Exam #5 (Modules 9 & 10) - NUR415

A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test? A. "I didn't shampoo my hair." B. "I ate breakfast this morning." C. "I didn't take my anticonvulsant today." D. "It was hard not to drink coffee this morning, but I knew that I couldn't, so I didn't."

A. "I didn't shampoo my hair."

The home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction? A. "I should put a steam vaporizer in her room." B. "I'll take her out into the cool, humid night air." C. "I can open the freezer door and encourage her to breathe in the cool air." D. "I can run the hot water in my bathroom and cuddle her in the steamy room."

A. "I should put a steam vaporizer in her room."

A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take? A. Taking the client's vital signs B. Giving the client a drink of water C. Monitoring the client for a sore throat D. Being alert to complaints of heartburn

A. Taking the client's vital signs

The home care nurse is providing instructions to the mother of a 3-year-old with hemophilia regarding care of the child. Which statements by the mother indicate a need for further instructions? Select all that apply. A. "I will be so glad when my baby outgrows all of this bleeding." B. "I need to cancel all of the dental appointments that I've made for him." C. "If he gets a cut, I should hold pressure on it until the bleeding stops." D. "I should check the house for any household items that could fall over easily." E. "I should move furniture with sharp corners out of the way and pad the corners of the furniture."

A. "I will be so glad when my baby outgrows all of this bleeding." B. "I need to cancel all of the dental appointments that I've made for him."

A client with cardiovascular disease is scheduled to receive a daily dose of furosemide. Which potassium level would cause the nurse, reviewing the client's electrolyte values, to contact the primary health care provider before administering the dose? A. 3.0 mEq/L (3.0 mmol/L) B. 3.8 mEq/L (3.8 mmol/L) C. 4.2 mEq/L (4.2 mmol/L) D. 5.2 mEq/L (5.2 mmol/L)

A. 3.0 mEq/L (3.0 mmol/L)

The nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which serum potassium reading does the nurse associate this finding? A. 3.1 mEq/L (3.1 mmol/L) B. 4.2 mEq/L (4.2 mmol/L) C. 4.5 mEq/L (4.5 mmol/L) D. 5.4 mEq/L (5.4 mmol/L)

A. 3.1 mEq/L (3.1 mmol/L)

A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than which value? A. 7% B. 9% C. 10% D. 15%

A. 7%

A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which intervention does the nurse prepare the client? A. An ultrasound examination B. Internal fetal monitoring C. Administration of oxytocin D. A manual (digital) pelvic examination

A. An ultrasound examination

A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client? A. Assess the patency of the airway B. Check tubes and drains for patency C. Check the dressing for bleeding D. Assess the vital signs to compare them with preoperative measurements

A. Assess the patency of the airway

A client arrives in the emergency department for treatment of a surface injury sustained when sand blew into the eye. Which action does the nurse take first? A. Assessing the client's vision B. Placing ice on the eye C. Removing the sand particles D. Irrigating the eye with sterile saline solution

A. Assessing the client's vision

The nurse enters a client's room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first? A. Beginning chest compressions B. Checking the client's pulse oximetry reading C. Placing an oxygen mask on the client D. Counting the client's carotid pulse for 15 seconds

A. Beginning chest compressions

A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client? A. Bleeding B. Renal colic C. Infection at the site D. Increased temperature

A. Bleeding

The nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which instruction does the nurse plan to include? A. Call the primary health care provider if the infant is lethargic. B. Expect increased urine output with the shunt. C. Call the primary health care provider if the anterior fontanel bulges when the infant cries. D. Position the infant on the side of the shunt for sleep.

A. Call the primary health care provider if the infant is lethargic.

The home care nurse visits a pregnant client with a diagnosis of mild preeclampsia. During the assessment, the client tells the nurse that she has had an upset stomach and pain in the epigastric area. What should the nurse most appropriately do? A. Contact the primary client's health care provider B. Tell the client to avoid lying flat C. Instruct the client to eat a small portion of food every 2 to 3 hours D. Administers an antacid to the client and tell her to take a dose every 6 hours

A. Contact the primary client's health care provider

The nurse is monitoring a client after transurethral resection (TUR) of the prostate for benign prostatic hypertrophy (BPH). The client has a bladder irrigation infusing, and the urine output is a light cherry color. The nurse performs a follow-up assessment 1 hour later and notes that the urine output is now bright red in color with clots and that the client's blood pressure has dropped. Which action by the nurse is appropriate? A. Contacting the primary health care provider B. Continuing to monitor the client C. Increasing the flow rate of the intravenous (IV) solution D. Placing pressure on the bladder to aid expulsion of any additional clots

A. Contacting the primary health care provider

A nurse is preparing to examine a client's skin using a Wood light. What should the nurse do to facilitate this procedure? A. Darken the examining room B. Administer a local anesthetic C. Obtain a signed informed consent D. Shave the skin and scrub it with povidone-iodine (Betadine)

A. Darken the examining room

The nurse is admitting a client with a diagnosis of renal calculi. What does the nurse know can contribute to the client's diagnosis? A. Dehydration B. Foods low in protein C. Decreased intake of dairy products D. Low level of parathyroid hormone (PTH)

