Comp predictor B

A nurse is caring for a client in the 4th stage of labor and is receiving oxytocin via continuous IV infusion. Which assessment is the nurse's priority? A) Amount of vaginal bleeding B) Amount of urinary output C) Pain level D) Fundal height

A) Amount of vaginal bleeding

A nurse is providing dietary teaching to a patient taking phenelzine. Which food recommendations should the nurse make? (Select all) A) Broccoli B) Yogurt C) Pepperoni pizza D) Cream cheese E) Bologna sandwich

A) Broccoli B) Yogurt D) Cream cheese

A nurse is caring for a newborn who has herpes simplex virus (HSV). Which isolation precaution should the nurse initiate? A) Contact B) Droplet C) Airborne D) Protective environment

A) Contact

A nurse is updating the plan of care for a patient 48 hours post-op following a laryngectomy and is unable to speak. What action should the nurse take first? A) Determine the client's reading skills. B) Instruct the client on the technique for esophageal speech. C) Provide the client with an alphabet board. D) Show the client how to use an artificial larynx.

A) Determine the client's reading skills.

A nurse on a med-surg unit is assessing a client who had a stroke. Which finding indicates a need for a referral for occupational therapy? A) Difficulty performing ADLs B) Inability to swallow clear liquids C) Elevated blood glucose levels D) Unsteady gait when ambulating

A) Difficulty performing ADLs

A nurse is admitting a client with pneumonia. The nurse should initiate which isolation precaution? A) Droplet B) Airborne C) Contact D) Protective environment

A) Droplet

A nurse is preparing to transfer a client who had a stroke to a rehab facility. The client's family tells the nurse they are concerned about the level of care the client will receive. What action should the nurse take? A) Facilitate an interdisciplinary conference at the new facility for the family. B) Refer the client and family to a social worker for assistance and a follow-up meeting. C) Reassure the client's family that the same provider will provide care at the new facility. D) Tell the family that the rehabilitation facility has an excellent client care record.

A) Facilitate an interdisciplinary conference at the new facility for the family.

A nurse is assessing a patient who received 2 units of packed RBCs 48 hours ago. Which finding should indicate the therapy is effective? A) Hemoglobin 14.9 g/dL B) WBC 12,000/mm3 C) Potassium 4.8 mEq/L D) BUN 18 mg/dL

A) Hemoglobin 14.9 g/dL

A nurse is providing teaching to a patient with a new diagnosis of type 1 DM. The nurse should instruct the client to monitor which finding as a manifestation of hypoglycemia? A) Irritability B) Increased urination C) Vomiting D) Facial flushing

A) Irritability

A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 minutes. The patient weighs 198 lb. What is the amount in grams the nurse should administer? (Whole number)

18 g

A nurse is planning to delegate client care tasks to an AP. Which task should the nurse plan to delegate to the AP? A) Perform gastrostomy feedings through a client's established gastrostomy tube. B) Administer a glycerin suppository to a client who is constipated. C) Provide instructions about client care to a family member over the telephone. D) Teach a client how to measure his own blood pressure.

A) Perform gastrostomy feedings through a client's established gastrostomy tube.

A nurse is assessing a client with pulmonary edema. Which finding should the nurse expect? A) Pink, frothy sputum B) Bradycardia C) Flushed, dry skin D) Wheezing

A) Pink, frothy sputum

A nurse is caring for a client with a prescription for continuous passive motion (CPM) machine following a TKA. Which action should the nurse take? A) Turn off the CPM machine during mealtime. B) Maintain the client's affected hip in an externally rotated position. C) Instruct the client how to adjust the CPM settings for comfort. D) Store the CPM machine under the client's bed when not in use.

A) Turn off the CPM machine during mealtime.

A nurse is assessing an older adult client with pneumonia. Which finding should the nurse expect? A) Paradoxic chest movement B) Subcutaneous emphysema C) Acute confusion D) Distended neck veins

C) Acute confusion An older adult client who has pneumonia will also typically have acute confusion, fatigue, lethargy, and anorexia.

A client is receiving IV fluids at 150 mL/hr. Which finding indicates the client is experiencing fluid overload? A) Oliguria B) Bradycardia C) Dyspnea D) Poor skin turgor

C) Dyspnea

A nurse is assessing a client for compartment syndrome. Which finding should the nurse expect? A) Fever B) Shortened femoral neck C) Edema D) Dark brown urine

C) Edema

A nurse is caring for a patient with acute blood loss following a trauma. The patient refuses a blood transfusion that could save his life. Which action should the nurse take first? A) Document the client's refusal in the medical record. B) Honor the client's decision to refuse the blood transfusion. C) Explore the client's reasons for refusing the treatment. D) Discuss the client's refusal with the provider.

C) Explore the client's reasons for refusing the treatment.

A charge nurse is providing an educational session about infection control for a group of staff nurses. Which statement by a staff nurse indicates understanding of isolation precautions? A) "Droplet precautions should be initiated for a client who tests positive for measles." B) "A client who requires airborne precautions should be placed in a negative-pressure airflow room." C) "Airborne precautions should be initiated for a client who has Clostridium difficile." D) "A clients who is immunocompromised should be placed in a negative-pressure airflow room."

B) "A client who requires airborne precautions should be placed in a negative-pressure airflow room." The nurse should initiate airborne precautions, rather than droplet precautions, for a client who has measles.

A nurse is providing teaching about lithium to a client with bipolar disorder. Which statement should the nurse include in the teaching? A) "Expect to have blurred vision while taking this medication." B) "Notify your provider if you experience increased thirst." C) "You might be unable to have an orgasm while taking this medication." D) "You should take this medication on an empty stomach."

B) "Notify your provider if you experience increased thirst." The nurse should recognize that an increase in thirst is a manifestation of lithium toxicity. The nurse should instruct the client to report increased thirst, vomiting, diarrhea, or tremors to the provider.

A nurse is preparing to replace a patient's transdermal fentanyl patch after 72 hours of use. After opening the packet with the new pouch, the patient refuses to accept it. Which action should the nurse take? A) Withhold pain medications for 24 hr after the old patch is removed. B) Ask another nurse to witness the disposal of the new patch. C) Seal the patches in a plastic bag and place in the client's trash basket. D) Stick the two patches to each other and place them in the sharps bin.

B) Ask another nurse to witness the disposal of the new patch.

A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which action should the nurse take? A) Insert air in the tube and listen for gurgling sounds in the epigastric area. B) Aspirate contents from the tube and verify the pH level. C) Review the medical record for previous x-ray verification of placement. D) Auscultate the lungs for adventitious breath sounds.

B) Aspirate contents from the tube and verify the pH level.

A nurse is caring for a patient receiving hemodialysis with an AV fistula in the right arm. Which intervention should the nurse include in the patient's plan of care? A) Avoid elevating the affected extremity. B) Auscultate the affected extremity for a bruit. C) Discourage range-of-motion exercises in the affected extremity. D) Perform venipuncture in the affected extremity.

