribed antibiotics.2

The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL through an indwelling urinary catheter for the last 2 hours. Based on this finding, which would be the nurse's actions at this time? Select all that apply.

Check the client's overall intake and output record.5Gather data about the urinary catheter and check for patency.

A client has just undergone endoscopy. Which is the essential postprocedure nursing intervention?

Check the gag reflex before giving oral foods or fluids.4

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions?

Droplet4

The nurse is reinforcing instructions to a client about complete/high quality protein foods. Which food choices would indicate the client understood the teaching? Select all that apply.

Eggs Chicken

The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How would the nurse correctly document this observation in the medical record?

Kussmaul's respirations Submit

A client who has recently been started on enteral feedings begins to complain of abdominal cramping, followed by passage of two liquid stools. The nurse notes that the client has abdominal distention as well. The nurse reviews the nutritional content on the label of the can to see if it contains which ingredient?

Lactose3

The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mEq/L (1.8 mmol/L). Which sign would the nurse expect to note in the client, based on this magnesium level?

Loss of deep tendon reflexes Submit

The nurse will perform a sterile dressing change after removing the old dressing with clean gloves. The nurse removes the gloves, uses alcohol-based hand sanitizer to perform hand hygiene, and prepares to perform open sterile gloving. The nurse removes the gloves from the outer package. The nurse is right-handed. The nurse opens the inner wrapper and flattens the wrapper to expose the gloves. Which is the next action the nurse takes when donning sterile gloves?

Pick up right glove at cuff with left thumb and forefinger.

A client with diabetes mellitus has a glycosylated hemoglobin A (HbA1c) level of 8%. Which instruction does the nurse plan to reinforce to the client based on this test result?

Prevent hyperglycemia.

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse would monitor the client for which acid-base imbalance?

Respiratory acidosis

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 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 reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. What would the nurse look for on the cardiac monitor as a result of this laboratory value?

Narrow, peaked T waves

A primary health care provider (PHCP) has written a prescription for a preoperative client to have "enemas until clear." The nurse has administered three enemas, and the client is still passing brown liquid stool. Which action would the nurse take next?

Notify the primary health care provider.2

A client who has been prescribed indomethacin for gout is asked to provide a stool sample for guaiac testing. The nurse explains that the purpose of the test is to make which determination?

Occult blood3

The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and would avoid which while changing the client's hospital gown?

Disconnecting the IV tubing from the catheter in the vein3

A client has had a bone scan procedure. The nurse determines that the client understands the elements of follow-up care if the client states which postprocedural care?

Drink plenty of water for a day or two following the procedure.

The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety seats. Which information related to the safety of the infant is correct?

Restrain in a car seat in the back seat in a semi-reclined, rear-facing position.3

The licensed practical nurse (LPN) is assisting in the care of a client who overdosed on acetylsalicylic acid 24 hours ago. The LPN would report to the registered nurse (RN) which findings associated with an anticipated acid-base disturbance?

Drowsiness, headache, and tachypnea2

The nurse prepares to administer a prescribed dose of scopolamine. The nurse would monitor for which side effect of this medication?

Dry mouth2

The nurse reinforces what information to a client who is scheduled for an electromyogram (EMG)?

Electrodes will be inserted into the skeletal muscles.3

A client has been admitted to the hospital with a diagnosis of severe nausea and vomiting. The client has an indwelling intravenous (IV) catheter. The client's morning laboratory results show a serum blood sodium level of 130 mEq/L (130 mmol/L) and a serum blood chloride level of 92 mEq/L (92 mmol/L). Which IV fluids would provide free water, sodium, and chloride to the client? Select all that apply.

0.45% sodium chloride in water solution4Dextrose 5% in 0.225% sodium chloride solution

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

Which clients would the nurse determine is at risk for development of metabolic alkalosis? Select all that apply.

Client who has been vomiting for 2 days5Client receiving oral furosemide 40 mg daily

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 determines that which clients are at high risk for metabolic acidosis? Select all that apply.

Clients with diabetes3 Clients with kidney failure5 Clients with malnourishment Submit

A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder?

Decreased respiratory depth and rate and dysrhythmias Submit

An outbreak of illness has occurred in a community and is suspected to be related to food ingestion. A community health nurse places priority on which intervention?

Determining what common food item was ingested by those affected2

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 injury3 A client diagnosed with acute kidney injury (AKI)5

The nurse is providing directions to the assistive personnel (AP) regarding clients' hygiene needs. Based on the client needs, the nurse instructs the AP to bathe which client first?

