Com Pre RN

A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A. Rinse the catheter to remove secretions. B. Don sterile gloves. C. Apply suction while rotating the catheter. D. Insert the catheter during the client's inspiration. E. Turn on the suction and set the pressure.

1. B. Don sterile gloves. 2. E. Turn on the suction and set the pressure. 3. D. Insert the catheter during the client's inspiration. 4. C. Apply suction while rotating the catheter. 5. A. Rinse the catheter to remove secretions.

A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? A. "I can give you information about respite care if you are interested." B. "I am sure you're doing a great job taking care of your mother." C. "You should consider taking a sleeping pill before bed each night." D. "It is always difficult caring for someone who is terminally ill."

A. "I can give you information about respite care if you are interested." Offering information about respite care provides the son with an option to take a break and get some rest while ensuring his mother's care is still managed by professionals.

A nurse is teaching a prenatal class about infection prevention at a community center.Which of the following statements by a client indicates an understanding of the teaching? A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted." B. "I should take antibiotics when I have a virus." C. "I should wash my hands for 10 seconds with hot water after working in the garden." D. "I can clean my cat's litter box during my pregnancy."

A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted." Chickenpox is contagious until the sores have crusted over, which generally takes about 5-7 days. Visiting after this period reduces the risk of infection.

A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include? A. "Participate in range-of-motion exercises." B. "Place a pillow under your knees while in bed." C. "Remain on bed rest for 24 hours following the procedure." D. "Use an incentive spirometer every 4 hours."

A. "Participate in range-of-motion exercises." Participating in range-of-motion exercises helps prevent circulation problems and joint stiffness that can result from prolonged immobility after surgery.

Client reports to clinic for monthly prenatal visit. Client is at 20 weeks of gestation. Since last visit, client reports concern about the occurrence of intermittent mild backaches, increased heartburn, generalized itching, and vaginal discharge. Which one of the following statements should the nurse include in the clients teaching? Select all that apply A. "Try using an abdominal support belt." B. "Take hot showers to help relieve itching" C. "Wear loose-fitting clothing" D. "Wear flat or low-heeled shoes" E. You can douche twice weekly F. Eat two large meals a day. G. " You should avoid fried foods."

A. "Try using an abdominal support belt." C. "Wear loose-fitting clothing" D. "Wear flat or low-heeled shoes" G. " You should avoid fried foods."

A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching? A. "You can receive the immunization for influenza at any time during your pregnancy." B. "The hepatitis B immunization should not be obtained until after you finish breastfeeding." C. "You can receive the rubella immunization during the third trimester of pregnancy." D. "The immunization for varicella should be given at least 1 month prior to delivery."

A. "You can receive the immunization for influenza at any time during your pregnancy." Influenza immunization is recommended for pregnant individuals, and it can be given at any time during pregnancy, especially during flu season.

A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate? A. "You don't have to go through with the treatment." B. "Your doctor wouldn't have ordered this treatment unless it was necessary." C. "Most people who have this procedure feel better following the treatment." D. "It's okay to be nervous before this treatment."

A. "You don't have to go through with the treatment." Informed consent means the client has the right to refuse treatment even after giving initial consent. The nurse should respect the client's autonomy and decision.

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first? A. A client who has a fracture and is in balance suspension traction. B. A client who is bedridden and wears a hearing aid. C. A client who uses a wheelchair and is confused. D. A client who is ambulatory and receiving oxygen.

A. A client who has a fracture and is in balance suspension traction. A client who is in balance suspension traction requires specialized equipment and careful handling. Evacuating this client safely would require additional assistance and coordination due to the equipment involved.

A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? A. A client who is scheduled for a procedure in 1 hr B. A client who received a pain medication 30 min ago for postoperative pain C. A client who has 100 mL of fluid remaining in his IV bag D. A client who was just given a glass of orange juice for a low blood glucose level

A. A client who is scheduled for a procedure in 1 hr A client who is scheduled for a procedure in 1 hour. The nurse should assess the client who is scheduled for a procedure in 1 hour first. Assessing this client is time-sensitive to ensure they are prepared for the upcoming procedure, meet any pre-procedure requirements, and have any concerns addressed. While the other clients also require attention, their needs are not as immediately time-sensitive in this context:

A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration? A. A residual of 65 mL 1 hr postprandial B. Sitting in high-Fowler's position during the feeding C. A history of gastroesophageal reflux disease D. Receiving a high-osmolarity formula

A. A residual of 65 mL 1 hr postprandial A large residual volume (greater than 50-100 mL) after feeding can indicate delayed gastric emptying and increases the risk of aspiration.

A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin? A. Acetaminophen B. Ibuprofen C. Naproxen sodium D. Aspirin

A. Acetaminophen Acetaminophen can be taken concurrently with enoxaparin without significant interactions or increased bleeding risk.

A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? A. Administer a cathartic suppository 30 min prior to scheduled defecation times. B. Encourage a maximum fluid intake of 1,500 mL per day. C. Increase the amount of refined grains in the client's diet. D. Provide the client with a cold drink prior to defecation.

A. Administer a cathartic suppository 30 min prior to scheduled defecation times. Administering a cathartic suppository can help stimulate bowel movement and facilitate a bowel-training program, particularly for individuals with altered bowel function due to spinal cord injury.

A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating? A. Banana slices B. Hot dog C. Grapes D. Popcorn

A. Banana slices Banana slices are a soft and easily manageable food that encourages a toddler's independence in eating. They can be easily held by the toddler and self-fed.

A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating? A. Beneficence B. Autonomy C. Fidelity D. Veracity

A. Beneficence Beneficence refers to the ethical principle of doing good and taking actions that promote the well-being and best interests of the client. Sitting with the client to provide comfort aligns with this principle.

A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer? A. Bisacodyl 10 mg rectal suppository B. Loperamide 4 mg PO C. Magnesium hydroxide 30 mL PO D. Famotidine 20 mg PO

A. Bisacodyl 10 mg rectal suppository Bisacodyl is a stimulant laxative that can help stimulate bowel movement. It can be administered rectally to help relieve constipation.

A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include in the teaching? A. Blow into the meter as hard and quickly as possible. B. Maintain a semi-Fowler's position during testing. C. Record the average of the readings. D. Place tongue on the mouthpiece of the meter.

A. Blow into the meter as hard and quickly as possible. The child should be instructed to blow into the peak expiratory flow meter as hard and quickly as possible to achieve maximal effort. This provides an accurate measure of peak expiratory flow, which is important in assessing asthma control.

A nurse is reviewing the laboratory results of a client who is receiving total parenteral nutrition.Which of the following results should the nurse identify as an indication that the client has developed a common complication of this nutritional therapy? A. Capillary glucose 198 mg/dL. B. Serum albumin 3.9 g/dL. C. Hgb 15.6 g/dL. D. WBC 7,000/mm.

A. Capillary glucose 198 mg/dL.

A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include? A. Continuously monitor the child's respiratory status. B. Administer pancreatic enzymes with meals. C. Assess the child for frequent swallowing. D. Carefully suction the child's oropharynx to remove secretions.

A. Continuously monitor the child's respiratory status. Epiglottitis can cause airway obstruction, so continuous respiratory monitoring is crucial to detect any signs of respiratory distress.

A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure.Which of the following actions should the nurse take? A. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. B. Ensure that the client's family supports the provider's decision for surgery. C. Determine if the procedure is medically necessary for the client. D. Send the unsigned informed consent form to the facility's risk manager.

A. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. In cases where the client is unable to provide informed consent due to incapacitation, the health care surrogate or legally authorized representative should be involved in the decision-making process.

A nurse is caring for a client who is experiencing seizures due to alcohol withdrawal.Which of the following medications should the nurse plan to administer? A. Diazepam. B. Naltrexone. C. Acamprosate. D. Disulfiram.

A. Diazepam. Diazepam is a benzodiazepine medication commonly used to manage seizures, including those associated with alcohol withdrawal. It acts as a central nervous system depressant, reducing excessive neuronal activity and helping control seizures. Diazepam is considered the first-line medication for managing alcohol withdrawal seizures due to its efficacy and safety profile when administered under medical supervision.

A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching? A. Drink 1.5 L of fluids each day. B. Take mineral oil at bedtime. C. Decrease insoluble fiber intake. D. Increase exercise activity.

A. Drink 1.5 L of fluids each day. Opioid medications can cause constipation, and increasing fluid intake helps prevent dehydration and promotes bowel regularity.

A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take? A. Educate the family to avoid sharing personal belongings. B. Ensure the state health department has been notified. C. Administer antitoxin. D. Assess for skin necrosis.

A. Educate the family to avoid sharing personal belongings. Lyme disease is primarily transmitted through ticks. Educating the family to avoid sharing personal belongings can help prevent the spread of ticks.

A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take? A. Ensure that multiple nurses are present for the physical examination. B. Reassure the child that no one will be told about the abuse. C. Explain to the child what will happen when the abuse is reported. D. Use leading statements to obtain information from the child.

A. Ensure that multiple nurses are present for the physical examination. Having multiple nurses present during the physical examination ensures a safe and professional environment during the examination of a potential abuse victim.

A nurse inadvertently administered 160 mg of valsartan PO to a client who was scheduled to receive 80 mg. Which of the following actions is the priority for the nurse to take? A. Evaluate the client for orthostatic hypotension. B. Check the client for nasal congestion. C. Obtain the client's laboratory results. D. Monitor the client's urine output.

A. Evaluate the client for orthostatic hypotension. The priority is to assess the client for any adverse effects of the medication, such as a drop in blood pressure, which can result in orthostatic hypotension.

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take? A. Evaluate the client's ability to help with repositioning. B. Reposition the client without the use of assistive devices. C. Discuss the client's preferences for determining a repositioning schedule. D. Raise the side rails on both sides of the client's bed during repositioning.

A. Evaluate the client's ability to help with repositioning. Evaluating the client's ability to assist with repositioning is important to ensure safe and appropriate positioning that considers the client's capabilities and comfort.

A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client? A. Having interdisciplinary team meetings for the client on a regular basis B. Noting changes in the treatment plan in the client's medical record C. Recording the client's progress in the nurses' notes D. Posting swallowing precautions at the head of the client's bed

A. Having interdisciplinary team meetings for the client on a regular basis Having regular interdisciplinary team meetings allows healthcare professionals from various disciplines to collaborate, share information, and ensure coordinated care for the client with complex needs.

A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take? A. Hold the client's eyes shut for a few seconds. B. Cross the client's arms across their chest. C. Remove the client's dentures from their mouth. D. Place the client in a high-Fowler's position.

A. Hold the client's eyes shut for a few seconds. Holding the client's eyes shut for a few seconds after death helps keep the eyelids closed and gives a more peaceful appearance.

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin? A. INR B. Fibrinogen level C. aPTT D. Platelet count

A. INR The International Normalized Ratio (INR) is used to monitor the effectiveness of warfarin therapy, which is commonly prescribed to prevent blood clotting. The INR provides information about the client's prothrombin time (PT) in relation to a standardized value.

A nurse in a long-term care facility is providing care for a client who has been receiving donepezil. Which of the following findings indicates that the medication is effective? A. Improved short-term memory B. Increased food Intake C. Can perform ADLs independently D. Enhanced mood

A. Improved short-term memory Donepezil is a medication used to treat Alzheimer's disease and is expected to improve cognitive function, including short-term memory.

A nurse is caring for a client who is receiving penicillin G via intermittent IV piggyback. Which of the following actions should the nurse take? A. Infuse the medication over 10 min. B. Check the client for a sulfa allergy. C. Refrigerate the medication after reconstitution. D. Instruct the client to notify the provider if diarrhea develops.

A. Infuse the medication over 10 min. Penicillin G should be infused over a recommended time to prevent adverse effects and ensure proper administration.

A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect? A. Malaise B. Tinnitus C. Rhinorrhea D. Drooling

A. Malaise Malaise, which is a general feeling of discomfort or unease, is a common manifestation of bacterial pneumonia in children.

A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practical nurse? A. Perform a sterile dressing change for a client who has an abdominal wound. B. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus. C. Perform an admission assessment for a client who is scheduled for surgery. D. Complete the Glasgow Coma Scale for a client who has an evolving stroke.

A. Perform a sterile dressing change for a client who has an abdominal wound. Performing a sterile dressing change falls within the scope of practice for a licensed practical nurse (LPN).

A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? A. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate. B. Measure the fundal height to determine the placement of the ultrasound stethoscope. C. Place the client in a side-lying position prior to assessing the fetal heart rate. D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.

A. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate. At 12 weeks of gestation, the nurse should position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first? A. Provide oral hygiene care. B. Administer an antiemetic medication. C. Replace the NG tube. D. Evaluate the functioning of the suction device.

A. Provide oral hygiene care. Providing oral hygiene care is the first priority after a client has vomited to prevent complications and ensure their comfort.

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Reinforce orientation to time, place, and person. B. Allow the client to choose among a variety of activities each day. C. Give the client one simple direction at a time. D. Establish eye contact when communicating with the client. E. Refute the client's delusions using logic.

A. Reinforce orientation to time, place, and person. B. Allow the client to choose among a variety of activities each day. C. Give the client one simple direction at a time. D. Establish eye contact when communicating with the client. A. Correct. Reinforcing orientation to time, place, and person helps ground the client in reality, even if their memory is impaired. B. Correct. Allowing the client to choose activities empowers them and helps maintain a sense of control. C. Correct. Providing one simple direction at a time helps prevent confusion and frustration for clients with dementia. D. Correct. Establishing eye contact while communicating can enhance the client's focus and understanding.

A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home.Which of the following instructions should the nurse include? A. Report sudden, persistent headaches. B. Apply cold compresses to painful areas. C. Restrict fluid intake during times of stress. D. Avoid meningococcal immunizations.

A. Report sudden, persistent headaches.

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis? A. Sacrum B. Palms of the hands C. Shoulders D. Area of trauma

A. Sacrum The sacrum is a good location to assess for cyanosis in individuals with dark skin. Cyanosis, a bluish discoloration of the skin, may be more visible in areas where the skin is thinner, such as the sacral area.

A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client's food tray? A. Scrambled eggs and toast with milk B. Bacon and cheese quiche with milk C. Ham sandwich with milk D. Shrimp salad and tomato soup with milk

A. Scrambled eggs and toast with milk Scrambled eggs and toast are generally kosher-friendly options. However, milk may not be suitable if the client keeps kosher dietary laws, as it cannot be mixed with meat in the same meal.

A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take? A. The nurse should use a filter needle to withdraw the medication. B. The nurse should use the same needle to draw up and inject the client. C. The nurse should break the neck of the ampule toward their body. D. The nurse should dispose of the ampule in the trash can.

A. The nurse should use a filter needle to withdraw the medication. A filter needle should be used to withdraw medication from an ampule to prevent drawing up any glass fragments into the syringe.