B) Auscultate the affected extremity for a bruit.

A nurse is assessing a client taking propranolol. Which finding should indicate to the nurse the client is experiencing an adverse reaction to propranolol? A) Weight loss B) Coughing at night C) Blood pressure 146/92 mm Hg D) Heart rate 110/min

B) Coughing at night

A nurse is caring for a client who is taking chlorpromazine. Which finding should the nurse identify as an indication that the med is effective? A) Decreased blood pressure B) Decreased hallucinations C) Decreased cholesterol D) Decreased esophageal reflux

B) Decreased hallucinations

A nurse is assessing a newborn following a vaginal delivery. Which finding should the nurse report to the provider? A) Heart rate 136/min B) Nasal flaring C) Tongue not protruding D) Overlapping of sutures

B) Nasal flaring

A nurse is providing discharge education to a patient who is to receive home oxygen therapy. Which instruction should the nurse include in the teaching? A) Check the functioning of oxygen equipment once each week. B) Wear clothing made with cotton fabrics while oxygen is in use. C) Apply petroleum-based lubricant to the nares as needed. D) Store full oxygen tanks on their side.

B) Wear clothing made with cotton fabrics while oxygen is in use. The nurse should teach the client to apply a water-soluble lubricant to soothe irritation of the mucous membranes, because products containing oils are flammable when near oxygen.

A nurse in a peds clinic is assessing the reflexes of an infant who is 1 week old. Which image demonstrates correct procedure to elicit the palmar grasp reflex?

The nurse should elicit the palmar reflex by touching the palms of the infant's hands near the base of the digits, causing flexion of the fingers.

A nurse is conducting a visual acuity test using the Snellen letter chart for a school-age child with eyeglasses. Which instructions should the nurse give to the child? A) "You should remove your glasses throughout the testing." B) "You should stand 15 feet away from the chart." C) "You should get three symbols on a line correct to pass the line." D) "You should keep both eyes open during the testing."

D) "You should keep both eyes open during the testing."

A nurse is assessing a client who has depressive disorder and is taking amitriptyline. Which finding is an adverse effect of this medication? A) Diarrhea B) Frequent urination C) Excessive salivation D) Blurred vision

D) Blurred vision

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which action should the nurse take first? A) Instruct a staff member to maintain a log of emergency care provided. B) Apply cervical spine collars to children who have suspected neck trauma. C) Notify parents of the emergency and injuries to their children. D) Survey the scene for potential hazards to staff and children.

D) Survey the scene for potential hazards to staff and children.

A nurse is preparing to administer dextrose 5% in water 1,000 mL to infuse over 8 hours to a client. Set the IV pump to delivery how many mL/hr? (Whole number)

125 mL/hr

A charge nurse notices that one of the nurses on her shift frequently violates unit policies by taking an extended amount of time for her break. Which statement should the charge nurse make to address this conflict? A) "I would like to talk to you about the unit policies regarding break time." B) "If you continue to take a long lunch break, I will have to report this to the nurse manager." C) "Have you thought about how your extended lunch breaks affect the other members of our team?" D) "Did you inform the other members of your team about when you left and returned from break?"

A) "I would like to talk to you about the unit policies regarding break time."

A nurse is providing teaching about advance directives to a middle adult client. Which client response indicates an understanding of the teaching? A) "I can designate my partner as my health care surrogate." B) "I am only 40 years old, so I don't need to worry about this yet." C) "I will need a lawyer's help to draw up the documents." D) "I have no family, so I don't need to worry about having advance directives."

A) "I can designate my partner as my health care surrogate."

A hospice nurse is consulting with a patient and her family about receiving home services. Which statement should the nurse identify as an indication that the family understands home hospice care? A) "We can expect the hospice nurse to provide support for us after our mother's death." B) "A hospice nurse will come to the house each time our mother needs pain medication." C) "Now that my mother is receiving hospice services, we will not be able to get respite care." D) "Hospice care focuses on arranging treatment that will prolong our mother's life."

A) "We can expect the hospice nurse to provide support for us after our mother's death."

A nurse is providing teaching for a client about his right to confidentiality. Which statement should the nurse make? A) "You can provide a list of family members who can receive information about your diagnosis." B) "Your provider can legally discuss your test results with your partner without your permission." C) "Your provider will need to approve your advance directives before we can implement them." D) "You can give your friend who is an RN in another department permission to access your medical records."

A) "You can provide a list of family members who can receive information about your diagnosis."

A nurse must recommend clients for discharge to make room for several critically injured clients from a local disaster. Which client should the nurse recommend for discharge? A) A client who has cellulitis and is receiving oral antibiotics every 8 hr B) A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex C) A mother and her newborn 12 hr postdelivery D) A client who has lower extremity weakness and is newly admitted for observation

A) A client who has cellulitis and is receiving oral antibiotics every 8 hr

An antepartum nurse is caring for 4 patients. Which patient should the nurse initiate seizure precautions? A) A client who is at 33 weeks of gestation and has severe gestational hypertension B) A client who is at 16 weeks of gestation and has a hydatidiform mole C) A client who is at 28 weeks of gestation and is experiencing vaginal bleeding D) A client who is at 12 weeks of gestation and has group B streptococcus

A) A client who is at 33 weeks of gestation and has severe gestational hypertension The nurse should initiate seizure precautions for a client who has severe gestational hypertension because an extremely elevated blood pressure in an antepartum client can trigger seizure activity. The nurse should provide the client with a quiet, darkened environment; place suction equipment and oxygen at the bedside; and place the call button within the client's reach.

A nurse has received report on 4 patients. Which should the nurse assess first? A) A client who is postoperative with abdominal distention and no bowel sounds B) A client who has diabetes mellitus and a blood glucose level of 105 mg/dL C) A client who has heart failure and 2+ pitting edema D) A client who is receiving maintenance IV fluids and needs a new IV catheter

A) A client who is postoperative with abdominal distention and no bowel sounds

A nurse manager is preparing an education session about advocacy to a group of nurses. The nurse manager should include what information in the teaching? A) Advocacy is a leadership role that helps others to self-actualize. B) Subordinates are an advocate for the nurse manager. C) Advocacy is to encourage client dependence in decision making. D) Nurse managers should distrust people who speak out about harmful or inappropriate professional practices.

A) Advocacy is a leadership role that helps others to self-actualize.

A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse gathers information from which source? A) Agency for Healthcare Research and Quality B) National Institutes of Health C) Department of Agriculture D) World Health Organization

A) Agency for Healthcare Research and Quality The nurse should gather data from the Agency for Healthcare Research and Quality (AHRQ) regarding health care services for migrant farmworkers. The AHRQ strives to improve the quality of health care services for all populations, including low-income groups and minorities. This data should help the nurse to develop an evidence-based plan to improve health care services for specific populations.