A confused client who is incontinent of stool and urine3

A client is to have an upper gastrointestinal (GI) series. Which nursing action would be done concerning the procedure?

Administer a laxative after the procedure because barium was administered.4

During a fire drill, the nurse enters a laundry room and a waste basket is marked as on "fire." The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher and returns to the laundry room. Which action by the nurse shows that additional training is needed?

Aiming at the top flames of the fire2

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 reviews a client's serum sodium level and notes that the level is 150 mEq/L (150 mmol/L). The primary health care provider prescribes dietary instructions for the client based on the sodium level. Which food items would the nurse instruct the client to avoid? Select all that apply.

Bacon2Salami Processed oat cereals Submit

The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill?

Blotting up the spill with a face cloth or cloth towel4

A client has been placed on neutropenic precautions. Which information is appropriate when explaining what this means? Select all that apply.

Get plenty of sleep and rest.2Take all medications as prescribed. Wash your hands frequently with antibacterial soap.5 Contact the primary health care provider (PHCP) if even a low-grade fever develops. Submit

A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which items are inappropriate to use and could cause harm to the client? Select all that apply.

Restraints2 Padded tongue blade Submit

A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse reinforces dietary teaching about the types of foods to avoid. The nurse determines that there is a need for further teaching if the client states that which food choices are good? Select all that apply.

Sauerkraut6American cheese

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.3 After injecting the irrigating solution, pull back on the irrigation syringe.5

A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the nurse observed the client has a patent airway. Which is the next nursing assessment?

Vital signs2

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.4Use soap and water, not alcohol-based hand rub, for hand hygiene.

The registered nurse (RN) reviews the results of the arterial blood gas (ABG) values with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN would expect to note which on the laboratory result report?

pH 7.25, Pco2 50 mm Hg4

The nurse is caring for a client who is nervous and is hyperventilating. The nurse would monitor the client for signs of which acid-base imbalance?

Respiratory alkalosis Submit

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 in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week, yet is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern about not being able to continue the tube feedings at home with family caregivers. Which nursing response would be appropriate at this time?

"Tell me more about your concerns with your feedings after going home."

A child with leukemia is hospitalized and is receiving chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response by the nurse is appropriate?

"The flowers from your garden are beautiful, but they should not be placed in the child's room at this time."4

A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which questions would assist the nurse in the collection of data regarding the client's problem? Select all that apply.

"What have you been eating and drinking since the surgery?"5"Have you been experiencing any urge to move your bowels?"6"What kind and how often have you been taking medications for pain?"

The nurse reviews the client's laboratory results. Which abnormal findings would the nurse report? Select all that apply.

Calcium 8.2 mg/dL Potassium 6 mEq/L Magnesium 2.9 mg/dL Phosphorus 5.2 mg/dL

The nurse is preparing to deliver a food tray to a client whose religion is Judaism and follows kosher preferences. The nurse checks the food on the tray and notes that the client has received a roast beef dinner with whole milk as a beverage. Which action would the nurse take?

Call the dietary department and ask for a new meal tray without the milk. Submit

A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. The nurse gives a response to the client that provides reassurance, based on which understanding?

Discomfort may occur with needle insertion, and there is minimal exposure to radiation.4

A client undergoing diagnostic testing for cancer is scheduled for magnetic resonance imaging (MRI). The nurse reinforces to the client which information about the procedure?

Expect the MRI machine to make loud noises.3

The nurse is assigned to care for a client on contact precautions. On review of the client's record, the nurse notes that the client has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client's room and obtains which necessary protective items?

Gloves, mask, gown, and goggles4

The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse use during the bathing of this client?

Gown and gloves3

The nurse is preparing a client for a right below-the-knee amputation. The nurse anticipates that the client is likely to experience which psychosocial problems in the perioperative period? Select all that apply.

Grief4Anxiety5Altered body image

The nurse is reviewing the laboratory results of a client scheduled for surgery. Which laboratory result would indicate to the nurse that the surgery might be postponed?

Hemoglobin, 8.4 g/dL3

A client has been taking prednisone for 3 years. She is scheduled for abdominal hysterectomy. The nurse plans care realizing that postoperatively the client is at risk for which conditions? Select all that apply.