A nurse is planning assignments for the upcoming shift.Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.) A. Transfer a client to physical therapy. B. Obtain a client's vital signs every 4 hr .C. Instruct a client on the use of an incentive spirometer. D. Insert an NG tube for a client who requires enteral feedings. E. Record a client's intake after each meal.

A. Transfer a client to physical therapy. B. Obtain a client's vital signs every 4 hr E. Record a client's intake after each meal.

The nurse continues to care for the client. Which of the following actions should the nurse take? Select all that apply. A. Urine culture B. Ibuprofen 600 mg every 6 hr for mild to moderate pain C. Obtain provider prescription for phenazopyridine D. Vaginal culture E. Obtain provider prescription for antibiotics

A. Urine culture C. Obtain provider prescription for phenazopyridine E. Obtain provider prescription for antibiotics

A nurse is caring for a client in the medical-surgical unit. Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client?Select all that apply. A. Use soap and water to provide perineal care. B. Change the indwelling urinary catheter tubing every 3 days C. Encourage the client to drink 3000 ml of fluid daily. D. Review the need for the indwelling urinary catheter daily F. Place the drainage beg on the bed when transporting the client

A. Use soap and water to provide perineal care. D. Review the need for the indwelling urinary catheter daily

A nurse is caring for a client who presents to the emergency department. A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation?(Select All that Apply.) A. Weight B. Report of cough C. Blood pressure D. Travel history E. Sputum characteristics F. Temperature G. Heart Rate

A. Weight D. Travel history E. Sputum characteristics F. Temperature G. Heart Rate

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective? A. Weight loss B. Increased blood pressure C. Decreased pain D. Decreased inflammation

A. Weight loss Furosemide is a diuretic that promotes the excretion of excess fluid and electrolytes. Weight loss is a direct outcome of diuresis and indicates the effectiveness of furosemide in reducing fluid volume excess.

Select the 4 findings that require follow-up. A. Witnessing their family's death B. Caregiver reporting client acting differently than usual C. Attends school regularly D. Startles easy during thunderstorm E. Heart rate 99/min F. BP 122/80 mmHg G. Smoking marijuana to clear their mind H. Client experiences nightmares

A. Witnessing their family's death B. Caregiver reporting client acting differently than usual D. Startles easy during thunderstorm G. Smoking marijuana to clear their mind H. Client experiences nightmares

A nurse is teaching a client about using transdermal scopolamine to treat motion sickness.Which of the following instructions should the nurse include? A. "Store unused patches in the refrigerator." B. "Apply the patch prior to traveling." C. "Place the patch on your upper arm." D. "Replace a dislodged patch onto the same location."

B. "Apply the patch prior to traveling." Applying the patch prior to traveling is the correct choice. Transdermal scopolamine patches are used to prevent motion sickness. Applying the patch before the journey allows the medication to be absorbed before exposure to motion, ensuring its effectiveness during travel.

A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state? A. "What are the voices telling you?" B. "Have you taken your medication today?" C. "I realize the voices are real to you, but I don't hear anything." D. "How long have you been hearing the voices?"

B. "Have you taken your medication today?" the priority response is to assess if the client has taken their antipsychotic medication, as noncompliance with medication can contribute to auditory hallucinations and other symptoms.

A nurse is providing discharge teaching to a client who has a new ostomy.Which of the following instructions should the nurse include? A. "Apply sterile gloves when changing your ostomy pouch." B. "Notify the provider if your stoma becomes pink and moist." C. "Empty your ostomy pouch when it is half full." D. "Use a moisturizing soap to cleanse your stoma."

B. "Notify the provider if your stoma becomes pink and moist." Notifying the provider if the stoma becomes pink and moist is crucial information for the client. A pink and moist stoma indicates good blood supply and healing, while changes in color or moisture might indicate complications. This instruction is essential for the client's ongoing care and to prevent potential complications, making choice B the correct

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? A. "The child usually has an aura prior to onset." B. "This type of seizure can be mistaken for daydreaming." C. "This type of seizure lasts 30 to 60 seconds." D. "This type of seizure has a gradual onset."

B. "This type of seizure can be mistaken for daydreaming." Absence seizures often involve a brief period of staring and decreased responsiveness. They can indeed be mistaken for daydreaming, as they are not as dramatic as other types of seizures.

:A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress.Which of the following instructions should the nurse give the client about using progressive relaxation? A. "Think about a positive outcome to a stressful situation." B. "Tighten a muscle group, then release the tension and move to the next one." C. "Picture taking the stress you feel and pushing it down and out of your feet." D. "Focus on a pleasant memory and express your emotions in writing."

B. "Tighten a muscle group, then release the tension and move to the next one." Teaching the client to tighten a muscle group, release the tension, and then move to the next one is a technique used in progressive muscle relaxation (PMR) PMR is a stress management technique that involves tensing and relaxing different muscle groups to reduce muscle tension and promote relaxation. This method helps individuals become more aware of the sensations associated with muscle tension and relaxation, making it an effective strategy for managing anxiety and stress.

A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? A. "I'm sure you can find alternative remedies through an online support group." B. "We can review some information to help you select a safe alternative practitioner." C. "Feel free to try whatever therapies that fit within your personal belief system." D. "If there are therapies available to you, your provider will tell you about them."

B. "We can review some information to help you select a safe alternative practitioner." This response acknowledges the client's interest and offers to provide guidance in selecting a safe alternative practitioner. It's important to ensure that any alternative therapies are safe and evidence-based.

A nurse is caring for a client who has been admitted to the antepartum unit. For each potential provider's prescription, specify if the potential prescription is anticipated or unanticipated for the client. A. Administer oxytocin. B. Administer terbutaline. C. Administer betamethasone. D. Limit fluid intake to 3.000 mL/day. E. Maintain bed rest with bathroom privileges. F. Place the client in the supine position.

B. Administer terbutaline. C. Administer betamethasone. E. Maintain bed rest with bathroom privileges.

A client with Crohn's disease is preparing for discharge from the hospital following treatment for an exacerbation of diarrhea, abdominal pain, and rectal bleeding. Which dietary recommendation(s) should the nurse discuss with the client? (Select all that apply.) A. Drink dairy and effervescent sodas for hydration. B. Avoid eating fried, fatty foods and large meals. C. Enjoy fast food restaurants only if dining with friends. D. Limit high fiber foods, such as beans, popcorn, seeds. E. Take a vitamin supplement daily with a meal.

B. Avoid eating fried, fatty foods and large meals. D. Limit high fiber foods, such as beans, popcorn, seeds. E. Take a vitamin supplement daily with a meal.

A nurse is caring for a client in a clinic. Based on the information in the client's medical record, which of the following findings requires immediate follow-up? Select the 4 findings that require follow-up. A. Attends school regularly B. Caregiver reporting client acting differently than usual C. Witnessing their family's death D. Heart rate 99/min E. Smoking marijuana to clear their mind F. Client experiences nightmare G. Client experiences nightmares H. Startles easy during thunderstorm

B. Caregiver reporting client acting differently than usual C. Witnessing their family's death E. Smoking marijuana to clear their mind F. Client experiences nightmare

A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take? A. Limit oral feedings to 30 min in length. B. Check the infant's oxygen saturation every 6 hr. C. Weigh the infant every other day. D. Place the infant in the prone position for naps.

B. Check the infant's oxygen saturation every 6 hr. Monitoring oxygen saturation is crucial in infants with heart failure to assess respiratory status and response to interventions.