A nurse is caring for a group of clients. Which client should the nurse see first? A) An older adult client who is anxious and attempting to pull out his IV line B) A middle adult client who is reporting nausea after receiving her pain medication C) An older adult client who has kidney failure and returned from dialysis 4 hr ago D) A middle adult client who has a terminal illness and is requesting a visit from the chaplain

A) An older adult client who is anxious and attempting to pull out his IV line

A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which ethical principle? A) Autonomy B) Nonmaleficence C) Justice D) Fidelity

A) Autonomy

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on the forearms. These behaviors are characteristics of which personality disorder? A) Borderline B) Antisocial C) Histrionic D) Paranoid

A) Borderline The nurse should recognize that clients who have borderline personality disorder are unstable emotionally, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting, substance use, and suicidal thoughts.

A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which method should the nurse include in the teaching? A) Delegate non-nursing tasks to ancillary staff. B) Stock client rooms with extra supplies. C) Assign dedicated equipment to each client's room. D) Change continuous IV infusion tubing every 24 hr.

A) Delegate non-nursing tasks to ancillary staff. Delegating non-nursing tasks to ancillary staff is an effective method of providing high quality, cost-effective care because this will allow additional time for nurses to focus on skilled tasks.

A nurse manager in a long-term care facility is having difficulty with staffing weekend shifts and is planning to implement changes to the scheduling procedure. Which action should the nurse manager take first? A) Form a committee of staff members to investigate current staffing issues. B) Provide support to staff members who are resistant to staffing changes. C) Schedule a staff meeting to present the different options to staff members. D) Give the staff members advance written notice of staffing changes.

A) Form a committee of staff members to investigate current staffing issues.

A nurse on an impatient unit is caring for a client with schizophrenia and recently started taking risperidone. Which action should the nurse take? A) Implement fall precautions for the client. B) Monitor the client's thyroid function. C) Place the client on a fluid restriction. D) Discontinue the medication if hallucinations occur.

A) Implement fall precautions for the client. Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. Therefore, the nurse should initiate fall precautions for the client.

A nurse is caring for a client with a magnesium level of 2.5. Which intervention should the nurse plan to take? A) Initiate continuous cardiac monitoring. B) Administer 40 mEq/L potassium chloride PO with orange juice. C) Provide a diet rich in legumes, nuts, and whole-grain cereal. D) Monitor the client for tetany.

A) Initiate continuous cardiac monitoring. The nurse should initiate continuous cardiac monitoring because a client who has hypermagnesemia is at risk for cardiac dysrhythmias and cardiac arrest.

A nurse is preparing a client for a paracentesis. What action should the nurse take? A) Instruct the client to void. B) Position the client on his left side. C) Insert an IV catheter. D) Prepare the client for conscious sedation.

A) Instruct the client to void. The nurse should instruct the client to void because an empty bladder decreases the risk of a bladder puncture and minimizes the client's discomfort from the need to void. The nurse should position the client upright or in Fowler's position.

A nurse enters a client's room and sees smoke coming from a small fire in the trash can. What should the nurse do first? A) Remove the client from the room. B) Activate the fire alarm. C) Close the door to the client's room. D) Extinguish the fire with a fire extinguisher.

A) Remove the client from the room.

A nurse in the ED is assessing a preschooler who has a facial laceration. Which finding is a potential indication of sexual abuse? A) The child exhibits discomfort while sitting. B) The child lacks personal hygiene. C) The child has a laceration on the torso. D) The child does not cry during wound care.

A) The child exhibits discomfort while sitting.

A nurse is assessing a client at 11 weeks gestation and reports drinking ginger tea. Which finding indicates the client's use of ginger tea is effective? A) The client reports a decrease in episodes of nausea. B) The client reports a decrease in breast tenderness. C) The client reports a decrease in headaches. D) The client reports a decrease in urinary frequency.

A) The client reports a decrease in episodes of nausea.

A nurse is caring for a client receiving continuous heparin infusion. What lab test should the nurse review prior to adjusting the client's heparin? A) aPTT B) PT C) INR D) WBC count

A) aPTT Prior to adjusting the client's continuous heparin infusion, the nurse should review the client's activated partial thromboplastin time (aPTT). The expected reference range for the aPTT is 40 seconds. Clients who are receiving continuous heparin therapy should have an aPTT of 60 to 80 seconds, which is 1.5 to 2 times of the expected aPTT level. The nurse should increase or decrease the heparin infusion according to this value.

A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which question should the nurse ask to assess for an adverse effect of this med? A) "Have you suffered with muscle stiffness?" B) "Have you had any stomach pain or bloody stools?" C) "Have you experienced a dry cough?" D) "Have you noticed an increase in urine output?"

B) "Have you had any stomach pain or bloody stools?"

A nurse is providing discharge teaching for the parents of a preschoo;-age child taking amoxicillin/clavulanate suspension. Which instructions should the nurse include in the teaching? (Select all) A) "You will give the medication every 4 hours." B) "Shake the medication bottle well before each dose is given." C) "Store the medication in the refrigerator." D) "Report diarrhea to the provider immediately." E) "Discard the unused portion of medication after 21 days."

B) "Shake the medication bottle well before each dose is given." C) "Store the medication in the refrigerator." D) "Report diarrhea to the provider immediately."

A nurse is caring for a client with cancer and is deciding between 2 treatment options. The client asks the nurse for assistance with the decision. Which response should the nurse make? A) "It's been difficult for everyone who has ever had to make this decision." B) "Tell me more about your understanding of the options." C) "I'm sure you will make the right choice." D) "I will contact your provider to have him talk with you further."

B) "Tell me more about your understanding of the options."

A nurse is caring for a patient with major depressive disorder and has signed an informed consent to receive ECT. The patient states "I'm not sure about this now. I'm afraid it's too risky." What response should the nurse make? A) "Perhaps you think the ECT is dangerous, but I can guarantee it's quite safe." B) "You have the right to refuse to have the ECT, even after you have agreed to it." C) "Everyone gets a little nervous about this procedure as the time for it approaches." D) "Your doctor wouldn't have suggested this procedure if he didn't think it would help you."

B) "You have the right to refuse to have the ECT, even after you have agreed to it."

A nurse is assessing a client whose partner recently died. The client states "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make? A) "It's natural for you to feel this way now, but things will get better with time." B) "You seem to be having a difficult time right now." C) "Why do you feel like your life isn't worth living?" D) "You'd be surprised how many people experience these feelings."

B) "You seem to be having a difficult time right now."

A nurse is providing teaching to a patient 24 weeks gestation and is scheduled for a 3 hour oral glucose tolerance test. Which instruction should the nurse include in the teaching? A) "Limit your fat intake for 72 hours before the test." B) "You will need to fast the night before the test." C) "We will collect a urine sample on the morning of the test." D) "A blood sample will be collected every 30 minutes during the test."

