CDM passpoint 1

A client who has suffered a stroke is brought to the emergency department. The physician has ordered t-PA 0.9mg/kg for a client who weighs 198 lbs (90 kg). Directions for administration are to mix the 100 mg vial of t-PA with 100 ml of Sterile water to yield 1 mg/ml. How many ml of t-PA should be removed from the vial and discarded before administration? Record your answer using a whole number.

19

An infusion of lidocaine hydrochloride is running at 30 mL/hour. The dilution is 1,000 mg/250 mL. What dosage is the client receiving per minute? Record your answer using a whole number.

2

After undergoing small-bowel resection, a client is prescribed metronidazole 500 mg intravenously. The mixed solution is 100 ml. The nurse is to administer the drug over 30 minutes. The drop factor of the available intravenous tubing is 15 gtt/ml. What is the drip rate in drops per minute? Record your answer using a whole number

50

A client with schizophrenia is admitted to the psychiatric unit of a hospital. Nursing assessment should include careful observation of the client's: a) thinking, perceiving, and decision-making skills. b) psychomotor activity. c) affect and behavior. d) verbal and nonverbal communication processes.

A

A client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza? a) Meningitis b) Pneumonia c) Pulmonary edema d) Septicemia

B

When teaching a parent of a school-age child about signs and symptoms accompanying fever that require immediate notification of the physician, which of the following descriptions should the nurse include? a) Burning or pain with urination b) Reports of a stiff neck c) History of febrile seizures d) Cough progressing to productive sputum

B

A 17-year-old adolescent with a history of muscular dystrophy is admitted with aspiration pneumonia. The client's medical history reveals that this is the third time in the past 6 months that the client has been diagnosed with pneumonia. Which of the following topics should the nurse plan to address for teaching? a) Need to avoid crowds and large gatherings b) Need for good hand hygiene c) Need for a feeding tube d) Need for an advance directive

C

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that she has made. The nurse is most clearly demonstrating which of the following professional values? a) Integrity. b) Human dignity. c) Altruism. d) Social justice.

A

A client is taking vancomycin. The nurse should report which possible side effect to the health care provider (HCP)? a) ataxia b) muscle stiffness c) vertigo d) tinnitus

D

Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: The nurse is instructing a client with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. In which order from first to last should the nurse explain the steps to the client? All options must be used. 1 "Breathe in normally through your nose for two counts (while counting to yourself, one, two)." 2"Pucker your lips as if you were going to whistle." 3 "Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four)." 4 "Relax your neck and shoulder muscles."

4, 1, 2, 3

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method? a) Place a tongue blade lightly on the posterior aspect of the pharynx. b) Place a tongue blade on the uvula. c) Place a tongue blade on the middle of the tongue and ask the client to cough. d) Place a tongue blade on the front of the tongue and ask the client to say "ah."

A

A client is admitted to the emergency department with a history of abdominal aortic aneurysm. The nurse assesses the client for which sign or symptom that suggests the client's abdominal aortic aneurysm is extending? a) Increased abdominal and back pain b) Decreased pulse rate and blood pressure c) Retrosternal back pain radiating to the left arm d) Elevated blood pressure and rapid respirations

A

A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? a) Decreased cardiac output b) Imbalanced nutrition: Less than body requirements c) Impaired physical mobility d) Risk for infection

A

After teaching a new mother about the care of her neonate after circumcision with a Gomco clamp, which statement by the mother indicates to the nurse that the mother needs additional instructions? a) "I will remove any yellowish crusting gently with water." b) "I will leave the gauze in place for 24 hours." c) "The petroleum gauze may fall off into the diaper." d) "A few drops of blood oozing from the site is normal."

A

After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching? a) "I'll have to wear an external collection pouch for the rest of my life." b) "I'll need to drink at least eight glasses of water a day." c) "I'll have to catheterize my pouch every 2 hours." d) "I should eat foods from all the food groups."

A

An Alzheimer's client has difficulty following instructions but listens intently when he hears the voice of a nurse, who is his primary caregiver. The physician orders an electrocardiogram (ECG) to ascertain cardiac status. The client becomes agitated when the ECG technician enters the room. What is the nurse's best course of action? a) Sit next to the client and provide verbal support until he calms down. b) Offer the client a sedative and attempt to obtain the ECG when the client is calmer. c) Ask the client to try to understand what's going to happen. d) Assure the client that he's safe and explain the purpose of the procedure in simple terms.

A

How should the nurse instruct the parent to position an infant to assess the thyroid gland? a) Supine on the mother's lap b) Prone over the mother's knees c) Sitting upright in the infant carrier d) Standing on the examination table

A

The nurse is teaching a client newly diagnosed with cancer about chemotherapy. The nurse tells the client he'll receive an antitumor antibiotic. The nurse knows that this type of medications is: a) cell-cycle nonspecific. b) cell-cycle specific in the P phase. c) cell-cycle specific in the M phase. d) cell-cycle specific in the S phase.

A

To reduce the possibility of catheter-related urinary tract infections (CAUTIs), the nurse should: a) minimize urinary catheter use and duration of use in all clients. b) clean the periurethral area with antiseptics. c) ensure that clients who are incontinent have indwelling urinary catheters. d) use sterile technique when providing catheter care.

A

Which statement by the nurse would be most appropriate when responding to a primigravid client who asks, "What should I do about this brown discoloration across my nose and cheeks?" a) "This usually disappears after childbirth." b) "It will fade if you use a prescribed cream." c) "It is a sign of skin melanoma." d) "The discoloration is due to dilated capillaries."

A

While examining a 2-year-old child, the nurse sees that the anterior fontanel is open. The nurse should: a) notify the physician. b) recognize this as a normal finding. c) look for other signs of abuse. d) ask about a family history of Tay-Sachs disease.