A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase? A. Family history of malignant hypertension B. Chronic obstructive pulmonary disease C. Hip arthroplasty 1 week ago D. Acute renal failure 6 months ago

B. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a contraindication for alteplase due to increased bleeding risk from fragile lung vessels.

A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use? A. Arrange for the nurses to have as few shifts together as possible. B. Encourage collaboration between the two nurses when making assignments. C. Tell the nurses that the assignments will be more equitable in the future. D. Ask each nurse to take turns making the assignments.

B. Encourage collaboration between the two nurses when making assignments. Encouraging collaboration empowers the nurses to work together and find common ground in making assignments.

A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? A. Metallic taste in the mouth B. Excessive sweating C. Increased urinary frequency D. Dry cough

B. Excessive sweating Excessive sweating (diaphoresis) is a potential adverse effect of sertraline and other selective serotonin reuptake inhibitors (SSRIs).

A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Bleeding gums B. Faintness upon rising C. Swelling of the face D. Urinary frequency

B. Faintness upon rising Faintness upon rising can be a sign of orthostatic hypotension, which can be a concern during pregnancy and should be reported to the provider.

A nurse is assessing a 24-month-old toddler at a well-child checkup.Which of the following findings indicates to the nurse that the toddler has developmental delay? A. Runs with a wide stance. B. Falls when throwing a ball overhand. C. Refers to self by name. D. Goes up stairs with two feet on each step.

B. Falls when throwing a ball overhand. Falling when throwing a ball overhand requires coordination and motor skills. By the age of 24 months, most toddlers can throw a ball with some degree of accuracy. Inability to do so may indicate a developmental delay in motor skills, making choice B the correct answer.

A nurse is planning care for a client who is experiencing benzodiazepine toxicity.The nurse should plan to administer which of the following medications? A. Atropine. B. Flumazenil. C. Activated charcoal. D. Naloxone.

B. Flumazenil. Flumazenil is a selective antagonist for the benzodiazepine receptor and is used as an antidote for benzodiazepine toxicity. It competitively inhibits the effects of benzodiazepines by binding to the same receptor sites in the central nervous system. Flumazenil can rapidly reverse the sedative and respiratory-depressant effects of benzodiazepine overdose, making it the appropriate choice in this scenario.

A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which of the following actions should the nurse plan to take? A. Measure gastric residual volumes every 4 hr. B. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication. C. Maintain the head of the bed at a 20° angle. D. Advance the rate of the feeding every 2 hr.

B. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication. Flushing the NG tube with saline before and after medication helps ensure proper medication administration and prevents clogging.

A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal? A. Bulging fontanels B. Hypertonicity C. Bradycardia D. Acrocyanosis

B. Hypertonicity Hypertonicity, or increased muscle tone, is a common sign of neonatal withdrawal from opioids such as methadone. It can manifest as increased resistance to passive movement.

A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first? A. Schedule nursing staff training for infection control procedures. B. Identify possible precipitating factors related to the infections. C. Meet with providers to discuss measures to decrease the infections. D. Revise the current policy for catheter care.

B. Identify possible precipitating factors related to the infections. Identifying the possible factors contributing to the infections is the first step in addressing the issue and preventing further infections.

A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session? A. Encourage clients to establish a timeline for their own grieving process. B. Initiate a discussion with clients about ways to cope with changes in family dynamics. C. Assist clients in identifying ways suicide could have been prevented. D. Discourage clients from sharing negative aspects of their relationship with the deceased persons.

B. Initiate a discussion with clients about ways to cope with changes in family dynamics. Coping with changes in family dynamics is a relevant topic for a support group of this nature, as suicide often brings significant family changes.

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter.Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI? A. Loop the tubing so that it is lower than the collection bag. B. Keep the urinary bag at bladder level when ambulating. C. Obtain urinary samples by disconnecting the tubing connections. D. Secure the catheter to the client's thigh.

B. Keep the urinary bag at bladder level when ambulating.

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect? A. Natural loss of deciduous teeth B. Nontender, protruding abdomen C. Palpable fontanels D. Head circumference exceeds chest circumference

B. Nontender, protruding abdomen Toddlers often have a nontender, protruding abdomen due to their underdeveloped abdominal muscles.

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate? A. Clamp the catheter tubing for 30 min. B. Obtain a urine specimen for culture and sensitivity. C. Initiate continuous bladder irrigation. D. Administer a fluid bolus.

B. Obtain a urine specimen for culture and sensitivity. Dark yellow urine can be an indication of concentrated urine or blood in the urine. Obtaining a urine specimen for culture and sensitivity can help identify any infection or other issues.

A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture? A. Place a towel roll under the client's neck. B. Position a pillow under the client's knees. C. Apply an orthotic to the client's foot. D. Align a trochanter wedge between the client's legs.

B. Position a pillow under the client's knees. Positioning a pillow under the client's knees helps maintain the knee joint in a slightly flexed position, which can prevent contractures in the knee joint.

A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take? A. Insert a pillow under the client's knees. B. Position the client in reverse Trendelenburg. C. Assist the client into the lithotomy position. D. Place a wedge under one of the client's hips.

B. Position the client in reverse Trendelenburg. Positioning the client in reverse Trendelenburg (head of the bed elevated) helps prevent the weight of the gravid uterus from compressing the inferior vena cava, which can compromise blood flow back to the heart and decrease placental blood flow during a cesarean birth.

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? A. Suggest rinsing his mouth with an alcohol-based mouthwash. B. Provide humidification of the room air. C. Offer the client saltine crackers between meals. D. Instruct the client on the use of esophageal speech.

B. Provide humidification of the room air. Providing humidification of the room air can help alleviate the symptoms of xerostomia.

A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant.The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months? A. Varicella. B. Rotavirus. C. Influenza. D. Hepatitis A.

B. Rotavirus.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse? A. Bilateral diffuse wheezing. B. Shortness of breath on exertion. C. Temperature of 100.5 °F (38.1 °C). D. Yellow expectorated sputum.

B. Shortness of breath on exertion.

A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease? A. Sit on the bed next to the client. B. Sit in a chair next to the bed. C. Stand at the side of the bed. D. Stand at the foot of the bed.

B. Sit in a chair next to the bed. Sitting in a chair next to the bed at the client's eye level helps establish a more comfortable and empathetic interaction.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. Encourage the client to watch television. B. Sit with the client to provide a sense of security. C. Administer a dose of atomoxetine to decrease anxiety. D. Teach the client how to meditate.

B. Sit with the client to provide a sense of security. Sitting with the client and providing a sense of security can help them feel more grounded and supported during the panic attack.

A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? A. Moving both crutches with the stronger leg forward first B. Stepping with his affected leg first when going up stairs C. Positioning both hands on the grips with his elbows slightly flexed D. Supporting his body weight while leaning on the axillary crutch pads

B. Stepping with his affected leg first when going up stairs When using a three-point gait with crutches, the affected leg should be advanced first when going upstairs.

A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider? A. Pale and a 24-hr fluid deficit of 30 mL B. Sunken fontanels and dry mucous membranes C. Temperature 38°C (100.4°F) and pulse rate 124/min D. Decreased appetite and irritability

B. Sunken fontanels and dry mucous membranes Sunken fontanels and dry mucous membranes are signs of dehydration, a potential complication of gastroenteritis. These findings should be reported to the provider for further evaluation and intervention.

A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly? A. Initiate seclusion protocol. B. Tell the client, "You seem to be very upset." C. Use a face shield with a mask when providing care to the client. D. Engage the panic alarm.