B) "You will need to fast the night before the test."

A nurse at a mental health clinic is caring for 4 clients. Which client is using dissociation as a defense mechanism? A) A client forgets to buy her partner a birthday gift after a disagreement. B) A client who was abused as a child describes the abuse as if it happened to someone else. C) A client who is shorter than average is verbally assertive with his co-workers. D) A client states that she did not get a job promotion because the boss does not like her.

B) A client who was abused as a child describes the abuse as if it happened to someone else. The nurse should recognize that this client is using dissociation because he is separating painful events from his conscious mind and is describing the events as if they happened to another person.

A nurse is caring for an older adult client experiencing chronic anorexia and is receiving enteral tube feedings. Which lab values indicates the client needs additional nutrients added to the feeding? A) Creatinine 1.1 mg/dL B) Albumin 2.8 g/dL C) Triglycerides 100 mg/dL D) Alkaline phosphatase 118 units/L

B) Albumin 2.8 g/dL

A nurse is caring for a patient taking clonidine. Which finding is an adverse effect of this medication? A) Diarrhea B) Dry mouth C) Photophobia D) Bruising

B) Dry mouth

A nurse is assessing a client with bipolar disorder. Which alterations in speech is the client using? (Listen to the clip) A) Tangentiality B) Flight of ideas C) Word salad D) Perseveration

B) Flight of ideas Flight of ideas is an alteration in speech in which the speaker talks continuously with sudden, frequent topic changes.

A nurse at an urgent care clinic is assessing a patient with impaired vision in 1 eye. Which report from the patient should indicate to the nurse that the client has a detached retina? A) Halos around lights B) Floating dark spots C) Pain in the affected eye D) Cloudy vision

B) Floating dark spots

A nurse is performing an abdominal assessment. Identify the sequence of actions the nurse should take. A) Auscultation B) Inspection C) Palpation D) Percussion

B) Inspection A) Auscultation D) Percussion C) Palpation

A nurse is caring for a client who has a DVT. Which action should the nurse take? A) Teach the client to massage the affected extremity. B) Instruct the client to elevate the affected extremity when sitting. C) Assess pulses proximal to the affected area. D) Apply a cold compress to the affected extremity.

B) Instruct the client to elevate the affected extremity when sitting.

A nurse is caring for a patient receiving continuous bladder irrigation following a transurethral resection of the prostate. The patient reports bladder spasms and the nurse observes a decreased urinary output. Which action should the nurse take? A) Increase tension on the urinary catheter. B) Irrigate the catheter with 0.9% sodium chloride irrigation. C) Assist the client to ambulate. D) Remove the urinary catheter immediately.

B) Irrigate the catheter with 0.9% sodium chloride irrigation. Decreased urine output and bladder spasms indicate internal obstructions of the catheter. Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify the provider if the obstruction does not clear.

A nurse is assessing an infant with hydrocephalus and is 6 hours post-op following placement of a VP shunt. Which finding should the nurse report to the provider? A) Heart rate 122/min B) Irritability when being held C) Hypoactive bowel sounds D) Urine specific gravity 1.018

B) Irritability when being held

A nurse is caring for a patient taking valproic acid for seizure control. Which adverse effect should the nurse monitor and report? A) Weight loss B) Jaundice C) Bradycardia D) Polyuria

B) Jaundice The nurse should monitor the client for jaundice and report any indication to the provider. Clients who take valproic acid are at risk for liver damage, which can lead to jaundice.

A nurse is assigning task roles for a group of patients in a community mental health clinic. Which task should the nurse assign to the mother of the group functioning as the orienter? A) Measuring the group's work against the assigned objectives B) Noting the progress of the group toward assigned goals C) Sharing experiences as an authority figure D) Offering new and fresh ideas on an issue

B) Noting the progress of the group toward assigned goals

A nurse is reviewing the urinalysis report of a client with acute glomerulonephritis. Which finding should the nurse expect in the client's urine? A) Uric acid crystals B) Protein C) WBCs D) Nitrates

B) Protein Increased glomerular permeability allows protein to filter into the urine. Therefore, this is an expected finding in a client who has glomerulonephritis.

A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which action by the nurse manager demonstrates a democratic leadership style? A) Avoids initiating change B) Seeks input from the other nurses C) Makes decisions quickly D) Limits the amount of feedback to the staff

B) Seeks input from the other nurses

A nurse is caring for a school-age child taking valproic acid. The nurse should expect the provider to order which diagnostic test? A) Chest x-ray B) Serum liver enzyme levels C) ABGs D) Urine culture and sensitivity

B) Serum liver enzyme levels Valproic acid can cause hepatic toxicity. Therefore, the nurse should expect the provider to prescribe laboratory tests to assess the child's liver function.

A nurse is providing teaching to a client who is to undergo ECT. The nurse should inform the client that which finding is an adverse effect of ECT? A) Agitation B) Short-term memory loss C) Post-treatment seizures D) Incontinence of the bowel and bladder

B) Short-term memory loss

A nurse preceptor is evaluating the performance of a newly licensed nurse. Which action by the newly licensed nurse requires intervention by the preceptor? A) Documents client tasks upon completion B) Starts a task then determines what supplies are needed C) Completes a client assessment while infusing an IV antibiotic over 30 min D) Returns to the nurse's station after completing several tasks in the same location

B) Starts a task then determines what supplies are needed

A nurse is creating a plan of care for a patient with left-sided weakness following a stroke. Which intervention should the nurse include in the plan? A) Massage bony prominences on the client's left side. B) Support the client's left arm on a pillow while sitting. C) Position the bedside table on the client's left side. D) Place the client's cane on his left side while ambulating.

B) Support the client's left arm on a pillow while sitting.

A nurse is caring for a client receiving PEEP via mechanical ventilation. What is an adverse effect of PEEP? A) Hypoxemia B) Tension pneumothorax C) Malignant hypertension D) Atelectasis

B) Tension pneumothorax The nurse should monitor the client's lung sounds hourly for indications of a tension pneumothorax, such as tracheal deviation, absent breath sounds, and distended neck veins, which is a possible adverse effect of PEEP.

A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lb) and is being breastfed. Which finding indicates effective breastfeeding? A) The newborn nurses every 4 hr during the day and sleeps through the night. B) The newborn has six to eight wet diapers per day. C) The newborn's current weight is 3.18 kg (7 lb). D) The newborn has sticky greenish stools.

B) The newborn has six to eight wet diapers per day.