A. Dehydration

A client with a history of lung disease is at risk for respiratory acidosis. For which signs/symptoms does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth

A. Disorientation and dyspnea

The emergency department nurse assesses a client who has a diagnosis of left-sided heart failure. Which findings does the nurse expect to note? Select all that apply. A. Dyspnea B. Dependent edema C. Neck vein distention D. Abdominal distention E. Crackles on auscultation of the lungs

A. Dyspnea E. Crackles on auscultation of the lungs

A nurse is preparing a client for transfer to the operating room. Which action should the nurse take in the care of this client at this time? A. Ensuring that the client has voided B. Administering all daily medications C. Practicing postoperative breathing exercises D. Verifying that the client has not eaten for the last 24 hours

A. Ensuring that the client has voided

A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure? A. Flat B. Semi-Fowler C. Side-lying, with the head of the bed elevated D. Sitting up in a recliner with the feet elevated

A. Flat

A nurse is performing nasotracheal suctioning on a client. Which observations should be cause for concern to the nurse? Select all that apply. A. The client becomes cyanotic. B. Secretions are becoming bloody. C. The client gags during the procedure. D. Clear to opaque secretions are removed. E. The heart rate varies from 80 to 82 beats/min.

A. The client becomes cyanotic. B. Secretions are becoming bloody.

A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription? Select all that apply. A. Giving the client a device holder to wear around the waist B. Giving the client a diary in which to record activity and signs/symptoms C. Telling the client to rest as much as possible during the next 24 hours D. Instructing the client to enclose the monitor in plastic wrap before taking a bath E. Telling the client that occasional slight shocks from the monitor will be felt but that they are harmless

A. Giving the client a device holder to wear around the waist B. Giving the client a diary in which to record activity and signs/symptoms

A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon's office? Select all that apply. A. Hematocrit 30% (0.30) B. Sodium 141 mEq/L (141 mmol/L) C. Hemoglobin 8.9 g/dL (89 g/L) D. Platelets 210× 103/μL (210 × 109/L) E. Serum creatinine 0.8 mg/dL (70 μmol/L)

A. Hematocrit 30% (0.30) C. Hemoglobin 8.9 g/dL (89 g/L)

The nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of new-onset glomerulonephritis. Which finding would the nurse expect to note? A. Hypertension B. Low serum potassium C. Increased creatinine level D. Cloudy yellow urine

A. Hypertension

A client has been given a diagnosis of multiple myeloma. Which result does the nurse reviewing the client's laboratory findings recognize as being specifically related to this diagnosis? A. Increased calcium level B. Decreased blood urea nitrogen (BUN) C. Increased white blood cell (WBC) count D. Decreased number of plasma cells in the bone marrow

A. Increased calcium level

A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client for the procedure? A. Left Sims' position B. Lithotomy position C. Knee-chest position D. Right Sims' position

A. Left Sims' position

The nurse is assessing a 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child? A. Lethargy B. Bradycardia C. Hyperactivity D. Reddened cheeks

A. Lethargy

The nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. What should the nurse tell the client to do? A. Limit sodium in the diet B. Increase fluid intake to at least 3000 mL/day C. Lie down when vertigo occurs and keep a light on in the room D. Move the head from the right to the left when vertigo occurs to determine the extent of its effects

A. Limit sodium in the diet

A client is brought to the emergency department by a neighbor. The client is lethargic and has a fruity odor on the breath. The client's arterial blood gas (ABG) results are pH 7.25, PaCO234 mm Hg (4.52 kPa), PaO2 86 mm Hg (11.3 kPa), HCO3 14 mEq/L (14 mmol/L). Which acid-base disturbance does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL (34.4 mmol/L). After the nurse calls the primary health care provider to report the finding and monitors the client closely for which condition? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

A nurse is reading the radiology report of a client who has a chest tube attached to a closed drainage system and has undergone chest x-ray. The report states that the client's affected lung is fully re-expanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding? A. No fluctuation in the water seal chamber B. Continuous bubbling in the water seal chamber C. Increased drainage in the collection chamber D. Continuous gentle suction in the suction control chamber

A. No fluctuation in the water seal chamber

A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply. A. That informed consent is required B. That the test takes about 4 hours to complete C. That no premedication for sedation will be necessary D. That food and fluids will be withheld before the procedure E. That multiple position changes may be necessary to pass the tube

A. That informed consent is required D. That food and fluids will be withheld before the procedure E. That multiple position changes may be necessary to pass the tube

A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The nurse should take which immediate action? A. Notify the surgeon B. Continue the assessment C. Check the client's blood pressure D. Obtain a flashlight, gauze, and a curved hemostat

A. Notify the surgeon

A nurse checks the residual volume from a client's nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client? A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed B. Discard the residual volume properly and record it as output on the client's fluid balance record C. Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger D. Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger

A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed

The nurse is caring for a client in the intensive care unit (ICU) who is being mechanically ventilated. As the nurse prepares medications, the client suddenly becomes anxious and pulls out the endotracheal tube. After the nurse assesses the client for spontaneous breathing, what does the nurse do next? A. Prepares for reintubation B. Restrains the client's wrists C. Calls the rapid response team (RRT) D. Administers an antianxiety medication to the client

A. Prepares for reintubation

A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume? A. Pulse rate B. Blood pressure C. Pulmonary artery systolic pressure D. Pulmonary artery end-diastolic pressure

A. Pulse rate

The nurse assessing a client in the fourth stage of labor notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. On the basis of this finding, what does the nurse most appropriately do? A. Record the findings B. Massage the fundus C. Contact the primary health care provider D. Help the mother void

A. Record the findings

The nurse provides dietary instructions to the mother of a child with celiac disease. Which food does the nurse tell the mother to include in the child's diet? A. Rice B. Wheat cereal C. Rye crackers D. Oatmeal biscuits

A. Rice

A nurse is reviewing laboratory results for a newly admitted client. Which serum lab result does the nurse document as abnormal? A. Serum creatinine 0.2 mg/dL (17.6 μmol/L) B. Prothrombin time 11.0 to 12.5 seconds; 85% to 100% C. Sodium cholesterol D. Serum sodium (NA) 136 to 145 mEq/L or 136/145 mmol/L (SI units)

A. Serum creatinine 0.2 mg/dL (17.6 μmol/L)

A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply. A. Setting the suction pressure to 60 mm Hg B. Applying suction throughout the procedure C. Assessing breath sounds before suctioning D. Placing the client in a supine position before the procedure E. Hyperoxygenating the client with 100% oxygen before suctioning

A. Setting the suction pressure to 60 mm Hg B. Applying suction throughout the procedure D. Placing the client in a supine position before the procedure

An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse that some of the client's lab data are abnormal? Select all that apply. A. Sodium (NA) 149 mEq/L B. Hematocrit (HCT) 30% (0.30) C. Calcium (CA) 9 mg/dL D. LDL Cholesterol 140 E. Magnesium (MG) 2.2 mEq/L F. Bicarbonate 21 mEqL

A. Sodium (NA) 149 mEq/L B. Hematocrit (HCT) 30% (0.30) D. LDL Cholesterol 140 F. Bicarbonate 21 mEqL

A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication of which? A. The tube is patent B. There is probably a kink in the tubing C. Suction should be added to the system D. The client is retaining airway secretions

A. The tube is patent

A client has undergone creation of an Indiana pouch for urine diversion after cystectomy, and the nurse provides instructions about reservoir catheterization. What does the nurse tell the client? A. To plan to drain the reservoir every 2 to 3 hours initially B. That if mucus drains from the reservoir the primary health care provider should be contacted C. That sometimes force is needed to insert the catheter into the reservoir D. To obtain 26F catheters from the medical supply store for the irrigations

A. To plan to drain the reservoir every 2 to 3 hours initially

A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the primary health care provider? Select all that apply. A. Unequal chest expansion B. Pulse rate of 82 beats/min C. Respiratory rate of 22 breaths/min D. Diminished breath sounds in the right lung E. Complaints of discomfort at the needle insertion site

A. Unequal chest expansion D. Diminished breath sounds in the right lung

The nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next? A. Use the AED B. Stop the resuscitation efforts C. Perform CPR until emergency medical services arrives D. Check for a pulse for 30 seconds before continuing CPR

A. Use the AED

The nurse is reading the medical record of a pregnant client in the second trimester with a diagnosis of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented? A. Uterine tenderness B. Lack of uterine activity C. Painless vaginal bleeding D. Constipation

A. Uterine tenderness

The nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan? A. Visitors must be limited to one half-hour per day. B. Visitors must remain at least 2 feet (61 cm) from the client. C. A dosimeter badge must be placed on the client's bedside stand. D. The client may be maintained in a semiprivate room as long as the client uses a commode.

A. Visitors must be limited to one half-hour per day.

A client with diabetes mellitus (DM) is scheduled to have blood drawn in the morning for a fasting blood glucose determination. What does the nurse tell the client that it is acceptable to consume on the morning of the test? A. Water B. Tea without any sugar C. Coffee without any milk D. Clear liquids such as apple juice

A. Water

Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the primary health care provider's prescriptions to ensure that the prescribed flow is not greater than which liter (L) per minute (min)? A. 1 L/min B. 3 L/min C. 4 L/min D. 6 L/min

B. 3 L/min

The nurse is caring for a client with Crohn's disease whose magnesium level is 1.0 mEq/L (0.5 mmol/L). Which assessment findings does the nurse expect to note? Select all that apply. A. Hypotension B. Abdominal distention C. Trousseau sign D. Skeletal muscle weakness E. Decreased deep tendon reflexes

B. Abdominal distention C. Trousseau sign

The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction? A. "I need to keep the sun off the radiation site." B. "I can use over-the-counter cortisone cream on the radiation site if it gets red." C. "I need to be careful not to wash off the marks that the radiologist made on my skin." D. "I need to wash the skin at the radiation site with a mild soap and water and pat it dry."