A

"mother verbalizing labor and delivery experience. doesnt appear confident about holding her baby or changing diapers. asking appropriate questions." A nurse is caring for a 1-day postpartum client. The progress note below informs the nurse that the client is in which phase of the postpartum period? a) Taking hold. b) Taking in. c) Holding out. d) Letting go.

B

A 42-year-old client was admitted from a homeless shelter with a diagnosis of tuberculosis and alcoholism. It is essential that which health care team member attends the care conference to discuss discharge planning and community resources? a) pharmacist b) social worker c) infection control nurse d) dietitian

B

A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is reporting pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time? a) Replace ice packs to the perineum. b) Administer pain medication per prescription. c) Initiate anesthetic sprays to the perineum. d) Begin sitz baths.

B

A client is experiencing an acute myocardial infarction (MI) and I.V. morphine is ordered. The nurse knows that morphine is given because it: a) raises the blood pressure, lowers myocardial oxygen demand, and eliminates pain. b) lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand. c) eliminates pain, reduces cardiac workload, and increases myocardial contractility. d) increases venous return, lowers resistance, and reduces cardiac workload.

B

A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for: a) severe midsternal pain. b) moderate pain that worsens on inspiration. c) a mild but constant aching in the chest. d) muscle spasm pain that accompanies coughing.

B

A nurse is assessing a 4-year-old child's peripheral IV line, observing that it is not infusing. What is the first action the nurse should take to correct this situation? a) Change the IV bag. b) Reposition the child's extremity. c) Check the power source of the pump. d) Adjust the height of the IV bag.

B

A nurse is caring for an elderly client in a long-term care facility. This client has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard him express feelings of hopelessness to other residents. Which intervention should the nurse perform first? a) Setting aside time to listen to the client b) Removing items that the client could use in a suicide attempt c) Communicating a nonjudgmental attitude d) Referring the client to a mental health professional

B

A physician orders codeine, ½ grain every 4 hours, for a client experiencing pain. How many milligrams of codeine should the nurse administer? a) 60 mg b) 30 mg c) 15 mg d) 120 mg

B

After abdominal surgery, a client is reluctant to turn in bed. The nurse should: a) have the family encourage the client to turn. b) explain the importance of turning to the client. c) allow the client to turn when desired. d) remind the client to follow the health care provider's prescriptions.

B

The health care provider (HCP) prescribes risperidone for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which behavior? a) sleep disturbances b) agitation and assaultiveness c) concomitant depression d) confusion and withdrawal

B

The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should: a) apply a half-leg pneumatic compression device. b) encourage the client to avoid standing in one position for long periods of time. c) assess the client for foot ulcers. d) suggest the client contact her health care provider.

B

When preparing to deliver back slaps to an infant who is choking on a foreign body, the nurse should place the infant in which position? a) head to one side and even with the trunk lower than the head b) head down and lower than the trunk c) head parallel to the nurse and supported at the buttocks d) head up and raised above the trunk

B

A 68-year-old client is admitted to the addiction unit after treatment in the emergency department for an overdose of oxycodone. Her son calls the unit and expresses intense anger that his mother is being treated as a "common street addict." He says she has severe back pain and was given that prescription by her health care provider (HCP). "She just accidentally took a few too many pills last night." Which reply by the nurse is most therapeutic? a) "I understand that your mother may not have intentionally taken too many pills. This medication can cause one to forget how many have been taken." b) "It may be appropriate for your mother to be referred to a pain management program." c) "I can hear how upset you are. You sound very concerned about your mother." d) "Unfortunately, it is fairly common for clients with pain to increase their use of pain pills over time."

C

A child is in the emergency department with suspected epiglottitis and has been ordered an X-ray to confirm the diagnosis. The nurse would prepare the child for X-ray by which of the following methods? a) In surgery, by portable X-ray b) In radiology, transported by stretcher, accompanied by a nurse c) In the emergency department, by portable X-ray d) In radiology, transported by wheelchair, accompanied by a nurse

C

A client at 28 weeks gestation is admitted to the maternity unit in preterm labor. The client asks the nurse if there is anything that can be done to stop the preterm labor. Which one of the following is the most appropriate response from the nurse? a) "Is there any family member that I can call for you?" b) "The obstetrician will have to evaluate the viability your fetus." c) "A cerclage may be performed depending on the competency of your cervix." d) "There is nothing that can stop the progression of the birth."

C

A client is admitted to the Emergency Department with a full thickness burn to the right arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should: a) administer morphine sulfate IV push for the severe pain. b) continue to assess the arm every hour for any additional changes. c) call the health care provider (HCP) to report the loss of the radial pulse. d) instruct the client to exercise his fingers and wrist.

C

A client is admitted to the oncology unit with an infection. It is suspected that the infection may be related to the vascular access device (VAD). The nurse should draw the blood cultures from which site? a) all lumens of the VAD b) a peripheral site only c) a peripheral site and all lumens of the VAD d) the proximal lumen of the VAD only

C

A client is hospitalized for severe preeclampsia and complete placenta previa. The husband tells the nurse that he is frustrated to have been waiting for 3 hours for the physician to discuss his wife's condition and plan of care with them. What is the nurse's most appropriate action? a) Tell the husband that the physician is very busy and will come when he/she is available. b) Reassure the husband that the mother's condition is stable at present. c) Notify the physician that the husband has been waiting to discuss his wife's condition. d) Ask the husband if there is any family support that can come to the hospital.