A nurse administers an incorrect dose of a med to a client. The nurse recognizes the error immediately and completes an incident report. Which fact related to the incident should the nurse document in the client's medical record? A) Completion of the incident report B) Time the medication was given C) Reason for the medication error D) Notification of the pharmacist

B) Time the medication was given

A nurse is caring for a patient who asks about taking ginseng to improve her appetite. Ginseng can decrease the effectiveness of which med? A) Ethinyl estradiol/drospirenone B) Timolol C) Fluoxetine D) Warfarin

B) Timolol The nurse should identify that timolol is an ophthalmic antiglaucoma medication. Ginseng can decrease the effectiveness of this medication. Therefore, the nurse should instruct the client to speak with the provider prior to taking the supplement.

A nurse in the ED is caring for a patient with nausea and vomiting for 2 days. Which finding should the nurse expect? A) Hgb 15.0 g/dL B) Urine specific gravity 1.052 C) Urine osmolality 300 mOsm/L water D) Hct 44%

B) Urine specific gravity 1.052 The nurse should recognize this urine specific gravity is significantly elevated, indicating dehydration from vomiting.

A nurse is providing teaching to the parents of a child who has autism spectrum disorder. Which instruction should the nurse include? A) Maintain a flexible daily schedule for the child. B) Use a reward system to modify the child's behavior. C) Provide a variety of family members to care for the child. D) Administer alprazolam as needed to reduce the child's anxiety.

B) Use a reward system to modify the child's behavior.

A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place. The client is non-weight bearing for 6 weeks. Which instruction should the nurse include in the teaching? A) Adjust the crutches for comfort as needed. B) Use a three-point gait. C) Wear leather-soled shoes. D) Advance the affected leg first when walking upstairs.

B) Use a three-point gait. A three-point gait allows the client to be mobile without bearing weight on the affected extremity.

A nurse is providing teaching to a client who speaks a different language than the nurse about an upcoming diagnostic procedure. What action should the nurse take? A) Speak in a loud voice when explaining the procedure to the client. B) Use pictures to illustrate the procedure to the client. C) Use medical terminology to explain the procedure to the client. D) Validate the client's understanding of the procedure by watching for the client to smile and nod.

B) Use pictures to illustrate the procedure to the client.

A nurse is talking with a patient who has stage 4 breast cancer. The nurse should recognize which statement by the client as a constructive use of a defense mechanism? A) "I have experienced physical discomfort when intimate with my partner since my diagnosis." B) "I wish other women would stop socializing with my partner." C) "I told my doctor that I would like to start a support group for other women who are sick in my community." D) "I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness."

C) "I told my doctor that I would like to start a support group for other women who are sick in my community." This statement indicates that the client is using the constructive defense mechanism sublimation by devising a socially acceptable alternative to facing a reality that she does not wish to accept.

A home health nurse is evaluating a school-age child with cystic fibrosis. The nurse should indicate a request for a high-frequency chest compression vest in response to which parent statement? A) "My child doesn't like to sit still for nebulizer treatments." B) "I think that my child has been running a fever over the last couple of days." C) "My child has only a small amount of mucus after percussion therapy." D) "I am concerned about my child's future participation in team sports."

C) "My child has only a small amount of mucus after percussion therapy."

A nurse is caring for a patient who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donor states "I don't want my brother to die, but what if I need this kidney one day?" Which response should the nurse make? A) "I understand your hesitation, but I'm very proud of you for making the right decision." B) "Organ donation from a first-degree relative is your brother's best chance of survival." C) "You're afraid that your other kidney will fail at some point after the organ donation." D) "I know this process won't be easy, but you should focus on saving your brother's life."

C) "You're afraid that your other kidney will fail at some point after the organ donation."

A nurse is providing patient education about the basal body temperature method of birth control. What information should the nurse include in the teaching? A) "Your body temperature will drop approximately 1 degree 1 week after ovulation." B) "You should take your body temperature each evening prior to going to sleep." C) "Your body temperature might decrease slightly just prior to ovulation." D) "Your body temperature is at its highest during menstruation."

C) "Your body temperature might decrease slightly just prior to ovulation." The nurse should teach the client that a drop in body temperature of approximately 0.25° C (0.5° F) commonly occurs immediately prior to ovulation.

A nurse in an outpatient mental health clinic is caring for 4 patients. The nurse should recognize which client is effectively using sublimation as a defense mechanism? A) A client who transfers his anger about his job onto his family and then apologizes B) A client who misses provider appointments because he says he is too busy C) A client who channels her energy into a new hobby following the loss of her job D) A client whose partner died 4 years ago sets a place for him at dinner each night

C) A client who channels her energy into a new hobby following the loss of her job

A nurse is creating a plan of care for a child with acute lymphoid lukemia and an absolute neutrophil count of 400. Which intervention should the nurse do? A) Initiate contact precautions for the child. B) Administer the varicella vaccine to the child. C) Administer granulocyte colony-stimulating factor to the child. D) Provide a low-protein diet for the child.

C) Administer granulocyte colony-stimulating factor to the child. The nurse should administer granulocyte colony-stimulating factor to the child to promote the production of granulocytes in the bone marrow to help fight infection.

A nurse is providing teaching to a client who has a peripheral arterial disease. Which client action indicates understanding of the teaching? A) Warms her feet with a heating pad while sleeping B) Trims toenails with a rounded edge C) Applies lubricating lotion to her feet D) Elevates the feet above the level of the heart when resting

C) Applies lubricating lotion to her feet

A nurse is caring for 4 patients. Which task can the nurse delegate to the AP? A) Evaluate dietary intake for a client who has anorexia. B) Measure the vital signs of a client who just returned from the PACU. C) Arrange the lunch tray for a client who has a hip fracture. D) Assess I&O for a client who is receiving dialysis.

C) Arrange the lunch tray for a client who has a hip fracture.

A nurse is caring for a patient with GI bleeding and an NG tube in place. While performing gastric lavage, which action should the nurse take? A) Instill 50 mL of sterile water. B) Instill 75 mL of 0.9% sodium chloride irrigation. C) Ask the client to lie on the left side. D) Ask the client to lie supine.

C) Ask the client to lie on the left side. The nurse should ask the client to lie on the left side because this position limits the flow of the instilled solution out of the stomach and prevents aspiration.

A nurse is providing teaching to a client 26 weeks gestation and is to have an oral glucose tolerance test. Which action should the nurse instruct the client to take before the test? A) Reduce carbohydrate intake for at least 24 hr. B) Eat a snack. C) Avoid caffeine. D) Restrict physical activity for 3 days.

C) Avoid caffeine.

A nurse is caring for a multiparous client following a vacuum-assisted birth. The nurse should assess the client for which complication related to this birth method? A) Endometrial infection B) Intestinal gas C) Cervical laceration D) Retained placenta

C) Cervical laceration The nurse should assess the client for maternal complications associated with vacuum-assisted birth such as perineal, vaginal, or cervical lacerations.