B. "I can use over-the-counter cortisone cream on the radiation site if it gets red."

The nurse provides instructions to a client with chronic obstructive pulmonary disease (COPD) about the positions that are most effective in alleviating dyspnea. Which statement by the client indicates a need for further instruction? A. "I should sit up in my recliner." B. "I should lie on my right side in bed." C. "I should sit on the side of my bed and lean on the overbed table." D. "I should stand with my back and hips against the wall and my shoulders bent slightly forward."

B. "I should lie on my right side in bed."

The nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to prevent reflux during sleep. The nurse determines that the client needs additional instructions if the client makes what comment? A. "I should take an antacid at bedtime." B. "I should sleep flat on my right side." C. "The histamine antagonist will help me." D. "I should avoid eating in the 3 hours before bedtime."

B. "I should sleep flat on my right side."

A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client's request? A. "Short walks are OK." B. "You need to stay in your room for now." C. "Yes, it's fine to take a walk around the nursing unit." D. "Do you think that a walk around the unit will tire you out?"

B. "You need to stay in your room for now."

A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than which value? A. 140 mg/dL (<3.64 mmol/L) B. 200 mg/dL (<5.2 mmol/L) C. 250 mg/dL (<6.5 mmol/L) D. 300 mg/dL (<7.8 mmol/L)

B. 200 mg/dL (<5.2 mmol/L)

A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes? A. Giving the client thin liquids B. Alternating liquids with solids C. Giving foods that are primarily liquid D. Placing food in the affected side of the client's mouth

B. Alternating liquids with solids

A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. What does the nurse immediately do? A. Call a code B. Assess the client C. Check the cardiac leads and wires D. Obtain a rhythm strip from the monitor device

B. Assess the client

A stapedectomy is performed on a client with otosclerosis. During the preparations for discharge, which home care instruction does the nurse give the client? A. Expect excessive ear drainage for about 2 weeks. B. Avoid rapidly moving the head and bending over for at least 3 weeks. C. Rinse the ear canal at least twice a day to clear out any excess drainage. D. It is all right to shower as long as the ear dressing is changed immediately after the shower.

B. Avoid rapidly moving the head and bending over for at least 3 weeks.

A hospitalized client with chronic renal failure has returned to the nursing unit after a hemodialysis treatment. Which parameters contained in the predialysis and postdialysis documentation does the nurse utilize to determine if the procedure was effective? A. Weight and BUN B. Blood pressure and weight C. Potassium and creatinine levels D. Blood urea nitrogen (BUN) and creatinine levels

B. Blood pressure and weight

The nurse provides instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse determines that the mother understands the instructions if the mother says that she will do what? A. Bottle feed only B. Breastfeed the newborn every 2 to 3 hours C. Provide water feedings between breast feedings D. Feed her newborn less frequently until the bilirubin level drops

B. Breastfeed the newborn every 2 to 3 hours

A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which action should the nurse take first? A. Contact the primary health care provider B. Check for kinks in the drainage system C. Check the client's blood pressure and heart rate D. Connect a new drainage system to the client's chest tube

B. Check for kinks in the drainage system

A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? A. Continue suctioning to remove the blood B. Check the degree of suction being applied C. Encourage the client to cough out the bloody secretions D. Remove the suction catheter from the client's nose and begin vigorous suctioning through the mouth

B. Check the degree of suction being applied

Blood for arterial blood gas determinations is drawn on a client with pneumonia, and testing reveals a pH of 7.45, PaCO2 of 30 mm Hg (3.99 kPa), and HCO3 of 19 mEq/L (19 mmol/L). The nurse interprets these results as indicative of which disorder? A. Compensated metabolic acidosis B. Compensated respiratory alkalosis C. Uncompensated metabolic alkalosis D. Uncompensated respiratory acidosis

B. Compensated respiratory alkalosis

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could cause which effect? A. Be drying to nasal passages B. Decrease the client's oxygen-based respiratory drive C. Increase the risk of pneumonia as a result of drier air passages D. Decrease the client's carbon dioxide-based respiratory drive

B. Decrease the client's oxygen-based respiratory drive

A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. A. Decreased pulse B. Decreased urine output C. Increased blood pressure D. Increased respiratory rate E. Decreased respiratory depth

B. Decreased urine output D. Increased respiratory rate

The nurse is caring for a client with a diagnosis of suspected uric acid calculi. The nurse is carefully checking the history of the client. What areas should the nurse focus on? Select all that apply. A. History of anemia B. Dietary supplements C. Previous problems with fluid overload 8.9 mg/dL (529.9 μmol/L) D. Family history of urinary calculi E. Prescribed and OTC medications F. Previous episodes of stone formation

B. Dietary supplements D. Family history of urinary calculi E. Prescribed and OTC medications F. Previous episodes of stone formation

A client has just returned to the nursing unit after a computerized tomography (CT) with contrast medium. Which action should the nurse plan to take as part of routine after-care for this client? A. Administering a laxative B. Encouraging fluid intake C. Maintaining the client on strict bed rest D. Holding all medications for at least 2 hours