C

A client recovering from a drug overdose is interacting with the nurse and recounting her exploits at numerous parties she has attended. Which action is most therapeutic? a) allowing the client to continue with her stories b) questioning the client further about her exploits c) directing the conversation to realistic concerns d) telling the client you have heard the stories before

C

A client with chronic bowel inflammation reports abdominal cramping and diarrhea for the past 4 days. The nurse would anticipate which of the following tests based on the client's concerns? a) Ova and parasites b) Fat and undigested food c) Occult blood and organisms d) Culture and sensitivity

C

A nurse is teaching accident prevention to the parents of a toddler. Which instruction is appropriate for the nurse to tell the parents? a) Don't allow the toddler to use pillows when sleeping. b) The toddler should wear a helmet when roller blading. c) Place locks on cabinets containing toxic substances. d) Teach the toddler water safety.

C

A teenage client is a high school wrestler who fasts before every wrestling tournament and then binges immediately after the tournament. On the way to each tournament, the client walks rapidly up and down the bus aisle and spits repeatedly into a cup. Which of the following is the best initial intervention for this client? a) Call the high school principal to report the wrestling coach for not stopping this behavior. b) Ask the physician for medication to treat the eating disorder. c) Discuss secondary gains that are unconsciously driving the client's behavior. d) Teach the client's mother about nutritional requirements of teenagers.

C

The nurse administers intravenous morphine to a client following surgery. Fifteen minutes later the client reports severe itching. What is the nurse's best action? a) Administer naloxone b) Discontinue administration of morphine c) Administer diphenhydramine d) Contact the healthcare provider

C

The parent of a young adult client diagnosed with schizophrenia is asking questions about his son's antipsychotic medication, ziprasidone. Which statement by the parent reflects a need for further teaching? a) "The ziprasidone should help him be more motivated and less withdrawn." b) "If he becomes dizzy, I will make sure he does not drive." c) "I should give him benztropine to help prevent constipation from the ziprasidone." d) "If he experiences restlessness or muscle stiffness, he should tell the health care provider."

C

The recipient of a donated organ asks the nurse, "What did the donor die from?" Which response by the nurse is most appropriate? a) "Did you want to send the donor family a thank you card?" b) "I will have the surgeon speak with you." c) "The transplant coordinator can give you information about the donor's medical history." d) "Contact between the donor and the recipient is prohibited."

C

What is the most important nursing intervention when caring for a child with a newly applied wet hip-spica cast? a) Use the fingertips when handling the cast b) Use the abductor bar to help move the child c) Reposition the child every 1 to 2 hours d) Cover the cast in plastic to keep it clean

C

What recommendation should the nurse give a family about appropriate beverages for children? a) Offering sports drinks is the ideal way to provide hydration during physical activity. b) Give children whole milk until 5 years of age. c) Sugary drinks, including juice, should be avoided. d) It is better to give your child bottled water rather than tap water.

C

Which condition poses the greatest risk to a 32-year-old client who is 15 weeks pregnant and has a history of hypertension? a) Spontaneous abortion b) Anemia c) Abruptio placentae d) Preterm labor

C

Which instruction should the nurse expect to include in the discharge teaching plan for the parent of an infant who has had an inguinal herniorrhaphy? a) Keep the incision covered with a sterile dressing. b) Restrain the infant's hands. c) Change diapers as soon as they become soiled. d) Apply an abdominal binder.

C

day 1: intake: 1,850 ml output: 1,550 ml day 2: intake: 2,200 ml output: 1,150 An adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis of stage I chronic renal failure. See the accompanying chart. Based on these findings, the nurse should: a) increase the client's fluids. b) restrict the client's fluids. c) notify the health care provider (HCP). d) continue monitoring intake and output.

C

"client admitted with elevated temp, c/o bone pain and muscle spasms. lab called w the following result: rheumatoid factor negative; blood culture positive for staphylococcus aureus; alk phos 60 international units/liter; erythrocyte sedimentation rate 10 mm/hr." A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation below, which laboratory result is the priority for the nurse to report to the physician? a) Rheumatoid factor b) Alkaline phosphatase c) ESR d) Blood culture

D

A client is scheduled for a laparoscopic cholecystectomy and is surprised to learn that he will be discharged later the same day, provided there are no complications. When caring for a client who will be discharged shortly after a procedure, the nurse must: a) ensure that the client is safe to drive before being discharged. b) administer prophylactic antibiotics four to six hours prior to surgery. c) ensure that this is specified in the client's informed consent document. d) ensure that health education is begun as early as possible.

D

A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: a) cooks tomato-based foods in iron pots. b) adds dried fruit to cereal and baked goods. c) adds vitamin C to all meals. d) drinks coffee or tea with meals.

D

A client who has been using benzodiazepines for anxiety wants to add an alternative therapy. The nurse suggests biofeedback. What is the best description of biofeedback? a) It is not as helpful as benzodiazepines. b) It is used to assist with controlling feelings towards others. c) It can balance the positive and negative energies emitted from the anxiety. d) It is a way to concentrate on the body's response during a stressful situation.

D

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? a) "You'll first regain use of your legs and then your arms." b) "It must be hard to accept the permanency of your paralysis." c) "You'll be permanently paralyzed; however, you won't have any sensory loss." d) "The paralysis caused by this disease is temporary."

D

A nurse fails to give the evening dose of an IV antibiotic that is to be administered every 12 hours. The evening dose was scheduled for 1800; it is now 2200. The nurse should next: a) assess the client for increasing signs of infection. b) administer the 1800 dosage now. c) call the pharmacist for instructions. d) report the incident to the health care provider.

D

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? a) Polyuria b) Tetanic contractions c) Weight loss d) Jugular vein distention

D

A nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he complains of dizziness. What is the nurse's priority action? a) Notify the attending physician. b) Administer lidocaine 100 mg IV push as ordered. c) Administer a 500 ml IV bolus of normal saline solution (0.9% NaCl). d) Administer atropine 0.5 mg IV push as ordered.

D

The nurse is conducting a small-group counseling session on depression. Which of the following client statements would indicate to the nurse that a client is at high risk for suicide? a) "I have thought about killing myself before." b) "I don't think anyone would care if I wasn't here anymore." c) "I am sad and hope that I can get over it." d) "I have a stockpile of pills in the medicine cabinet and gave my stuff away."