Increased risk for dehiscence3 Increased likelihood of surgical site infection5

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and would be reported to the primary health care provider before the surgery? Select all that apply.

Is allergic to penicillin Quit smoking 3 months earlier Wonders if the surgery could cause incontinence5 History of deep venous thrombosis in right leg 10 years earlier Submit

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

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. Submit

The nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which nursing interventions would the nurse initiate? Select all that apply.

Monitor the client for dysrhythmias.2 Notify the primary health care provider (PHCP) of the laboratory results. Submit

A client enters the emergency department confused, twitching, and having seizures. Upon assessment, flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor are noted. The serum sodium level is 172 mEq/L (172 mmol/L). Which interventions would the primary health care provider (PHCP) likely prescribe? Select all that apply.

Monitor vital signs.2Monitor intake and output.3Increase water intake orally.4Monitor electrolyte levels.5Provide a sodium-reduced diet.

A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are necessary when caring for this client? Select all that apply.

Monitoring the skin around the stoma site for skin irritation3

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which would the nurse include in the preparations? Select all that apply.

Open the distal flap of a sterile package first.3Prepare the sterile field just before the planned procedure. Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field. Submit

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.3 Gather data from the client related to signs of toxicity. Submit

The nurse informs a nursing student about various concepts of traditional Chinese medicine (TCM). The nurse determines the nursing student has a need for further teaching if the nursing student states that which concept is related to TCM?

Panchakarma

A primary health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?

Placing the heating pad under the client3

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse would dispose of the used needle by which method?-

Placing the needle and syringe in a puncture-resistant container3

The nurse is administering mouth care to an unconscious client. The nurse would avoid doing which actions? Select all that apply.

Positioning the client supine2Using products with lemon or alcohol3

The nurse is caring for a client with kidney failure. The nurse is told that the blood gas results indicate a pH of 7.30 and a HCO3- of 20 mm Hg, and that the client is experiencing metabolic acidosis. The nurse reviews the laboratory results and finds which value to be of concern?

Potassium level, 5.6 mEq/L3

The nurse is reinforcing instructions to a client on how to decrease the intake of potassium in the diet. The nurse determines the need for further teaching if the client selects which foods to include in the diet? Select all that apply.

Potatoes5Avocados6Salt substitute

The nurse is preparing to suction a client through a tracheostomy tube. The nurse would perform which actions when performing this procedure? Select all that apply.

Preoxygenating the client before suctioning Moistening the catheter tip in sterile saline solution before suctioning Introducing the catheter into the tracheostomy tube using a sterile gloved hand

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 is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 32 mm Hg (32 mm Hg). The nurse determines that these results are indicative of which acid-base disturbance?

Respiratory alkalosis

The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions would the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply.

Question the client about feelings of dizziness.4Put the client's shoes on to help the client avoid slipping on the floor during the transfer.5Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

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 assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action would the nurse plan to take first?

Recheck the vital signs in 15 minutes.

The nurse is preparing a client for a magnetic resonance imaging (MRI) examination. Which action by the nurse is important?

Remove metallic objects from the client.2

The nurse is working with an assistive personnel (AP) to care for clients. While observing the AP's delivery of care, the nurse notes which actions by the AP that indicate the need for further teaching regarding standard precautions? Select all that apply.

Removes gloves and immediately uses computer to document care4 Uses soap and water to wash hands for 5 seconds and then dries hands6Empties collection bag of an indwelling urinary catheter without wearing gloves Submit

The client is having a lumbar puncture (LP) performed. The nurse would place the client in which position for the procedure?

Side-lying, with legs pulled up and chin to the chest Submit

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 blood3Using a soft toothbrush for mouth care

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

A client is admitted to the surgical unit postoperatively with a self-suction Jackson-Pratt wound drain in place. The nurse determines the drain is functioning correctly with which observations? Select all that apply.

The bulb container is fully compressed.2Bright red bloody drainage is present in the bulb container.

The nurse educator is describing the yin and yang theory of the ancient Chinese philosophy of Tao to a group of nursing students. The nurse educator explains that in this theory, foods are classified as hot and cold and are transformed into yin and yang energy when metabolized by the body. The nursing student understands this theory when the student makes which statement?

The client consumes cold foods when a "hot" illness is present. Submit

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply.

The client with renal failure2 The client with chronic cirrhosis4

The nurse is reviewing the health care records of assigned clients. Which clients are at highest risk for excess fluid volume? Select all that apply.