B. Encouraging fluid intake

A nurse reviews a client's urinalysis report. Which findings does the nurse recognize as abnormal? Select all that apply. A. pH of 6.0 B. Glucose noted C. Casts apparent D. An absence of protein E. The presence of ketones F. Specific gravity of 1.018

B. Glucose noted C. Casts apparent E. The presence of ketones

The ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the mother needs further instruction if she indicates what? A. Avoid giving citrus juices to her child B. Have her child use a straw to make drinking easier C. Give acetaminophen to her child for discomfort D. Give her child extra fluids to relieve a foul odor from the mouth

B. Have her child use a straw to make drinking easier

A client with chronic kidney disease is undergoing his/her first hemodialysis treatment. The nurse is monitoring the client for signs/symptoms of disequilibrium syndrome. For which signs/symptoms of this syndrome does the nurse monitor the client? A. Fever and tachycardia B. Headache and confusion C. Bradycardia and hypothermia D. Irritability and generalized weakness

B. Headache and confusion

A client tells the nurse that he has been experiencing frequent heartburn and has been "living on antacids." For which acid-base disturbance does the nurse recognize a risk? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis

A nurse is caring for a client who is vomiting. For which acid-base imbalance does the nurse assess the client? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis

The nurse is monitoring a client with hyperparathyroidism for signs/symptoms of hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply. A. Paresthesias B. Muscle weakness C. Increased urine output D. Chvostek sign E. Hyperactive deep tendon reflexes

B. Muscle weakness C. Increased urine output

A client has been scheduled for magnetic resonance imaging (MRI). For which condition, a contraindication to MRI, does the nurse check the client's medical history? A. Pancreatitis B. Pacemaker insertion C. Type 1 diabetes mellitus D. Chronic airway limitation

B. Pacemaker insertion

A client has just undergone a renal biopsy. Which intervention should the nurse include in the post-procedure plan of care? A. Restricting fluid intake for the first 24 hours B. Periodically testing the urine for occult blood C. Avoiding the administration of opioid analgesics D. Having the client ambulate in the room and hall for short distances

B. Periodically testing the urine for occult blood

The nurse has admitted a client with a diagnosis of tuberculosis (TB) to the nursing unit. Which finding that confirms the diagnosis does the nurse expect to see documented in the client's record? A. Night sweats and a low-grade fever B. Positive result on an acid-fast bacillus smear C. Cough and expectoration of mucopurulent sputum D. A tuberculin skin test result that indicates 5 mm of redness

B. Positive result on an acid-fast bacillus smear

A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing pre-procedure instructions, should tell the client to implement which measure? A. Eat a regular supper and breakfast B. Remove all metal and jewelry before the test C. Expect diarrhea for a few days after the procedure D. Take all oral medications as scheduled with milk on the day of the test

B. Remove all metal and jewelry before the test

A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contrast medium by monitoring for the presence of which sign/symptom? A. Bradycardia B. Respiratory distress C. Hematoma in the right groin D. Discomfort in the right groin

B. Respiratory distress

The nurse is providing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. What does the nurse tell the client to do? A. Sit in soft, deep chairs B. Rock back and forth to start movement C. Exercise in the evening to combat fatigue D. Perform tasks with only the hand that has the tremor

B. Rock back and forth to start movement

A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac monitoring. The client suddenly complains of chest pain, and the nurse obtains a 12-lead electrocardiogram (ECG). Which finding would the nurse expect to note in the event of an ischemic episode? A. Peaked T waves B. ST-segment depression C. Widened QRS complex D. An isolated premature ventricular contraction (PVC)

B. ST-segment depression

A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client? A. Supine B. Semi-Fowler C. On the side that has undergone surgery D. Prone on the side that has undergone surgery

B. Semi-Fowler

A nurse is reviewing the results of serum laboratory studies of a client with suspected hepatitis. Which increased parameter is interpreted by the nurse as the most specific indicator of this disease? A. Hemoglobin B. Serum bilirubin C. Blood urea nitrogen (BUN) D. Erythrocyte sedimentation rate (ESR)

B. Serum bilirubin

A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though "something ripped." For which manifestations does the nurse, suspecting uterine rupture, assess the client? Select all that apply. A. Bradypnea B. Severe chest pain C. Absence of fetal heart tones D. Increased blood pressure E. Increased frequency of uterine contractions

B. Severe chest pain C. Absence of fetal heart tones

The nurse in a newborn nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the newborn's bedside? A. Flashlight B. Sterile dressing C. Cardiac monitor D. Blood pressure cuff

B. Sterile dressing

A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client? A. Assessing the client's chest for crepitus once every 24 hours B. Taping the connections between the chest tube and the drainage system C. Adding 20 mL of sterile water to the suction control chamber every shift D. Recording the volume of secretions in the drainage collection chamber every 24 hours

B. Taping the connections between the chest tube and the drainage system

A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells per cubic millimeter of blood. The nurse interprets this test result as indicating which? A. Improvement in the client B. The need for antiretroviral therapy C. The need to discontinue antiretroviral therapy D. An effective response to the treatment for HIV