D

The nurse is teaching an older adult how to prevent falls. The nurse should tell the client to: a) encourage the client to not use assistive devices because they reduce independence. b) turn on bright lights in the room so the client can see items in the room. c) instruct the client not to exercise painful joints. d) instruct the client to rise slowly from a supine position.

D

When planning pain control for a client with terminal gastric cancer, a nurse should consider that: a) only low doses of opioids are safe; higher doses may cause respiratory depression. b) a client who can fall asleep isn't in pain. c) pain medication should be given only when a client requests it. d) clients with terminal cancer may develop tolerance to opioids.

D

Which is an appropriate nursing goal for the client who has ulcerative colitis? The client: a) uses a heating pad to decrease abdominal cramping. b) accepts that a colostomy is inevitable at some time in his life. c) maintains a daily record of intake and output. d) verbalizes the importance of small, frequent feedings.

D

Choice Multiple question - Select all answer choices that apply. The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? Check all that apply. a) cutting food into large pieces of finger food b) restricting the diet to liquids until swallowing improves c) introducing foods on the unaffected side of the mouth d) keeping distractions to a minimum e) maintaining an upright position while eating

E, C, D

The nurse is preparing the room for a client diagnosed with Varicella. Identify which sign the nurse would place on the room door.

contact and airborne

Which instruction should the nurse give the client who has undergone chest surgery to prevent shoulder ankylosis? a) Turn from side to side. b) Flex and extend the elbow on the affected side. c) Raise and lower the head. d) Raise the arm on the affected side over the head.

D

Which medication can control the extrapyramidal effects associated with antipsychotic agents? a) Clorazepate b) Doxepin c) Perphenazine d) Amantadine

D

The nurse is observing a spouse administer eyedrops, as shown in the figure. What should the nurse instruct the spouse to do? a) Have the client raise the eyebrows. b) Administer the drops in the center of the lower lid. c) Move the dropper to the inner canthus. d) Have the client squeeze both eyes after administering the drops.

B

A nurse is caring for a client who has had extensive abdominal surgery and is in critical condition. Dextrose 5% in half-normal saline solution is infusing through a triple-lumen central catheter at 125 ml/hr. The health care provider's orders include gentamicin 80 mg IV piggyback in 50 ml D5W over 30 minutes; ranitidine 50 mg IV in 50 ml D5W over 30 minutes; one unit of 250 ml of packed red blood cells (RBCs) over three hours; and a nasogastric tube flush with 30 ml normal saline solution every two hours. How many milliliters should the nurse document as the intake for the 8-hour shift? Record your answer using a whole number.

1470ml

The nurse is teaching a small community group regarding methods to decrease the risk of burns. What is the priority method to decrease burn risks in the home? a) Elimination of the use of candles in the home b) Use of smoke detectors c) Ease of initiating an emergency response system d) Placement of fire extinguishers

B

A child is admitted to the emergency department with dyspnea related to bronchospasms. The nurse should place the client in which position? a) high Fowler's b) side-lying c) supine d) prone

A

A client is ordered diazepam to treat severe skeletal muscle spasms. During this therapy, the nurse monitors the client closely for adverse reactions. Which adverse reaction is most likely to occur? a) Sedation b) Hypotension c) Bradycardia d) Skin rash

A

A client with a diagnosis of major depression is ordered clonazepam for agitation in addition to an antidepressant. Client teaching should include which statement? a) Clonazepam may have a slight depressant effect. b) Stop taking the antidepressant. c) Clonazepam may interact with organ meats. d) Only take the clonazepam when feeling anxious.

A

A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? a) Blood pressure is 88/46 mm Hg. b) ST elevation is present on the electrocardiogram. c) Serum potassium is 3.5 mEq/L (3.5 mmol/L). d) Heart rate is 61 bpm.

A

A laboring client at -2 station has a spontaneous rupture of the membranes, and a cord immediately protrudes from the vagina. The nurse should first: a) place gentle pressure upward on the fetal head. b) place the cord back into the vagina to keep it moist. c) turn the client on her left side. d) begin oxygen by face mask at 8 to 10 L/min.

A

A nurse and newly hired nursing assistant are caring for a group of clients. The nurse is administering medications and needs to know the fingerstick glucose results before administering a medication. The nurse asks the nursing assistant if she has been validated on obtaining fingerstick glucose readings. The nursing assistant says she did not have the skill validated, but she has seen it done many times and knows she can do it. What should the nurse do? a) Go with the nursing assistant into the client's room, and validate her ability to perform the procedure. b) Give the nursing assistant the glucose meter, and let her perform the fingerstick. c) Perform the fingerstick glucose testing herself. d) Provide the nursing assistant with an article on the procedure.

A

A nurse instructs a client with allergic rhinitis about the correct technique for using an intranasal inhaler. Which statement indicates that the client understands the instructions? a) "I should hold one nostril closed while I insert the spray into the other nostril." b) "The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall." c) "It is important to not shake the canister because that can damage the spray device." d) "I should limit the use of the inhaler to early morning and bedtime use."

A

A nurse is evaluating a family in which chronic child abuse has occurred, and the parents have experienced chronic alcohol and drug abuse. Significant social supports have been established by social services and the parents have both received drug and alcohol treatment and parenting classes. Which of the following indicates that the parents have progressed in their treatment?? a) The parents report an understanding of normal growth and development. b) The parents report high expectations for the young children to manage the household tasks. c) The parents report continued use of spanking as discipline. d) The parents say they hope to attend parenting classes.