B. Tell the client, "You seem to be very upset." Acknowledging the client's emotions and showing empathy can help defuse the situation and promote effective communication.

A nurse is caring for a client who is admitted to the medical-surgical unit. The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up. A. Current medications B. Temperature C. Hemoglobin and hematocrit D. WBC count E. Blood pressure F. Respiratory rate G. Stool results Heart rate H. Heart rate

B. Temperature C. Hemoglobin and hematocrit D. WBC count E. Blood pressure H. Heart rate

A nurse in an emergency department is caring for a client following a motor-vehicle crash. The client's Glasgow coma scale rating is 15. Which of the following findings should the nurse expect? A. The client is unable to obey commands. B. The client is oriented times three. C. The client opens eyes to sound. D. The client withdraws from pain.

B. The client is oriented times three. A GCS rating of 15 indicates that the client is fully conscious and oriented to person, place, and time.

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make? A. "I can start the medication 30 minutes earlier." B. "I can infuse the medication at a faster rate." C. "I have up to 2 hours after the usual scheduled time to give you this medication." D. "I can adjust the time and schedule for when it's convenient for you."

C. "I have up to 2 hours after the usual scheduled time to give you this medication." Vancomycin, like many medications, usually has a time window around the scheduled administration time within which it can be given. This window is often referred to as the "grace period," and it allows flexibility in administering medications while still maintaining therapeutic levels.

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. "The client might act seductively." B. "The client is overly concerned about minor details." C. "The client exhibits impulsive behavior." D. "The client is exceptionally clingy to others."

C. "The client exhibits impulsive behavior." Impulsive behavior, such as reckless spending or self-harm, is a common feature of borderline personality disorder.

A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an understanding of the teaching? A. "My baby should always start on the same breast when feeding." B. "Manually expressing my milk will decrease my milk supply." C. "The more my baby is at the breast sucking, the more milk I will produce." D. "After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast."

C. "The more my baby is at the breast sucking, the more milk I will produce." Frequent and effective breastfeeding, along with proper latching and milk removal, stimulates the production of more milk.

A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make? A. "Why are you interested in seeing your therapist's notes?" B. "I don't think you will benefit from reviewing your therapist's notes right now." C. "We can provide a copy of your records, but the therapist's notes are not included." D. "Are you not happy with your treatment?"

C. "We can provide a copy of your records, but the therapist's notes are not included." This response is respectful of the client's request while also explaining the limitation related to therapist notes.

A nurse is assessing a client who is postoperative following orthopedic surgery.Which of the following findings should the nurse identify as an indication of paralytic ileus? A. Watery stool. B. Dizziness. C. Abdominal distention. D. Oliguria.

C. Abdominal distention. Abdominal distention is the correct choice. Paralytic ileus often presents with abdominal distention due to the accumulation of gas and fluids in the intestines. This distention can cause discomfort and a visible increase in the size of the abdomen.

A nurse is monitoring a client who is receiving a transfusion of packed RBCs.The client reports chills, headache, low-back pain, and a feeling of "tightness" in his chest.The nurse should identify that the client has developed which of the following types of transfusion reactions? A. Allergic. B. Febrile nonhemolytic. C. Acute hemolytic. D. Bacterial.

C. Acute hemolytic.

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? A. Perform the procedure twice each day. B. Hold the hand flat to perform percussions on the child. C. Administer a bronchodilator after the procedure. D. Perform the procedure prior to meals.

C. Administer a bronchodilator after the procedure. Administering a bronchodilator after postural drainage helps open the airways, facilitating easier breathing and the removal of mucus.

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next? A. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. B. Secure client consent for coronary angiography and percutaneous coronary intervention. C. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing. D. Place an indwelling urinary catheter and institute strict intake and output measurements.

C. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing.

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice? A. Leaving a nasogastric tube clamped after administering oral medication B. Placing a yellow bracelet on a client who is at risk for falls C. Administering potassium via IV bolus D. Documenting communication with a provider in the progress notes of the client's medical record

C. Administering potassium via IV bolus Administering potassium via IV bolus can be dangerous and is considered malpractice if not done properly. Rapid administration of potassium via IV bolus can lead to serious cardiac complications.

A nurse is providing discharge teaching to a client who has GERD.Which of the following information should the nurse include? A. Take antacids that contain mint for heartburn. B. Increase dietary intake of citrus fruits. C. Avoid consuming foods containing chocolate. D. Lie down for 30 min after eating a meal.

C. Avoid consuming foods containing chocolate. Avoiding consuming foods containing chocolate is important for individuals with gastroesophageal reflux disease (GERD) Chocolate contains substances that can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus, worsening GERD symptoms. Therefore, the nurse should include this information in the discharge teaching to help the client manage GERD effectively.

A nurse is assessing a client who is taking digoxin to treat chronic heart failure.Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity? A. Hearing loss. B. Tachycardia. C. Blurred vision. D. Insomnia.

C. Blurred vision. Blurred vision is a hallmark sign of digoxin toxicity. Digoxin can cause disturbances in color vision, such as seeing yellow or green halos around objects. Blurred vision is a significant indicator of digoxin toxicity and requires prompt medical attention.

A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse's priority? A. Constipation B. Euphoria C. Bradypnea D. Sedation

C. Bradypnea Bradypnea (slow breathing) is a potential adverse effect of morphine and can lead to respiratory depression, which is a serious concern.

A nurse is teaching a client who has rheumatoid arthritis about illness management. Which of the following instructions should the nurse include in the teaching? A. Administer biological response modifiers to prevent infection. B. Take a hot shower in the morning to decrease stiffness. C. Cluster physical activities during the day. D. Apply cold packs directly on the skin of the affected joints.

C. Cluster physical activities during the day. Clustering physical activities during the day helps manage energy levels and minimize joint strain for clients with rheumatoid arthritis.

A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure? A. Confirm that the client is able to urinate. B. Check the client's serum albumin levels. C. Compare the client's current weight with preprocedure weight. D. Examine for leakage at the site of the procedure.

C. Compare the client's current weight with preprocedure weight. Monitoring the client's weight is a common way to assess the effectiveness of a paracentesis, as the procedure aims to remove excess abdominal fluid (ascites), which can lead to a reduction in body weight.

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A. Hypertension B. Epigastric pain C. Contractions D. Vomiting

C. Contractions Amniocentesis can sometimes trigger contractions, especially if performed earlier in pregnancy. Monitoring for contractions is important to assess for preterm labor.

A nurse is caring for a female client who requests a contraceptive diaphragm. Which of the following actions should the nurse take first? A. Document the client's level of understanding about potential adverse effects. B. Teach the client how to insert the diaphragm. C. Determine the client's knowledge about diaphragm use. D. Supervise return demonstration of diaphragm use.

C. Determine the client's knowledge about diaphragm use. Before proceeding with teaching or other actions, it's important to determine the client's baseline understanding of diaphragm use.

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take? A. Call in additional medical-surgical unit nursing care staff. B. Recommend to the provider specific acute care clients for discharge. C. Determine the medical needs of incoming clients through the emergency department. D. Act as a liaison between the facility and the media.

C. Determine the medical needs of incoming clients through the emergency department. In a mass casualty event, the nurse should collaborate with the emergency department to determine the medical needs and prioritize care for incoming clients.

A nurse is assessing a client who is experiencing hypovolemia. Which of the following manifestations should the nurse expect? A. Headache B. Shortness of breath C. Dizziness D. Epistaxis

C. Dizziness Dizziness is a common manifestation of hypovolemia due to decreased blood volume and inadequate perfusion to the brain.