A nurse is performing an admission assessment on a patient with a recent positive pregnancy test. The first day of her last menstrual period was May 8. According to Nagele's rile, which of the following dates should the nurse document as the patient's estimated date of birth? A) February 1 B) February 8 C) February 15 D) February 22

C) February 15 Using Nägele's rule, the nurse should add 7 days to the first day of the client's LMP (8 + 7 = 15) and then subtract 3 months. Therefore, the nurse should document the client's EDB as February 15th.

A nurse is caring for a client in the resuscitation phase of burn injury. Which findings should the nurse expect? A) Decreased hematocrit B) Hypokalemia C) Hyponatremia D) Increased albumin

C) Hyponatremia The nurse should expect the client to have a decrease in sodium levels because sodium is drawn to the edematous burn area and lost through plasma leakage.

A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which component of the MSE is priority for the nurse to assess? A) Mood B) Speech C) Ideas of self-harm D) Perceptual disturbances

C) Ideas of self-harm

A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify which physiological change is the cause for the client's visual loss? A) An increase in the intraocular pressure B) Deterioration of the macula C) Increased opacity of the lens D) Vitreous hemorrhage

C) Increased opacity of the lens

A nurse is preparing to mix haloperidol lactate 5 mg/mL and diphenhydramine 25 mg/1.5 mL to administer IM for a client who is agitated. Which action should the nurse take? A) Administer the medication into the deltoid muscle. B) Use a 1/2-inch needle for the injection. C) Inject air into both vials prior to withdrawing the medications. D) Use a filter needle to administer the medication.

C) Inject air into both vials prior to withdrawing the medications. The nurse should avoid administering more than 1 mL of medication into the deltoid site. Both haloperidol and diphenhydramine should be administered deep into a large muscle mass. The nurse should plan to use a 2-in needle for an IM injection of the combination of the 2 medications.

A nurse on a med-surg unit is caring for a patient with a new diagnosis of terminal cancer. The patient wants to go home to be with family and loved ones. What action should the nurse take? A) Contact the facility chaplain to visit with the client. B) Explain the process of leaving the facility against medical advice. C) Make a referral for social services. D) Encourage the client to continue with inpatient care.

C) Make a referral for social services.

A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which step of the time management process should the nurse manager include as priority? A) Organizing the work environment B) Delegating assigned tasks appropriately C) Making a list of activities to complete D) Rewarding yourself for accomplishing goals

C) Making a list of activities to complete

A nurse is caring for a client who has fluid volume overload. Which task should the nurse delegate to the AP? A) Palpate the degree of edema. B) Regulate IV pump fluid rate. C) Measure the client's daily weight. D) Assess the client's vital signs.

C) Measure the client's daily weight.

A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. Which med should the nurse expect to administer? A) Nalbuphine B) Terbutaline C) Oxytocin D) Magnesium sulfate

C) Oxytocin A client should receive oxytocin, a hormone that stimulates uterine contractions, to prevent bleeding.

A nurse is teaching self-administration of insulin to a patient with a new prescription for a short-acting and intermediate-acting insulin. Which action by the client indicates an understanding of the teaching? A) Withdraws the intermediate-acting insulin before the short-acting insulin B) Injects the insulin into the deltoid muscle C) Pinches the skin prior to injecting the insulin D) Inserts the needle at a 30° angle

C) Pinches the skin prior to injecting the insulin

A nurse is providing care for a client with a colostomy. Which action should the nurse take? A) Cleanse the skin at the stoma site with povidone-iodine for 15 seconds. B) Dampen the skin before applying the skin barrier and ostomy pouch. C) Place the skin barrier over the stoma and hold it for 30 seconds. D) Apply sterile gloves before cleaning the stoma site.

C) Place the skin barrier over the stoma and hold it for 30 seconds.

A nurse in a provider's office is caring for an 19-month old toddler who has a blood lead level of 3. Which action should the nurse take? A) Schedule chelation therapy. B) Contact the poison control center. C) Recommend rescreening in 1 year. D) Refer the family to social services.

C) Recommend rescreening in 1 year. The nurse should schedule chelation therapy for a blood lead level greater than 45 mcg/dL.

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which finding should the nurse identify as an adverse effect of this medication? A) Hypotension B) Report of tinnitus C) Report of chest pain D) Ecchymosis

C) Report of chest pain The nurse should recognize that a report of chest pain by the client can indicate an adverse effect of the medication. Epinephrine increases cardiac workload and oxygen demand, which can result in angina.

A nurse is reviewing the ABG values of a client. pH 7.20, PaCo2 60, and HCO3 25. What acid-base imbalance does the client have? A) Respiratory alkalosis B) Metabolic alkalosis C) Respiratory acidosis D) Metabolic acidosis

C) Respiratory acidosis

A nurse is caring for a child with hypotonic dehydration and is receiving an oral rehydration solution. Which lab result indicates the treatment regimen is effective? A) Urine pH 6.0 B) Urine specific gravity 1.035 C) Serum sodium 136 mEq/L D) Serum potassium 3.9 mEq/L

C) Serum sodium 136 mEq/L A child who has hypotonic dehydration has a serum sodium level below 130 mEq/L. A serum sodium level of 136 mEq/L, which is within the expected reference range, indicates that this child is responding well to the oral rehydration solution.

An RN is observing an LPN and an AP move a client up in bed. Which situation should the nurse intervene? A) The side rails are lowered before lifting the client up in bed. B) Prior to lifting the client, the bed is put in high position. C) The LPN and the AP grasp the client under his arms to lift him up in bed. D) The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift him.

C) The LPN and the AP grasp the client under his arms to lift him up in bed.

A nurse is caring for a patient who is 2 days postpartum. Which behavior indicated the client is bonding with her newborn? A) The client calls the nurse for help when the newborn cries. B) The client wakes the newborn when she is sleeping. C) The client tells visitors how much the newborn looks like her sister. D) The client talks on the phone while feeding the newborn.

C) The client tells visitors how much the newborn looks like her sister. Comparing physical and behavioral attributes to those of family members demonstrates acceptance and bonding behaviors.

A nurse is preparing to transfer a patient from ICU to medical floor. The patient was weaned from mechanical ventilation following a pneumonectomy. Which information should the nurse include in report? A) The last time the provider evaluated the client B) The client's most recent ventilator settings C) The time of the client's last dose of pain medication D) The frequency in which the client presses the call button

C) The time of the client's last dose of pain medication

A nurse is caring for a client with hyperthyroidism. Which finding should the nurse expect? A) Dry, coarse hair B) Bradycardia C) Tremors D) Periorbital edema

C) Tremors

A nurse is caring for a newborn immediately after delivery. Which intervention should the nurse implement to prevent hearing loss by conduction? A) Dry the newborn immediately after birth. B) Maintain an ambient room temperature of 24° C (75.2° F). C) Use a protective cover on the scale when weighing the infant. D) Place the newborn's bassinet away from outside windows.

C) Use a protective cover on the scale when weighing the infant.