A

After receiving a change-of-shift report at 0700, the nurse should assess which client first? a) a 63-year-old with multiple sclerosis who has an oral temperature of 101.8° F (38.8° C) and flank pain b) A 23-year-old with a migraine headache who has severe nausea associated with retching c) A 59-year-old with Parkinson's disease who will need a swallowing assessment before breakfast d) A 45-year-old scheduled for a craniotomy in 30 minutes and who needs preoperative teaching

A

After teaching a child with leukemia about a scheduled bone marrow aspiration, the nurse determines that the teaching has been successful when the child identifies which place as the site for the aspiration? a) back of the hipbone b) right lateral side of the right wrist c) middle of the chest d) distal end of the thigh

A

The client is taking 50 mg of lamotrigine daily for bipolar depression. The client shows the nurse a rash on his arm. What should the nurse do? a) Question the client about recent sun exposure. b) Report the rash to the health care provider (HCP). c) Give the client an ice pack for his arm. d) Explain that the rash is a temporary adverse effect.

A

The client newly diagnosed with type 1 diabetes mellitus eats a lot of pasta products, such as macaroni and spaghetti, and asks if they can be included in the diet. The nurse should tell the client: a) "Pasta can be a part of your diet. It is included in the bread and cereal exchange." b) "Because you are overweight, it is better to eliminate pasta from your diet." c) "Eating pasta can cause hyperglycemia, so it is better to eliminate it." d) "Pasta can be included in your diet, but it should not be served with sauces."

A

The nurse is observing a new graduate nurse instill eyedrops into a client's eyes. The nurse evaluates that the new graduate is using appropriate technique when which of the following steps is incorporated into the procedure? a) The nurse's hand is stabilized on the client's forehead while instilling the drops. b) The client is instructed to look at the nurse while the drops are being instilled. c) The medication is placed onto the client's sclera. d) The client is instructed to apply pressure to the eyes after instillation of the eyedrops.

A

The nurse is to instill drops of phenylephrine hydrochloride into the client's eye prior to cataract surgery. What is the expected outcome? a) constriction of the pupil and constriction of blood vessels b) constriction of the pupil and dilation of blood vessels c) dilation of the pupil and constriction of blood vessels d) dilation of the pupil and blood vessels

A

The nurse should assess the client with chronic pancreatitis for the development of which disorder? a) diabetes mellitus b) hepatitis c) cholelithiasis d) irritable bowel syndrome

A

Upon review of a client's phenytoin levels, a nurse notes a value of 16 mcg/ml. What should the nurse do next? a) No action is needed at this time because the drug level is normal. b) Ask the laboratory to run the test again because these are critical values. c) Contact the physician because these levels are elevated and may require a change in dosage. d) Assess client compliance with the prescribed medication regimen because these values are below therapeutic levels.

A

Which assessment provides the best information about the client's physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal? a) vital signs b) evidence of tremors c) nutritional status d) sleep pattern`

A

Which intervention should be included in the care plan for a 6-month-old infant with a nursing diagnosis of mild Deficient fluid volume related to GI losses in stool and emesis? a) Oral electrolyte replacement solutions, breast milk, or lactose-free formula b) Clear fluids, such as fruit juices, carbonated soft drinks, and gelatin c) Delayed introduction of food for several days followed by the BRAT (bananas, rice, apples, and toast or tea) diet d) I.V. fluid replacement therapy

A

Choice Multiple question - Select all answer choices that apply. A client is admitted with pneumonia and shingles with draining lesions over the right anterior and posterior chest wall. Of the nurses scheduled for the shift, which nurses may be assigned to care for this client? Select all that apply. a) 24-year-old female who has never had the pneumococcal vaccine b) 43-year-old female who had a preexposure varicella vaccination c) 32-year-old female who is in the first trimester of pregnancy d) 48-year-old male who had shingles one year prior e) 36-year-old male taking steroids for an autoimmune disease

A, B, D

Choice Multiple question - Select all answer choices that apply. A nurse is planning a community education program on risk factors associated with coronary artery disease (CAD). Which of the following should be included in the teaching plan? Select all that apply. a) Low-cholesterol diet b) Use of alcohol c) Hypertension management d) Weight management e) Cigarette smoking cessation

A, C, D, E

Choice Multiple question - Select all answer choices that apply. A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The health care provider (HCP) is calling in a telephone prescription for ampicillin. The nurse should take which actions? Select all that apply. a) Repeat the prescription to the HCP. b) Ask the nursing supervisor to cosign the telephone prescription as transcribed by the nurse. c) Ask the HCP to come to the hospital and write the prescription on the medical record. d) Ask the HCP to confirm that the prescription is correct as understood by the nurse. e) Ask the unit clerk to listen on the speakerphone with the nurse and write down the prescription.

A, D

The nurse instructs the client who is taking gentamicin to monitor renal function. The nurse determines that the client needs additional instruction when he makes which statement? a) "I should call you if my urine looks dark or unusual." b) "I should call you if I have a fever." c) "I should call you if I notice that I am not urinating as much." d) "I should call you if my legs swell or I notice my skin looks puffy around my eyes."

B

A client develops atrial fibrillation following an acute myocardial infarction. The physician orders digoxin, 0.125 mg I.M. daily. The nurse clarifies the order with the physician because I.M. administration of digoxin leads to: a) a decreased serum digoxin level. b) an increased serum creatine kinase (CK) level. c) a decreased serum CK level. d) an increased serum creatinine level.

B

A client is prescribed metaproterenol via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report which adverse effect? a) pedal edema b) irregular heartbeat c) constipation d) decreased pulse rate

B

A client reports abdominal pain. Which action allows the nurse to investigate this complaint? a) Assessing the painful area first b) Assessing the painful area last c) Using deep palpation d) Checking for warmth in the painful area

B

A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. He tells the nurse that he doesn't want to be placed on a ventilator. What action should the nurse take? a) Have the client sign a do-not-resuscitate (DNR) form. b) Notify the physician immediately so he can determine client competency. c) Consult the palliative care group to direct care for the client. d) Determine whether the client's family was consulted about his decision.