A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? A. Take a 1-hr nap during the day. B. Perform exercises prior to bedtime. C. Eat a light snack before bedtime. D. Stay in bed at least 1 hr if unable to fall asleep.

C. Eat a light snack before bedtime. Eating a light snack before bedtime can help prevent waking due to hunger during the night.

A nurse is planning care for a client who has bipolar disorder and is experiencing mania.Which of the following interventions should the nurse include in the plan? A. Place the client in seclusion when he exhibits signs of anxiety. B. Encourage the client to spend time in the dayroom. C. Encourage the client to take frequent rest periods. D. Withdraw the client's TV privileges if he does not attend group therapy.

C. Encourage the client to take frequent rest periods. Encouraging the client to take frequent rest periods helps prevent overactivity and exhaustion, common in manic episodes.

A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet? A. Canned black beans B. Cheese C. Fish D. Red meat

C. Fish Fish, especially fatty fish like salmon, mackerel, and trout, are rich in omega-3 fatty acids, which have been associated with cardiovascular benefits, including reducing blood pressure.

A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution? A. Hold the bottle in the center of the sterile field when pouring the solution. B. Place sterile gauze over areas of spilled solution within the sterile field. C. Hold the irrigation solution bottle with the label facing away from the palm of the hand. D. Remove the cap and place it sterile-side up on a clean surface.

C. Hold the irrigation solution bottle with the label facing away from the palm of the hand. Holding the bottle with the label facing away from the palm helps prevent potential contamination of the sterile solution by avoiding contact between the hand and the bottle's label.

A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching? A. How to secure the tracheostomy tube with ties at the back of the neck B. How to change the tracheostomy dressing using clean technique C. How to operate the portable suction machine D. How to change the nondisposable tracheostomy tube daily

C. How to operate the portable suction machine Teaching the partner how to operate the portable suction machine is crucial for maintaining a patent airway. Suctioning is often necessary to clear mucus and secretions from the tracheostomy tube, especially when the client is at home.

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take? A. Position the client on the affected side for 4 hr following the procedure. B. Place the client in the prone position during the procedure. C. Instruct the client to avoid coughing during the procedure. D. Inform the client that he will be NPO for 6 hr prior to the procedure.

C. Instruct the client to avoid coughing during the procedure. Instructing the client to avoid coughing during the procedure is important to prevent accidental puncture of the lung.

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? A. Maintain eye contact with the newborn during feedings. B. Swaddle the newborn with his legs extended. C. Minimize noise in the newborn's environment. D. Administer naloxone to the newborn.

C. Minimize noise in the newborn's environment. Newborns with neonatal abstinence syndrome can be hypersensitive to stimuli, including noise. Minimizing noise in the environment helps reduce stress and overstimulation.

The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. After obtaining vital signs, the nurse should implement which intervention? A. Keep the bed in the lowest position and initiate seizure and fall precautions. B. Administer aspirin to prevent further clot formation and platelet clumping. C. Notify the stroke team to assist with acute assessment and management. D. Test for a swallowing reflex and perform communication deficit assessments.

C. Notify the stroke team to assist with acute assessment and management.

A nurse is caring for a client who has been admitted to the antepartum unit. The client is at risk for developing which of the following 2 complications? Select 2 complications the client is at risk of developing. A. Placenta previa B. Disseminated intravascular coagulation C. Preeclampsia D. Sepsis E. Preterm prelabor rupture of membranes (PROM) F. Seizures

C. Preeclampsia E. Preterm prelabor rupture of membranes (PROM)

A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? A. Suspicious of others B. Ritualistic behavior C. Preoccupied with aging D. Exhibits separation anxiety

C. Preoccupied with aging Preoccupation with aging and a fear of losing their physical attractiveness or power is a common trait in individuals with narcissistic personality disorder.

While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first? A. Ensure the device inspection sticker is current. B. Report the defect to the equipment maintenance staff. C. Remove the device from the room. D. Initiate a requisition for a replacement CPM device.

C. Remove the device from the room. The nurse's first priority should be ensuring client safety. Removing the device from the room prevents any potential harm from using the device with a frayed cord.

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond? A. Determine how the client is administering the medication. B. Advise the client to gargle with warm salt water twice daily. C. Report the client's jaw pain to the healthcare provider. D. Confirm that this is a common symptom of osteoporosis.

C. Report the client's jaw pain to the healthcare provider.

A nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke.Which of the following foods should the nurse recommend? A. Crispy rice bar. B. Peanut butter. C. Scrambled eggs. D. Soda crackers.

C. Scrambled eggs. Recommending scrambled eggs is appropriate for a client with dysphagia caused by a stroke. Scrambled eggs have a soft and moist texture, making them easier to swallow for individuals with difficulty swallowing. It is crucial to choose foods that are easy to chew and swallow, as well as foods that can be easily moistened with sauces or gravies to aid in swallowing.

A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take? A. Use gestures to convey meaning. B. Speak slowly when talking to the interpreter. C. Speak directly to the client. D. Pause in the middle of sentences.

C. Speak directly to the client. When using an interpreter, the nurse should address the client directly and speak as if they are having a direct conversation with the client.

A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol.For which of the following adverse effects should the nurse monitor? A. Insomnia. B. Hypertension. C. Tinnitus. D. Headache.

C. Tinnitus. Tinnitus (ringing in the ears) is a known adverse effect of disulfiram when alcohol is ingested. Disulfiram inhibits the breakdown of acetaldehyde, leading to an accumulation of this toxic substance in the body. Tinnitus is one of the symptoms of this toxic reaction and is a significant concern in individuals taking disulfiram for alcohol use disorder.

A nurse is caring for a client who has Crohn's disease.The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories? A. Overweight. B. Obesity class 1. C. Underweight. D. Healthy weight.

C. Underweight. Underweight is the correct choice. A BMI of less than 18.5 is considered underweight according to the World Health Organization (WHO) classification. A BMI of 17.2 falls below this threshold, indicating that the client is underweight. This is a cause for concern, as individuals with Crohn's disease often struggle with maintaining a healthy weight due to malabsorption issues and reduced appetite.

A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching? A. Clean the equipment with an alcohol-based cleaning product. B. Apply petroleum jelly to soothe the mucous membranes. C. Use synthetic fabrics for the client's bedding. D. Avoid using nail polish remover around the client.

C. Use synthetic fabrics for the client's bedding. Synthetic fabrics are less likely to generate static electricity, which could potentially lead to a fire hazard in the presence of oxygen.

A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan? A. Take a bubble bath after intercourse. B. Drink four 240 mL (8 oz) glasses of water each day. C. Wear loose-fitting underwear. D. Void every 5 to 6 hr during the day.

C. Wear loose-fitting underwear. Wearing loose-fitting underwear allows better airflow and decreases moisture, reducing the risk of UTIs.

A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include? A. "Documentation of sensitive material is performed by the charge nurse." B. You will be given access to the medical records of every client in the facility. C. You will be asked to change your password once per year. D. "Information Technology will install a firewall to secure client information."

C. You will be asked to change your password once per year. Regularly changing passwords helps maintain the security of the computerized documentation system.

A nurse is caring for a newborn. Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing______and ______ A. hypoglycemia B. tachycardia C. bronchopulmonary dysplasia D. transient tachypnea of the newborn

C. bronchopulmonary dysplasia D. transient tachypnea of the newborn

A nurse is teaching a client who is pregnant about nonstress testing.Which of the following statements by the client indicates an understanding of the teaching? A. "I will get oxytocin during this test." B. "During this test, I must not eat or drink anything." C. "This test will tell me if my baby has a genetic problem." D. "During this test, I will push a button if my baby moves."