The client with renal failure3 The client with chronic congestive heart failure (CHF) Submit

The nurse is assisting a client to ambulate when the client states he is feeling faint and cannot stand. Which action would the nurse take to assist the client now?

The nurse should extend one leg to use to slide the client's body down to the floor.4

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply.

The presence of purulent drainage3 Tender firmness palpable around the incision Submit

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.3 The student places the collection swab initially at the back of the client's tongue.5

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 Sardines6Mustard greens

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition?

Traumatic burn3

The nurse is caring for a non-English-speaking client. Best practices for client safety and quality of care incorporates which actions by the nurse? Select all that apply.

Use interpreters who are familiar with health care. . Avoid the use of relatives as interpreters to prevent misinterpretation. Use dialect-specific interpreters who are the same gender if possible. Become familiar with common health care words used in the client's language.

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 determines that the client has a proper fitting of the crutches when which criteria have been fulfilled? Select all that apply.

Handgrips are positioned so the elbows are bent approximately 30 degrees. The space between the axilla and the top of the crutch pad is 1½ to 2 inches. The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.

A health care worker who signed a waiver and never received the hepatitis B vaccine receives a needle stick from a client who has hepatitis B. Which treatments are indicated for the health care worker under this situation? Select all that apply.

Hepatitis B immune globulin Initiate hepatitis B vaccine series Cleanse needlestick site with soap and water

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed?

Leaving the rate of the heparin infusion as is

The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action would the nurse take first?

Lower the head of the bed slowly until the dizziness is relieved.

The nurse reviews the arterial blood gas results of a client and notes that the results indicate a pH of 7.30, Pco2 of 52 mm Hg, and HCO3- of 22 mEq/L. Which interpretation would the nurse correctly make about these results?

Respiratory acidosis

Which are the most important interventions that can help reduce the incidence of hospital-acquired urinary catheter infections? Select all that apply.

Use indwelling urinary catheters judiciously. Remove indwelling catheters when no longer needed. Use strict aseptic technique when inserting all urinary catheters

The nurse is reviewing the complete blood count (CBC) laboratory results of a female adult client suspected of having iron deficiency anemia. The nurse reviews the results and determines that which results are consistent with this diagnosis? Select all that apply.

Hematocrit (Hct) 30% Hemoglobin (Hgb) 8.8 g/dL Decreased mean corpuscular volume (MCV) 66 fL Submit

A client is seen in the urgent care center for complaints of chest pain 2 days ago. Since that time, the client has not been feeling well and fatigues easily. The nurse reviews the results of the laboratory tests. An elevation of which laboratory test indicates a myocardial infarction occurred at the time of chest pain 2 days ago?

Troponin I

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions would the nurse use to move this client? Select all that apply.

Use a mechanical lift to move the client.3 Keep elbows close and work close to the body.5 Obtain assistance of a second caregiver to assist with mechanical aids. Submit

The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse would take which actions? Select all that apply.

Check the placement of the tube.3 Aspirate the contents from the nasogastric tube.6Observe the characteristics and pH of the aspirate from the nasogastric tube. Submit

The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?

Checking the wound site for drainage from the drain Submit

While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate? Select all that apply.

Do you have a history of seizures? Do you have a history of a clotting disorder? How long and why have you been using ginkgo? Have you been diagnosed with diabetes mellitus?

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

The nurse reviews the client's laboratory data. Which data warrant notification of the registered nurse and an immediate call to the primary health care provider? Refer to chart.

Calcium level3

The nurse caring for a male client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30%. Which action would the nurse take?

Report the abnormally low level.2

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at the least likely risk for the development of third-spacing?

The client with diabetes mellitus

A client is being advanced to a full liquid diet on the second postoperative day. Which foods are allowed for this client? Select all that apply.

Tea2 \Ice cream4 Cream of tomato soup6

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 sign2

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

A 24-hour urine specimen for creatinine and electrolytes has been prescribed for a hospitalized client to evaluate kidney function. The nurse explains the procedure to the client. The client voids at 0900, and the urine is discarded. The client voids at 1200, and the urine is measured and placed in the collection container. At which time the next day would the 24-hour urine collection be complete? Fill in the blank with the correct military time.

0900

The nurse is instructing a group of assistive personnel (AP) in the principles of body mechanics. The nurse determines that an AP is using the principles appropriately if the nurse observes the AP doing which action?

Positioning a box that is to be lifted between the knees3