B

A client with schizophrenia has been stable for some time. What action is most important for preventing relapse? a) Attending group therapy sessions b) Consistently taking prescribed medications c) Going to social skills training sessions d) Participating in family support meetings

B

A client with severe angina pectoris and electrocardiogram changes is seen in the emergency department. What laboratory studies would the nurse most likely anticipate? a) Myoglobin b) Troponin c) Lactate dehydrogenase d) Creatine kinase

B

A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching? a) "I'll increase my intake of protein during exacerbations." b) "I should increase my intake of fresh fruits and vegetables during remissions." c) "I'll snack on nuts, olives, and popcorn during flare-ups." d) "I'll incorporate foods rich in omega-3 fatty acids into my diet."

B

A nurse is evaluating for treatment effectiveness in a client being discharged from the intensive outpatient drug and alcohol clinic. Which client behavior would the nurse evaluate as a positive treatment outcome? a) The client is planning to engage in social activities. b) The client is participating in scheduled group meetings. c) The client is applying the clinic rules to others. d) The client is following a regular sleeping routine.

B

A physician has ordered a new antipsychotic medication for a client with schizophrenia whose previous medication no longer provides the expected symptom relief. When the client tells the nurse that he cannot afford the additional cost of this new medication, what is the first action the nurse should take to help the client advocate for his needs? a) Teach the client to accept the fact that he cannot get full reimbursement for the cost of the medication. b) Help the client explore other financial options for obtaining medication reimbursement with a social worker. c) Talk with the client and the physician about whether this particular drug is necessary. d) Suggest that the client contact a legal representative about the situation.

B

After the surgeon's meeting with a client to obtain the client's informed consent for a modified radical mastectomy, the client asks the nurse many questions about breast reconstruction that the nurse finds difficult to answer. The nurse should: a) Inform the client she can ask the surgeon these questions later when the surgeon makes rounds. b) Inform the surgeon that the client has questions about reconstruction before she signs the consent. c) Inform the client that she should concentrate on recovering from the mastectomy first. d) Inform the client that she can have a consultation with the plastic surgeon in a few weeks.

B

An adolescent with cystic fibrosis has been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which initial nursing actions are most important? a) inserting an IV line and initiating antibiotic therapy b) implementing a high-calorie, high-protein, low-fat, vitamin-enriched diet and pancreatic granules c) placing the client on bed rest and obtaining a prescription for a blood gas analysis d) applying an oximeter and initiating respiratory therapy

B

Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine? a) when and with whom they use alcohol b) the reasons they choose to use alcohol c) what they know about the legal implications of drinking d) the type of alcohol they usually drink

B

The nurse observes a new parent give an oral medication to their 4-month-old infant. The parent instills the medication directly in the back of the infant's throat. Which of the following is the nurse's best action? a) Praise the parent's technique of giving the medication b) Instruct the parent to instill a small amount of the medication inside the baby's cheek c) Demonstrate to the parent ways to prop the infant in a sitting position for medication administration d) Have the parent lay the infant flat, restraining the arms, while giving the medication

B

Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients? a) Triage observation is appropriate for both clients at this time. b) The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent. c) It doesn't matter which client receives priority; they're at the same stage of labor. d) The nurse should assign priority to the first client. Her leaking amniotic fluid indicates that she'll soon go into labor.

B

When assessing an infant with suspected inguinal hernia, which finding would be most significant? a) The infant's diaper is wet with urine, and the abdomen is nontender. b) The inguinal swelling is reddened, and the abdomen is distended. c) The infant is irritable, and a thickened spermatic cord is palpable. d) The inguinal swelling can be reduced, and the infant has a stool in the diaper.

B

Which of the following statements indicates that a client understands the need for routine screening to detect colorectal cancer? a) "I need to have a barium enema after age 20." b) "I need to have an annual digital examination after age 40." c) "I need to have a carcinoembryonic antigen (CEA) test after age 50." d) "I need to have a proctosigmoidoscopy after age 30."

B

Choice Multiple question - Select all answer choices that apply. A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crises should the nurse provide to the client and his family? Select all that apply. a) Restrict activity to quiet board games b) Wash hands before meals and after playing c) Drink plenty of fluids d) Avoid foods high in folic acid e) Report a sore throat to an adult f) Use cold packs to relieve joint pain

B, C, E

Choice Multiple question - Select all answer choices that apply. The nurse is assessing a 60-year-old who has hoarseness and a chronic sore throat. What should the nurse determine while conducting a focused assessment? Select all that apply. a) use of acetaminophen b) history of tobacco use c) exposure to sun d) amount of alcohol consumption e) consumption of a high-fat diet

B, D

Choice Multiple question - Select all answer choices that apply. Which of the following actions should the nurse take prior to administering an oral medication to an infant? Select all that apply. a) Having the mother hold the infant b) Ensuring that it is the correct medication c) Checking the infant's pulse d) Verifying the infant's name e) Verifying that it is the correct dose

B, D, E,

Choice Multiple question - Select all answer choices that apply. The nurse is admitting a client diagnosed with primary hyperthyroidism. Which laboratory results should the nurse expect? Select all that apply. a) Decreased T4 levels b) Elevated thyroid stimulating hormone c) Decreased T3 levels d) Decreased thyroid stimulating hormone e) Elevated T3 levels f) Elevated T4 levels

B, E, F

A client believes she is experiencing premenstrual syndrome (PMS). The nurse should next ask the client about what symptom? a) menstrual cycle irregularity with increased menstrual flow b) midcycle spotting and abdominal pain at the time of ovulation c) tension and fatigue before menses and through the second day of the menstrual cycle d) mood swings immediately after menses

C

A client in the postanesthesia care unit with a left below-the-knee amputation has pain in the left big toe. What should the nurse do first? a) Explain to the client that the pain is real. b) Show the client that the toes are not there. c) Give the client the prescribed opioid analgesic. d) Tell the client it is impossible to feel the pain.