A nurse is preparing to administer an IM injection to a client who is obese. Which action should the nurse plan to take? A) Select a 1-inch needle. B) Use a 45º angle when inserting the needle. C) Use the ventrogluteal site. D) Pinch the skin up during injection.

C) Use the ventrogluteal site.

A nurse is caring for a client with a PE. The client is receiving heparin IV at 1,200 units/hr and warfarin 5 mg PO daily. The morning lab values are aPTT 98 seconds and INR 1.8. Which action should the nurse take? A) Prepare to administer vitamin K1. B) Prepare to administer alteplase. C) Withhold the heparin infusion. D) Withhold the next dose of warfarin.

C) Withhold the heparin infusion. The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage should be reduced or the infusion withheld until the aPTT returns to the therapeutic range.

A nurse is assessing a patient with hypocalcemia. Which site should the nurse tap to elicit a positive Chvostek's sign? A) between the eyebrows B) under the eye C) cheek D) chin

C) cheek

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 DM. Which activity is the nurse's priority? A) Instruct the client about the importance of regular medical appointments. B) Encourage the client to participate in daily exercise. C) Explain proper foot care techniques to the client. D) Ensure that the client understands the medication regimen.

D) Ensure that the client understands the medication regimen.

A community health nurse is providing teaching about home safety with a group of elderly clients. Which statement should the nurse make? A) "Unplug your appliances by grasping the cord and pulling it straight from the outlet." B) "Set your water heater temperature at 130 degrees Fahrenheit." C) "Use throw rugs in high-traffic areas to partially cover wood floors." D) "Have grab bars installed around your bathtub and toilet."

D) "Have grab bars installed around your bathtub and toilet."

A nurse is providing information to a client immediately before his scheduled Romberg test. Which statement should the nurse make? A) "You will be standing with your feet 1 foot apart." B) "You will place and hold your hands on your hips." C) "I will be standing across the room from you to evaluate your sense of balance." D) "I will be checking you once with your eyes open and once with them closed."

D) "I will be checking you once with your eyes open and once with them closed."

A nurse is providing discharge instructions about newborn care to a client 2 days postpartum. Which statements indicate understanding of the teaching? (Select all) A) "I will breastfeed my baby on a schedule of every 4 hours." B) "I will bathe my baby daily." C) "I will be place my baby on her stomach for sleeping." D) "I will cover my baby's body when I wash her hair." E) "I will use the bulb syringe first in her mouth and then in her nose."

D) "I will cover my baby's body when I wash her hair." E) "I will use the bulb syringe first in her mouth and then in her nose."

A nurse is providing education to the parent of a school-age child with asthma. Which statement by the parent indicates an understanding of the teaching? A) "I will administer aspirin to my child to treat pain or fever." B) "I will record an average of three readings from my child's peak expiratory flow meter." C) "I will place carpet in my child's bedroom to control allergens." D) "I will make sure my child receives a yearly influenza vaccination."

D) "I will make sure my child receives a yearly influenza vaccination." Children who have asthma should be immunized and protected from infections. Therefore, the nurse should educate the parent to ensure the child receives a yearly influenza vaccine.

A nurse is teaching a client at 20 weeks gestation about common prenatal discomfort. Which statement by the client indicates an understanding of the teaching? A) "I will decrease my intake of high-fiber foods." B) "I will apply an anti-inflammatory ointment if I develop a rash on my face." C) "I will sleep flat on my back if I develop back pain." D) "I will wear a supportive bra overnight."

D) "I will wear a supportive bra overnight."

A nurse is reviewing the lab results of a toddler with hemophilia A. Which aPTT value should the nurse expect? A) 11 seconds B) 22 seconds C) 30 seconds D) 45 seconds

D) 45 seconds This value is above the expected reference range, indicating a risk for spontaneous bleeding, which is a manifestation of hemophilia A.

A nurse on a pediatric unit received report on 4 children. Which child should the nurse assess first? A) A 6-month-old infant who has croup and an O2 saturation of 92% on room air B) A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication C) A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain

D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain Using the urgent vs. non-urgent approach to client care, the nurse should determine that the client to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this can be an indication of peritonitis from a ruptured appendix.

A nurse has received report on 4 patients. Which patient should the nurse intervene to prevent a potential food and medication interaction? A) A client who is receiving verapamil and has a continuous infusion of total parenteral nutrition (TPN) B) A client who is taking phenytoin and is requesting a milkshake C) A client who is receiving a diet high in potassium-rich foods and furosemide by mouth D) A client who is receiving an MAOI and is requesting a cheeseburger for dinner

D) A client who is receiving an MAOI and is requesting a cheeseburger for dinner

A nurse working in the ED is triaging 4 patients. Which patient should the nurse recommend for treatment first? A) An older adult client who has severe abdominal pain B) A preschooler who has a skin rash C) An adolescent who has a closed fracture D) A middle adult client who has unstable vital signs

D) A middle adult client who has unstable vital signs

A nurse educator is teaching a group of newly licensed nurses about the need to complete an incident report. Which example should the nurse include as a reportable incident and an indication for completing a report? A) A nurse has had two unsuccessful attempts at starting a new IV line on a client. B) Two visitors are heard arguing at the nurses' station. C) A client refuses to take his prescribed antibiotic medication. D) A nurse administered a medication via the wrong route.

D) A nurse administered a medication via the wrong route.

A nurse is creating a plan for care of a newly admitted child. Which action should the nurse include in the plan? (Click exhibit) A) Initiate droplet isolation precautions. B) Keep the child on NPO status for 12 hr. C) Maintain the child on bed rest for 24 hr. D) Administer high dose antibiotic therapy.

D) Administer high dose antibiotic therapy. The nurse should include administering high-dose antibiotic therapy in the child's plan of care. Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections such as Burkholderia cepacia.

A nurse is assessing a newborn's HR. Which action should the nurse take? A) Assess the apical pulse while the newborn is crying to detect cardiac problems. B) Palpate the radial pulse and determine the rate based on number of beats per minute. C) Listen to the apical pulse while palpating the radial pulse to detect variance. D) Auscultate the apical pulse and count beats for at least 1 min.

D) Auscultate the apical pulse and count beats for at least 1 min.

A nurse is developing a discharge plan for a school-age child with thrombocytopenia. The nurse should instruct the child to avoid what? A) Large groups of people B) Quickly changing positions C) Eating fresh fruits D) Blowing the nose

D) Blowing the nose The nurse should instruct the child who has thrombocytopenia to avoid blowing the nose because it increases the risk for bleeding or hemorrhaging.

A nurse is caring for a post-op patient after receiving moderate (conscious) sedation. The patient suddenly becomes restless and reports feeling lightheaded. Which action should the nurse take? A) Check the client's temperature. B) Prepare to administer acetylcysteine to the client. C) Place the client in the Trendelenburg position. D) Check the client's oxygen saturation level.