B. The need for antiretroviral therapy

A mother calls the clinic and tells the nurse that her newborn's umbilical cord site looks red and swollen. What should the nurse tell the mother? A. That this is a normal occurrence B. To bring the newborn to the clinic C. To increase the number of cord site cleanings each day D. To place an ice pack on the cord for 10 minutes three times a day

B. To bring the newborn to the clinic

The nurse is conducting an assessment of a client with mild preeclampsia. Which sign/symptom indicates improvement in the client's condition? A. Complaint of headache B. Trace protein in the urine C. Blood pressure 148/94 mm Hg D. Blood urea nitrogen (BUN) of 40 mg/dL (14.2 mmol/L)

B. Trace protein in the urine

A primary health care provider is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client? A. Supine B. Upright C. Left side-lying D. Right side-lying

B. Upright

A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. Where does the nurse caring for this client plan to place the client's personal care items? A. Within the client's reach on the left side B. Within the client's reach on the right side C. Just out of the client's reach on the left side D. Just out of the client's reach on the right side

B. Within the client's reach on the right side

The nurse provides instructions to a client about measures to prevent an acute attack of gout. What client statement does the nurse determine indicates that the client needs additional instructions? A. "It's important for me to drink a lot of fluids." B. "A fad diet or starvation diet can cause an acute attack." C. "I don't need medication unless I'm having a severe attack." D. "Physical and emotional stress can cause an attack."

C. "I don't need medication unless I'm having a severe attack."

The nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction? A. "I should always maintain good posture." B. "I should stop my exercises if I get tired." C. "I should avoid all exercise when my joints are inflamed." D. "Doing range-of-motion exercises every day will ease the pain."

C. "I should avoid all exercise when my joints are inflamed."

A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin. Which result indicates that the prescribed dose of phenytoin is therapeutic? A. 3 mcg/mL (12 µmol/L) B. 8 mcg/mL (32 µmol/L) C. 16 mcg/mL (63 µmol/L) D. 28 mcg/mL (111 µmol/L)

C. 16 mcg/mL (63 µmol/L)

The nurse arrives at the scene of a code and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest by what depth? A. ½ inches (1.27 cm) B. 1½ inches (3.8 cm) C. 2 inches (5 cm) D. 4 inches (10 cm)

C. 2 inches (5 cm)

A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above which value? A. 85% B. 89% C. 95% D. 100%

C. 95%

The nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A. A client admitted with pneumonia with a fever of 100° F (37.8°C) and some diaphoresis B. A client with congestive heart failure with clear lung sounds on the previous shift C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema (PE) D. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms

C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema (PE)

A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse most concerned? A. Oxygen saturation of 97% B. Equal breath sounds in both lungs C. Absence of cough and gag reflexes D. Respiratory rate of 20 breaths/min

C. Absence of cough and gag reflexes

The nurse notes that a client's serum potassium level is 5.8 mEq/L(5.8 mmol/L). What does the nurse interpret this expected finding to be related to? A. Diarrhea B. Wound drainage C. Addison disease D. Heart failure being treated with loop diuretics

C. Addison disease

A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? A. Preparing the client for a perfusion scan B. Attaching the client to a cardiac monitor C. Administering oxygen by way of nasal cannula D. Ensuring that the intravenous (IV) line is patent

C. Administering oxygen by way of nasal cannula

The nurse is reviewing medical records to assigned clients on the 7 am to 7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume? A. A 48-year-old client receiving diuretics to treat hypertension B. A 35-year old client who is vomiting undigested food after eating C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr D. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy

C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr

A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client needs further teaching if the client indicates planning to do what as part of aftercare? A. Use the antibiotic ointment as prescribed B. Return in 7 days to have the sutures removed C. Apply cool compresses to the site twice a day for 20 minutes D. Call the primary health care provider if excessive drainage from the wound occurs

C. Apply cool compresses to the site twice a day for 20 minutes

The nurse receives a telephone call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse rushes to the neighbor's house and notes that the child has sustained a contusion of the eye. What does the nurse advise the child's mother to immediately do? A. Call an ambulance B. Call an optometrist C. Apply ice to the affected eye D. Irrigate the eye with cool water

C. Apply ice to the affected eye

A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? Select all that apply. A. Clamp the chest tube B. Change the drainage system C. Assess the system for an external air leak D. Reduce the degree of suction being applied E. Document assessment findings, actions taken, and client response

C. Assess the system for an external air leak E. Document assessment findings, actions taken, and client response

A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives to the unit, what should the nurse do first? A. Weigh the child B. Take the child's temperature C. Attach the child to a pulse oximeter D. Administer the prescribed antibiotic

C. Attach the child to a pulse oximeter

The wife of a client with angina pectoris calls the primary health care provider's office and reports to the nurse that her husband is experiencing chest pain and has taken 2 sublingual nitroglycerin tablets 5 minutes apart, with no relief. What does the nurse tell the client's wife to do? A. Have her husband rest and, if no relief is obtained, call back B. Discuss the situation with the doctor, who will call her as soon as he gets into the office C. Call Emergency Medical Services to take her husband to the emergency department (ED) immediately D. Give her husband a third tablet and, if no relief is obtained, call an ambulance to have him transported to the ED