C

A client with acute kidney failure is placed on fluid restriction of 1000 mL of fluid over a 24-hour period. What is the priority nursing action? a) Eliminate the liquids between meal times. b) Divide the fluids equally among the three 8-hour nursing shifts. c) Offer the client proportioned fluids in the day and less during the night. d) Notify the dietary department of a clear fluids order.

C

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate? a) Abduction and flexion of the arms with flattened shoulders b) Neck extension and back arching with flattened shoulders c) Adduction and flexion of the extremities with gently rounded shoulders d) Hyperabduction and extension of the arms with external rotation of the hips

C

A nurse is caring for a client who is well known in society. A person inquires about the medical details of the client, saying that he is a family member. The nurse reveals the requested information. Later, the nurse comes to know that the inquirer was not a family member. Which of the following ethical rules of professional-client relationships has the nurse violated? a) Veracity. b) Privacy. c) Confidentiality. d) Fidelity.

C

What assessment data of a laboring woman would require further intervention by the nurse? a) Fetal heart rate (FHR) 150 beats/minute b) Temperature of 99.1° F (37.27° C) c) Moderate contractions 3 minutes apart d) Maternal heart rate 125 beats/minute

D

A nurse pages a client's primary care physician in response to a low blood pressure reading. When returning the nurse's page, the physician asks the nurse to temporarily hold the client's scheduled antihypertensive and diuretic medications. How should the nurse ensure correct documentation of this telephone order? a) Obtain confirmation of the order from a physician or nurse practitioner present on the unit. b) Record the order verbatim in the client's charts and follow it with the nurse's printed name and signature alone. c) Write "T.O." after the order and write out the physician's and nurse's names. d) Write out the order, the physician's name, the nurse's name, and the name of a witness.

C

A nurse-manager appropriately behaves as an autocrat in which situation? a) Planning vacation time for staff b) Evaluating a new medication-administration process c) Directing staff activities if a client experiences a cardiac arrest d) Identifying the strengths and weaknesses of a client-education video

C

A pregnant client late in her first trimester comes to the clinic for a follow-up visit. The woman tells the nurse that she has been having morning sickness, but she "tried using this band on her wrist," and it helped cut down on the number of episodes she was having. The nurse interprets this therapy as an example of: a) aromatherapy. b) biofeedback. c) acupressure. d) meditation.

C

A school nurse is examining a student at an elementary school. Which findings would lead the nurse to suspect impetigo? a) A discrete pink-red maculopapular rash that starts on the head and progresses down the body b) Red spots with a blue base found on the buccal membranes c) Vesicular lesions that ooze, forming crusts on the face and extremities d) Small, red lesions on the trunk and in the skin folds

C

After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which postoperative complication? a) extracapsular erosion b) detached retina c) intraocular hemorrhage d) prolapse of the iris

C

An assessment of a client on the first day after a thoracotomy shows a temperature of 100° F (37.8° C); heart rate, 96 bpm; blood pressure, 136/86 mmHg; and shallow respirations at 30 breaths/min, with rhonchi at the bases. The client is diaphoretic, anxious, and reports of incisional pain. Which nursing action is priority? a) Give ibuprofen as ordered to reduce the fever b) Help the client get out of bed c) Medicate the client for pain as ordered d) Encourage the client to cough and deep breathe

C

An expected outcome of theophylline ethylenediamine when administered to a client with chronic obstructive pulmonary disease is: a) strengthen myocardial contractions. b) reduce bronchial secretions. c) relax bronchial smooth muscle. d) decrease alveolar elasticity.

C

The nurse is assigned a client with an nasogastric (NG) tube attached to low intermittent suction. What intervention will the nurse include in the plan of care? a) Irrigate the NG tube every shift with normal saline b) Instruct the client to position NG tube as needed for comfort c) Turn off the NG tube suction while auscultating bowel sounds d) Assess lung sounds every 24 hours

C

The nurse is managing a pregnant client's second stage of labor. The nurse should intervene when observing which action? a) open glottis pushing b) squatting while pushing c) closed glottis pushing d) "rest and descent"

C

The nurse is preparing a teaching plan for a 14-year-old child who is newly diagnosed with asthma. Which of the following content should be taught first? a) Pathophysiology of asthma b) Consequences of long-term steroid use c) When to seek immediate medical attention d) Use of a peak flow meter

C

Which assessment would be most important for the nurse to make initially in a school-age child being seen in the clinic who has a sore throat, muscle tenderness, arms feeling weak, and generally is not feeling well? a) diet intake for the last 24 hours b) difficulty urinating c) difficulty swallowing d) exposure to illnesses

C

Which information is important for a nurse to include in a teaching plan for a client with schizophrenia who is taking clozapine? a) Stop the medication when symptoms subside. b) Monthly blood tests will be necessary. c) Report a sore throat or fever to the physician immediately. d) Blood pressure must be monitored for hypertension.