D) Check the client's oxygen saturation level.

A nurse in the ED is assessing a school-age child who was brought in by her parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which action should the nurse take? A) Discuss his suspicion of physical abuse with the provider. B) Confront the parents with his suspicion of physical abuse. C) Ask the hospital security to detain and question the parents. D) Contact child protective services.

D) Contact child protective services.

A nurse is preparing to teach about dietary management to a patient with Crohn's disease and an enteroenteric fistula. Which nutrient should the nurse instruct the client to decrease in his diet? A) Calories B) Protein C) Potassium D) Fiber

D) Fiber The nurse should instruct the client who has Crohn's disease and an enteroenteric fistula to consume a low-fiber diet to reduce residue and decrease exacerbations.

A nurse is caring for a client who has TB. Which action should the nurse plan to take to prevent the transmission of the disease? A) Initiate contact precautions for the client. B) Restrict visitors from entering the client's room. C) Wear a surgical mask during contact with the client. D) Have the client wear a surgical mask while being transported outside the room.

D) Have the client wear a surgical mask while being transported outside the room.

A nurse is caring for a patient with COPD and becomes extremely SOB. Which intervention by the nurse requires completion of an incident report? A) Elevating the client's head of bed to 45° B) Administering a prescribed anxiolytic IV C) Administering a PRN bronchodilator via nebulizer D) Increasing oxygen via nasal cannula to 6 L/min

D) Increasing oxygen via nasal cannula to 6 L/min

A nurse is caring for a child with sickle cell anemia and is having a vaso-occlusive crisis. Which intervention should the nurse implement first? A) Collect a blood sample for laboratory tests. B) Administer medication for pain. C) Apply warm packs to affected areas. D) Infuse IV fluids.

D) Infuse IV fluids. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to infuse IV fluids to promote hydration and circulation. Increased fluid reduces the tissue and organ ischemia caused by the clumping of the RBCs.

A nurse in the ED is caring for a child with a fever and fluid-filled vesicles on the trunk and extremities. Which intervention should the nurse identify as priority? A) Encourage oral fluids. B) Apply topical calamine lotion. C) Administer acetaminophen as an antipyretic. D) Initiate transmission-based precautions.

D) Initiate transmission-based precautions. These findings indicate this child most likely has varicella, which is an infectious disease. Therefore, the first action the nurse should take is to initiate transmission-based precautions.

A nurse is caring for a client with a fecal impaction. Which action should the nurse take when digitally evacuating the stool? A) Place the client in the lithotomy position. B) Elicit a vagal response by performing gentle rectal stimulation. C) Administer oral bisacodyl 30 min prior to the procedure. D) Insert a lubricated gloved finger and advance along the rectal wall.

D) Insert a lubricated gloved finger and advance along the rectal wall.

A nurse in the oncology unit is administering doxorubicin to a client with breast cancer. Which action should the nurse take? A) Hold the dose if the client's bilirubin level is 2.0 mg/dL. B) Inject the solution slowly over 2 min. C) Administer an antiemetic to the client 15 min prior to the medication. D) Inspect the client's mucosa for petechiae every 8 hr.

D) Inspect the client's mucosa for petechiae every 8 hr. The nurse should inspect the client's mucosa for petechiae every 8 hr because this medication causes thrombocytopenia and increases the risk of bleeding. The nurse should also assess the client for hematuria, guaiac, and bruising.

A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. What action should the nurse plan to perform? A) Administer a bowel preparation the night before the procedure. B) Place the client on bed rest for 24 hr after the procedure. C) Perform pulmonary function tests following the procedure. D) Instruct the client to avoid deep breathing during the procedure.

D) Instruct the client to avoid deep breathing during the procedure. It is important for the nurse to remind the client to avoid deep breathing during a thoracentesis to avoid puncturing the pleura.

A nurse is preparing a sterile field to perform a sterile dressing change. Which intervention should the nurse use to maintain surgical aseptic technique? A) Hold hands folded below the waist after donning sterile gloves. B) Pick up and pour solutions with the palm of the hand covering bottle labels. C) Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. D) Maintain sterile objects within the line of vision.

D) Maintain sterile objects within the line of vision. Objects out of the line of vision are not considered sterile. Therefore, the nurse should keep sterile objects in direct sight to maintain surgical asepsis.

During report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. What action should the day shift nurse take? A) Keep the client's television on with the volume low. B) Insert an indwelling urinary catheter to minimize interaction with the client. C) Consult the provider regarding administering a mild sedative on a schedule. D) Move the client to a room near the nurses' station.

D) Move the client to a room near the nurses' station.

A nurse in the ED is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which action should the nurse take? A) Contact the facility's ethics committee. B) Obtain consent from the client's employer. C) Limit care to comfort measures. D) Proceed with provision of medical care.

D) Proceed with provision of medical care.

A nurse is developing a client education program about osteoporosis for older adult clients. What variable is a risk factor for osteoporosis? A) Obesity B) Acromegaly C) Estrogen replacement therapy D) Sedentary lifestyle

D) Sedentary lifestyle

A nurse is reviewing the lab report of a client who has end-stage kidney disease and received hemodialysis 24 hours ago. Which of the following lab values should the nurse report to the provider? A) Platelets 268,000/mm3 B) Calcium 9.2 mg/dL C) WBC 5,200/mm3 D) Sodium 148 mEq/L

D) Sodium 148 mEq/L

A nurse is providing teaching to a school-age child with asthma about using albuterol mertered-dose inhaler. Which instructions should the nurse include? A) Clean the mouthpiece with warm water every 2 weeks. B) Wait 10 seconds between inhalations. C) Take a quick inhalation when pressing the dispenser. D) Take the medication 15 min before playing sports.

D) Take the medication 15 min before playing sports.

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which observation should the nurse identify as an indicator for potential violence? A) The client is taking numerous deep, measured breaths. B) The client is calmly telling his partner that "the staff here is so controlling." C) The client is sitting with his head in his hands and appears to be crying. D) The client is pacing around the chair in which his partner is sitting.

D) The client is pacing around the chair in which his partner is sitting. Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the client by speaking to him in a low, calm voice using short sentences.

A nurse is preparing to administer a blood transfusion to a client. Which procedure should the nurse follow to ensure proper client identification? A) Check the client's blood type and crossmatch it against the provider's orders. B) Ask the client to state her blood type prior to beginning blood administration. C) Compare information on the blood product to the informed consent form. D) Verify the client and blood product information with another licensed nurse.

D) Verify the client and blood product information with another licensed nurse.

A nurse is assessing a client with COPD. Which finding should the nurse expect? A) Weight gain B) Decrease in anteroposterior diameter of the chest C) HCO3- 24 mEq/L D) pH 7.31

D) pH 7.31 Respiratory acidosis is an expected finding for a client who has COPD. A pH level of 7.35 or less indicates respiratory acidosis.