C. Call Emergency Medical Services to take her husband to the emergency department (ED) immediately

A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client's bed and immediately does what? A. Document the event B. Notify the primary health care provider C. Check the client's bladder for distention D. Check to see whether the client has a prescription for an antihypertensive

C. Check the client's bladder for distention

A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client's urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take which action first? A. Call the primary health care provider Incorrect B. Increase the rate of the IV infusion C. Check the client's overall intake and output record D. Administer a 250-mL bolus of normal saline solution (0.9%)

C. Check the client's overall intake and output record

The nurse is caring for a hospitalized client who is undergoing peritoneal dialysis. The nurse notes that the outflow is less than the inflow on the first exchange. What should the nurse do first? A. Irrigate the catheter B. Reposition the client C. Check the system for kinks D. Hang the second exchange and continue to monitor the outflow

C. Check the system for kinks

A nurse administers scopolamine as prescribed to a client. For which side effect of this medication does the nurse monitor the client? A. Pupil constriction B. Increased urine output C. Complaints of dry mouth D. Complaints of feeling sweaty

C. Complaints of dry mouth

A nurse is monitoring a client who has undergone pleural biopsy. Which finding causes the nurse to suspect that the client is experiencing a complication? A. Warm, dry skin B. Mild pain at the biopsy site C. Complaints of shortness of breath D. Capillary refill time of less than 3 seconds

C. Complaints of shortness of breath

The nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client's blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, what should the nurse immediately do? A. Suction the client B. Obtain a pulse oximeter C. Contact the primary health care provider D. Increase the rate of the client's intravenous (IV) solution

C. Contact the primary health care provider

A client is receiving a continuous IV infusion of heparin for the treatment of deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) level is 88 seconds (88 seconds). The client's baseline before the initiation of therapy was 30 seconds (30 seconds). Which action does the nurse anticipate is needed? A. Shutting off the heparin infusion B. Increasing the rate of the heparin infusion C. Decreasing the rate of the heparin infusion D. Leaving the rate of the heparin infusion as is

C. Decreasing the rate of the heparin infusion

A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs/symptoms should the nurse assess the client to determine whether the tamponade is recurring? A. Decreasing pulse B. Rising blood pressure C. Distant muffled heart sounds D. Falling central venous pressure (CVP)

C. Distant muffled heart sounds

Polyethylene glycol-electrolyte solution is prescribed for a hospitalized client scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate? A. Administering a cleansing enema. B. Calling the primary health care provider C. Documenting the diarrhea in the medical record D. Giving intravenous replacement fluids in large amounts

C. Documenting the diarrhea in the medical record

A pelvic ultrasound is prescribed to evaluate a client's ovarian mass. What should the nurse giving pre-procedure instructions tell the client that is important to do before the procedure? A. Eat only a light breakfast B. Wear comfortable clothing and shoes C. Drink 6 to 8 glasses of water without voiding d. Stop eating or drinking at midnight before the test

C. Drink 6 to 8 glasses of water without voiding

A nurse has a prescription to discontinue a client's nasogastric tube. The nurse auscultates the client's bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath followed by what client action? A. Exhale during tube removal B. Bear down during tube removal C. Hold the breath during tube removal D. Breathe normally during tube removal

C. Hold the breath during tube removal

A client who is mouth breathing is receiving oxygen by face mask. The assistive personnel (AP) asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to promote which goal? A. Prevent the client from getting a nosebleed B. Give the client added fluid by way of the respiratory tree C. Humidify the oxygen that is bypassing the client's nose D. Prevent fluid loss from the lungs during mouth breathing

C. Humidify the oxygen that is bypassing the client's nose

The nurse is assessing a child with increased intracranial pressure who has been exhibiting decorticate posturing. The nurse notes extension of the upper and lower extremities, with internal rotation of the upper arms and wrists and the knees and feet. What does the nurse determine about the child's condition? A. Indicates improved neurological status B. Indicates decreased intracranial pressure C. Indicates deterioration in neurological function D. Is unchanged from the previous neurological assessment

C. Indicates deterioration in neurological function

A client is found to have AIDS. What is the nurse's highest priority in providing care to this client? A. Providing emotional support to the client B. Discussing the cause of AIDS with the client C. Instituting measures to prevent infection in the client D. Identifying risk factors related to contracting AIDS with the client

C. Instituting measures to prevent infection in the client

A nurse is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which coexisting problem is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate? A. Infection B. Hypertension C. Low blood pressure D. Loss of cough reflex

C. Low blood pressure

A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula? A. Irrigate the fistula with 3 mL of normal saline solution B. Infuse 50 mL of normal saline once per 24 hours C. Palpate for a vibrating sensation at the fistula site D. Flush the fistula with 1 mL of heparin solution once per shift