C

Which nursing measure will likely decrease the risk of a surgical wound infection in a client with an internal fixation and hip pinning? a) monitoring the incision for signs of redness, swelling, and warmth b) inserting an indwelling urinary catheter to prevent possible soiling of the dressing c) changing the surgical dressings using sterile technique d) accurately measuring drainage from the surgical drainage tube

C

Which of the following ethical principles supports expectant mothers when conflicts between maternal and fetal rights arise during childbirth? a) Jurisprudence b) Justice c) Autonomy d) Nonmaleficence

C

When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? a) cancer of any kind b) impaired hearing c) heart failure d) prescription drug intoxication

D

Choice Multiple question - Select all answer choices that apply. The nurse is caring for a client with a nasogastric tube who is due for an enteral feeding. Which of the following assessments by the nurse would indicate the need to withhold at this time? Select all that apply. a) Material like coffee grounds noted in the nasogastric tube b) Auscultation of air in the epigastric area when checking placement c) Distention of the upper abdomen with vomiting d) Aspiration of milky contents and reports of nausea e) Watery contents upon aspiration with a pH of 5

C, A, D

Choice Multiple question - Select all answer choices that apply. A nurse receives an order to start an infusion of blood for a client who is hemorrhaging due to a placenta previa. Which equipment will the nurse need to initiate the infusion? Select all that apply. a) 5% dextrose in water solution b) 18-gauge catheter c) Y tubing d) Normal saline solution e) Lactated Ringer's solution

C, D, B

Choice Multiple question - Select all answer choices that apply. A nurse is caring for a client who underwent surgical repair of a detached retina in the right eye. Which nursing interventions would the nurse perform postoperatively? Select all that apply. a) Place the client in a prone position. b) Administer a stool softener. c) Discourage the client from bending down. d) Orient the client to his environment. e) Approach the client from the left side. f) Encourage deep breathing and coughing.

C, E, D, B

When evaluating the effectiveness of airway suctioning, the nurse should use which criterion? a) respirations unlabored b) hollow sound on chest percussion c) decreased mucus production d) breath sounds clear on auscultation

D

Which health education topic is the priority when teaching parents ways to prevent urinary tract infections (UTIs) in their children? a) Encourage parents of male infants to avoid circumcision b) Teach parents to limit the frequency of tub baths c) Educate parents about hand washing, and the use of alcohol-based hand sanitizers d) Teach parents to promote adequate fluid intake

D

A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if he/she is allowed to perform this skill. What is the nurse's most appropriate response? a) "No, only certified registered nurses can perform this skill." b) "Yes, but only after you read about the procedure in the regional policy and procedure manual." c) "No, as per policy, you need to demonstrate this skill successfully in the hospital setting first." d) "Yes, but I will demonstrate it once and then supervise you while you perform the procedure."

D

A client and her partner come to the clinic stating they have been unable to have sexual intercourse. The female client states she has pain and her "vagina is too tight." The client was raped at age 15 years of age. Which nursing problem is most appropriate for this client? a) Dysfunctional Grieving related to loss of self- esteem because of lack of sexual intimacy b) Risk for Trauma related to fear of vaginal penetration c) Vaginismus related to vaginal constriction d) Sexual Dysfunction related to sexual trauma

D

A client is asking to go to the bathroom 45 minutes after childbirth. She had an epidural for labor and birth, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should: a) ask the client to ambulate the first time with a staff member at her side. b) encourage the client to sit at the side of the bed before ambulating to the bathroom. c) ask her to remain in bed until the 15-minute assessments are complete. d) assess the client's ability to stand and bear weight before going to the bathroom.

D

A client living in a long-term care facility has become increasingly unsteady when out of bed. The nurse is worried that the client is going to climb out of bed and fall. The facility has a least restraint policy for the clients. Which of the following actions should the nurse take to best ensure the safety of the client while complying with policy? a) Raise all side rails while the client is in bed. b) Have a family member stay with the client. c) Instruct the client on use of the call bell. d) Provide a bed that is low to the floor.

D

A client with a history of osteoarthritis is admitted to the rehabilitation unit after hospitalization for a hip fracture. Which plan by the multidisciplinary team best optimizes client outcomes? a) Alternating periods of activity with periods of rest to optimize client participation b) Coordinating activities in the morning so that the client can rest in the afternoon and evening c) Coordinating all activities in the afternoon so that the client is tired at bedtime. d) Including the client in developing a care plan that works toward meeting discharge goals

D

A partner of a man diagnosed with Karposi's Sarcoma has refused antiretroviral therapy. The partner confides in the nurse that, "He has just given up. I know if he just takes the medication he will get better and we can go back to the life we once had." The nurse identifies that the partner is experiencing which stage of grieving? a) Depression stage b) Bargaining stage c) Anger stage d) Denial stage

D

Nurses on a pediatric unit have developed a program to decrease the infection rate on the unit. What is an expected outcome of this quality improvement program? a) evaluation of staff members' performances b) preparation for accreditation of the organization c) improvement in efficiency of care d) evaluation of the system and client outcomes

D

The nurse is assigned a client with a nasogastric (NG) tube. What intervention will the nurse include in the client's plan of care? a) Administration of medications with enteral feed b) Irrigation of NG tube every 24 hours c) Lavage of the air vent d) Assessment of lung sounds every 4 hours

D

The nurse is aware that the best position for a client with impaired gas exchange is what? a) Sims b) Side-lying c) Semi-Fowler's d) High Fowler's

D

The nurse is caring for a client who has severe burns on the head, neck, trunk, and groin areas. Which position would be most appropriate for preventing contractures? a) semi-Fowler's b) prone c) high Fowler's d) supine

D

The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client: a) "Follow good health habits to change the course of the disease." b) "You will need to accept the necessity for a quiet and inactive lifestyle." c) "Practice using the mechanical aids that you will need when future disabilities arise." d) "Keep active, use stress reduction strategies, and avoid fatigue."

D

Choice Multiple question - Select all answer choices that apply. The client phones the outpatient surgery center following skin biopsy on the left shoulder. The client states that the site continues to drain pinkish drainage and is uncomfortable. Which triage questions are appropriate to evaluate the client's concern? Select all that apply. a) "When is your follow-up appointment?" b) "Did you have any other skin biopsies that day?" c) "What is your pain level on a 0-10 pain scale?" d) "How are you cleaning the area?" e) "On which day did you have the biopsy completed?" f) "Can you describe the drainage that you see."

E, C, D, F