D. "During this test, I will push a button if my baby moves."

A nurse is providing teaching about during administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? A. "You can add the medication to a half-cup of your child's favorite juice." B. "Repeat the dose if your child vomits within 1 hour after taking the medication." C. "Limit your child's potassium intake while she is taking this medication." D. "Have your child drink a small glass of water after swallowing the medication."

D. "Have your child drink a small glass of water after swallowing the medication." Having the child drink water after swallowing the medication helps ensure that the medication is fully swallowed and can enhance absorption.

A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching? A. "I can go jogging after 2 weeks." B. "I should bend at the waist when putting on my shoes." C. "I can lift objects that are less than 10 pounds." D. "I can resume activities, such as sewing."

D. "I can resume activities, such as sewing." After surgical repair of a detached retina, clients should avoid activities that might increase intraocular pressure, like heavy lifting or bending at the waist. Activities that do not strain the eye, like sewing, can typically be resumed earlier.

A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? A. "I can continue to take St. John's wort while taking this medication." B. "I should take this medication on an empty stomach." C. "I expect this medication to raise my blood pressure." D. "I know it will be a couple of weeks before the medication helps me feel better."

D. "I know it will be a couple of weeks before the medication helps me feel better." Amitriptyline and other antidepressants take a few weeks to reach their full therapeutic effect, so it's important for the client to understand this delayed response.

A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching? A. "I should replace any unused medication every 6 months." B. "I can crush the medication and mix it with applesauce." C. "I can store the medication in the refrigerator." D. "I should keep the medication in the original container."

D. "I should keep the medication in the original container." Keeping the medication in the original container helps protect it from moisture and ensures proper identification and labeling.

A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? A. "I try to respond to the baby quickly so she doesn't cry very long." B. "I have several friends who come by to help out with the baby." C. "I want to meet other parents to see if they are going through the same things." D. "I think the baby should be sleeping through the night by now"

D. "I think the baby should be sleeping through the night by now" "I think the baby should be sleeping through the night by now is the correct statement "I think the baby should be sleeping through the night by now," as a manifestation of increased risk for child abuse. This statement may indicate unrealistic expectations or frustration from the parent regarding the baby's sleep patterns. It is common for newborns to wake frequently during the night for feeding and care, and their sleep patterns can vary significantly in the early weeks and months of life. Unrealistic expectations or frustration about the baby's sleep habits can contribute to increased stress for the parent, which might increase the risk of child abuse or neglect.

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A. A client who is receiving heparin for deep-vein thrombosis B. A client who is 1 day postoperative following a vertebroplasty C. A client who has COPD and a respiratory rate of 44/min D. A client who has cancer and a sealed implant for radiation therapy

D. A client who has cancer and a sealed implant for radiation therapy If the client's condition is stable and manageable on an outpatient basis, early discharge is suitable.

A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings that requires follow-up care. A. A client who received a Mantoux test 48 hr ago and has an induration B. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L C. A client who is scheduled for a colonoscopy and is taking sodium phosphate D. A client who is taking warfarin and has an INR of 1.8

D. A client who is taking warfarin and has an INR of 1.8 An INR of 1.8 for a client on warfarin is below the therapeutic range (usually 2.0- 3.0 for most indications), indicating that the client's blood may not be adequately anticoagulated. This requires follow-up to adjust the warfarin dose.

A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port? A. A butterfly needle B. An angiocatheter C. A 25-gauge needle D. A noncoring needle

D. A noncoring needle A noncoring needle (Huber needle) is specifically designed for accessing implanted venous access ports to minimize damage to the port septum and prevent leakage.

A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care? A. Offer small amounts of clear liquids 6 hr following surgery. B. Give cromolyn nebulized solution every 8 hr. C. Apply a warm compress to the operative site once daily. D. Administer analgesics on a scheduled basis for the first 24 hr.

D. Administer analgesics on a scheduled basis for the first 24 hr. Administering analgesics on a scheduled basis helps manage postoperative pain and provides effective pain relief, promoting comfort and recovery.

A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take? A. Cover the adolescent with a thermal blanket. B. Initiate seizure precautions. C. Submerge the adolescent's feet in ice water. D. Administer oral acetaminophen.

D. Administer oral acetaminophen. Administering oral acetaminophen can help reduce fever and manage hyperthermia.

A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses.The nurse should include that which of the following procedures is outside the legal scope of practice for an RN? A. Changing the inner cannula on a tracheostomy. B. Inserting a tunneled central venous catheter. C. Irrigation of an external ear canal. D. Administering a platelet transfusion.

D. Administering a platelet transfusion.

A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next? A. Release the tourniquet. B. Retract the stylet. C. Flush the catheter with saline. D. Advance the catheter into the vein.

D. Advance the catheter into the vein. After noting a blood return in the flashback chamber, the next step is to advance the catheter into the vein to ensure proper placement for intravenous access.

A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? A. Encourage the client to lie down in a quiet room. B. Refer to the hallucinations as if they are real. C. Avoid eye contact with the client. D. Ask the client directly what he is hearing.

D. Ask the client directly what he is hearing. Asking the client directly about their hallucinations helps assess their content and severity, which is essential for developing an effective plan of care.

A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take? A. Refer the adolescent to a local mental health clinic. B. Advise the adolescent to place the newborn for adoption. C. Contact the adolescent's parent for assistance. D. Assist the adolescent in applying for Medicaid.

D. Assist the adolescent in applying for Medicaid. Assisting the adolescent in applying for Medicaid is a practical step to help her access financial assistance for her pregnancy-related care and the care of her baby.

A nurse is admitting a client to a medical-surgical unit. When performing medication reconciliation for the client, which of the following actions should the nurse take? A. Include any adverse effects of the medications the client might develop. B. Exclude nutritional supplements from the list of medications the client reports. C. Encourage the client to make his own list after he returns to his home. D. Compare new prescriptions with the list of medications the client reports.

D. Compare new prescriptions with the list of medications the client reports. Comparing new prescriptions with the client's reported medication list helps identify any discrepancies or potential interactions, ensuring safe and effective medication administration.

A nurse is assessing a child who is postoperative following a tonsillectomy.Which of the following findings should the nurse identify as the priority? A. Sore throat. B. Frequent swallowing. C. Blood-tinged mucus. D. Dark brown emesis.

D. Dark brown emesis.

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include? A. Remove the client's restraint every 4 hr. B. Attach the restraint to the bed's side rails. C. Request a PRN restraint prescription for clients who are aggressive. D. Document the client's condition every 15 min.

D. Document the client's condition every 15 min. When using restraints, it's important to document the client's condition frequently to assess for any potential adverse effects or discomfort.

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention? A. Using an electronic messaging system to remind clients when to take medications B. Helping clients understand health screenings covered by their insurance plans C. Providing clients with information about the benefits of exercise D. Educating clients about contraindications to specific immunizations

D. Educating clients about contraindications to specific immunizations Educating clients about contraindications to specific immunizations falls under tertiary prevention, which aims to minimize the impact of an illness or condition that is already present.

A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of0.35 seconds. Which of the following dysrhythmias is the client displaying? A. Premature atrial complexes B. Complete heart block C. Atrial fibrillation D. First-degree atrioventricular block

D. First-degree atrioventricular block In first-degree atrioventricular block, the P-R interval is prolonged beyond the normal range of 0.12-0.20 seconds. A constant P-R interval of 0.35 seconds indicates a first- degree atrioventricular block.

A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? A. Hypotension B. Weight loss C. Polyuria D. Hematuria

D. Hematuria Hematuria (blood in the urine) is a classic sign of acute glomerulonephritis, reflecting inflammation and damage to the glomeruli in the kidneys.

A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment? A. Obesity B. Hypothyroidism C. Hypertension D. Herpes zoster

D. Herpes zoster Herpes zoster (shingles) involves a reactivation of the varicella-zoster virus and can cause skin lesions. Acupuncture involves the insertion of needles through the skin, which could potentially worsen the condition or lead to the spread of the virus.

A nurse is caring for a client who is postoperative following a right hip arthroplasty. For each assessment finding, specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock. Each finding may support more than 1 disease process A. Wheezes B. Tachycardia C. Urticaria D. Hypercapnia E. Muscle Rigidity

D. Hypercapnia D. Hypercapnia - Malignant Hyperthermia. Hypercapnia (elevated levels of carbon dioxide in the blood) can be a sign of malignant hyperthermia due to increased muscle metabolism and metabolic acidosis.

A nurse is caring for a client who has experienced a stroke and is moving in with their adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles? A. Minimize open discussion regarding the changes to avoid embarrassment. B. Decrease socialization with extended relatives until roles are identified. C. Encourage authoritative communication from the adult child. D. Implement firm but flexible boundaries in their relationship.

D. Implement firm but flexible boundaries in their relationship. Implementing firm but flexible boundaries allows for a healthy balance between support and maintaining the client's independence and autonomy.

A nurse in an emergency department is administering naloxone to a client who had a heroin overdose.The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose? A. Decreased temperature. B. Polyuria. C. Bradycardia. D. Increased respiratory rate.

D. Increased respiratory rate.

A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse? A. Waits for 2 min between suctions B. Applies suction for 15 seconds C. Encourages the client to cough during suctioning D. Inserts the catheter without applying suction

D. Inserts the catheter without applying suction

A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? A. Talk with the client during her feeding. B. Discourage the client from coughing during feedings. C. Sit at or below the client's eye level during feedings. D. Instruct the client to lift her chin when swallowing.

D. Instruct the client to lift her chin when swallowing. Instructing the client to lift her chin when swallowing helps open the airway and may reduce the risk of aspiration.

A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take? A. Initiate airborne precautions. B. Monitor for the development of Koplik spots. C. Administer aspirin to the client. D. Isolate the client from staff who are pregnant.

D. Isolate the client from staff who are pregnant. Rubella is a teratogenic virus that can cause birth defects in pregnant women who are exposed to the virus. Isolation from pregnant staff members is important to prevent potential transmission.

A nurse is planning to teach a client about taking prednisone. Which of the following instructions should the nurse include? A. Take on an empty stomach. B. Schedule dosage at bedtime. C. Increase dietary calcium. D. Monitor for weight loss.

D. Monitor for weight loss. Monitoring for weight loss is important due to the potential for weight changes (both weight gain and weight loss) as a result of prednisone's effects on metabolism and appetite.

A nurse is caring for a client who has an indwelling urinary catheter. The nurse notes that sediment is present in the urine. Which of the following actions should the nurse take to obtain a sterile urine specimen? A. Use the balloon port to obtain the sterile specimen. B. Unclamp the collection port below the bag. C. Disconnect the catheter from the collection tubing. D. Obtain the specimen from the retention port.

D. Obtain the specimen from the retention port. The retention port is a sterile access point on the catheter itself, and it can be used to obtain a sterile urine specimen without compromising the sterility of the collection system.

A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider? A. Mild swelling under the sutures near the incisional line. B. Pink-tinged coloration on the incisional line. C. Crusting of exudate on the incisional line. D. Partial separation of the upper part of the incisional line.

D. Partial separation of the upper part of the incisional line. Partial separation of the upper part of the incisional line can indicate wound dehiscence, a potential complication that requires immediate attention to prevent infection and further complications.

A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? A. Encourage rural residents to focus health spending on tertiary health interventions. B. Launch a media campaign to increase awareness about industrial pollution. C. Have a nurse from outside the community provide health lectures at the county hospital. D. Provide anticipatory guidance classes to parents through public schools.

D. Provide anticipatory guidance classes to parents through public schools. Providing anticipatory guidance classes to parents through public schools is a community-based preventive approach that can address the health needs of families and children in the area.

An older client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client. Which action should the nurse take? A. Instruct the UAP to notify the nurse of any changes in the client's respiratory status. B. Remind the UAP to apply a fitted respirator mask before entering the client's room. C. Assign the UAP to provide care for another client and assume full care of the client. D. Review the need for the UAP to wear a face mask while in close contact with the client.

D. Review the need for the UAP to wear a face mask while in close contact with the client.

A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism? A. Nonreactive pupils B. Smacking lips C. Serpentine limb movement D. Shuffling gait

D. Shuffling gait Pseudoparkinsonism is a side effect of antipsychotic medications like haloperidol. It is characterized by motor symptoms similar to Parkinson's disease, including a shuffling gait, rigidity, bradykinesia (slowed movement), and resting tremor.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The bag has 20 mL remaining to infuse, but a new bag is not readily available. Which of the following actions should the nurse take? A. Temporarily discontinue the infusion. B. Give 500 mL of lactated Ringer's solution. C. Administer dextrose 10% in water. D. Slow the TPN infusion rate.

D. Slow the TPN infusion rate. Slowing the TPN infusion rate can help stretch the remaining volume until a new bag becomes available, preventing abrupt changes in glucose intake and minimizing the risk of hypoglycemia.

A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect? A. Polyhydramnios B. Uterine tenderness C. Nausea D. Spotting

D. Spotting Spotting or painless vaginal bleeding is a hallmark sign of placenta previa, which occurs when the placenta covers part or all of the cervix. It can be life-threatening if severe bleeding occurs.

A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension? A. The client's heart rate increases by 10/min. B. The client's diastolic blood pressure increases by 10 mm Hg. C. The client reports heart palpitations. D. The client's systolic blood pressure decreases by 25 mm Hg.

D. The client's systolic blood pressure decreases by 25 mm Hg.

A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take? A. Apply the largest cuff available. B. Place the arm above the level of the client's heart. C. Deflate the cuff quickly. D. Use the palpatory method to determine blood pressure.

D. Use the palpatory method to determine blood pressure. Using the palpatory method, the nurse can feel for the radial pulse while slowly deflating the blood pressure cuff. This helps estimate the systolic blood pressure when Korotkoff sounds are challenging to hear. It provides a rough estimate until clear sounds can be heard and ensures accurate blood pressure measurement.

A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching? A. Round the edges of toenails when trimming. B. Soak feet twice daily. C. Use moisturizing lotion between the toes. D. Wear clean cotton socks every day.

D. Wear clean cotton socks every day. Wearing clean cotton socks helps maintain proper foot hygiene and prevents moisture accumulation, reducing the risk of fungal infections.

A nurse is caring for a postpartum client in an outpatient setting. The client is at highest risk for developing______evidenced by the client's______

The client is at highest risk for developing mastitis evidenced by the client's visible crack noted on left nipple

A nurse is caring for a client who is admitted to the medical-surgical unit. Complete the following sentence by using the lists of options. The nurse anticipates the client will likely require an______as evidenced by the client's______

The nurse anticipates the client will likely require an upper gastrointestinal (GI) endoscopy as evidenced by the client's dark tarry stool