C. Palpate for a vibrating sensation at the fistula site

The nurse in the labor room is performing a vaginal assessment of a pregnant client who is in active labor. The nurse notes that the umbilical cord is protruding from the vagina. What does the nurse immediately do? A. Push the cord gently back into the vagina B. Prepare the client for cesarean delivery C. Place the client in the knee-chest position D. Prepare to administer a tocolytic medication

C. Place the client in the knee-chest position

The nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode. What does the nurse immediately do? A. Call a code B. Hold the infant in an upright position C. Place the infant in the knee-chest position D. Contact the respiratory therapy department

C. Place the infant in the knee-chest position

The nurse is developing a plan of care for a client with a new diagnosis of Graves disease. Which intervention does the nurse include in the plan? A. Keeping the room warm B. Placing extra blankets on the client C. Providing a high-calorie, high-protein diet D. Encouraging frequent ambulation and activities

C. Providing a high-calorie, high-protein diet

A client with histoplasmosis has the following arterial blood gas (ABG) results: pH 7.30, PaCO2 58 mm Hg (7.72 kPa), PaO2 75 mm Hg (9.93 kPa), HCO3 26 mEq/L (26 mmol/L). Which acid-base disturbance does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis

A nurse reviews the blood gas results of a client in respiratory distress. The pH is 7.32 and the PaCO2 is 50 mm Hg (6.65 kPa). Which acid-base imbalance does the nurse recognize in these findings? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis

The nurse is assessing a newborn for fetal alcohol syndrome (FAS). Which finding would the nurse expect to note in the newborn? A. Greater-than-average length B. Higher-than-normal birth weight C. Short palpebral fissures and a flat midface D. Greater-than-average head circumference

C. Short palpebral fissures and a flat midface

The nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A. Slow pulse B. Decreased urine output C. Skeletal muscle weakness D. Hyperactive bowel sounds E. Hyperactive deep tendon reflexes

C. Skeletal muscle weakness D. Hyperactive bowel sounds

A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The primary health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client's room before allowing the client to drink? A. Straw B. Napkin C. Suction equipment D. Oxygen saturation monitor

C. Suction equipment

A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs/symptoms of respiratory alkalosis does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth

C. Tachypnea, dizziness, and paresthesias

The nurse is teaching a client with diabetes mellitus who requires insulin about methods of preventing diabetic ketoacidosis (DKA) when the client is ill. What does the nurse tell the client to do? A. Contact the primary health care provider if a fever over 102° F (38.9°C) occurs B. Refrain from eating or drinking during periods of vomiting C. Take the prescribed insulin dose even if he/she is unable to eat D. Contact the primary health care provider when the premeal blood glucose value is greater than 350 mg/dL (19.4 mmol/L) Incorrect

C. Take the prescribed insulin dose even if he/she is unable to eat

During a client's yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. What does the nurse tell the client? A. That he has glaucoma in the left eye B. That he has glaucoma in the right eye C. That the intraocular pressure in both eyes is normal D. That he needs to increase his fluid intake, because the pressure in the right eye is low

C. That the intraocular pressure in both eyes is normal

A nurse is reading the chest x-ray report of a client who has just been intubated. The report states where the endotracheal tube is positioned. What finding is considered a normal position for the endotracheal tube? A. The first tracheal cartilaginous ring B. The point where the larynx connects to the trachea C. The bifurcation of the right and left main stem bronchi D. The area connecting the oropharynx to the laryngopharynx

C. The bifurcation of the right and left main stem bronchi

A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test? A. HIV infection has been confirmed B. The client probably has an opportunistic infection C. The test will need to be confirmed with the use of a Western blot D. A positive test is a normal result and does not mean that the client is infected with HIV

C. The test will need to be confirmed with the use of a Western blot

The nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. What does the nurse tell the client to do? A. Wear eyeglasses 24 hours a day B. Wear a patch on the affected eye C. Turn the head to scan the lost visual field D. Keep all objects in the impaired field of vision

C. Turn the head to scan the lost visual field

A nurse is watching as an assistive personnel (AP) measure the blood pressure (BP) of a hypertensive client. Which actions on the part of the AP would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply. A. Measuring the BP after the client has sat quietly for 5 minutes B. Having the client sit with the arm bared and supported at heart level C. Using a cuff with a rubber bladder that encircles at least 60% of the limb D. Measuring the BP after the client reports having just drank a cup (236 ml) of coffee E. Allowing the client to talk as the blood pressure is being measured

C. Using a cuff with a rubber bladder that encircles at least 60% of the limb D. Measuring the BP after the client reports having just drank a cup (236 ml) of coffee E. Allowing the client to talk as the blood pressure is being measured

A nurse in a primary health care provider's office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should provide which information to the client? A. Wear sweatpants and a heavy sweatshirt B. Eat a small meal just before the procedure C. Wear comfortable rubber-soled shoes such as sneakers D. Avoid consuming caffeine for 30 minutes before the procedure

C. Wear comfortable rubber-soled shoes such as sneakers

The emergency department nurse is caring for a client with acute pancreatitis who will be admitted to the hospital. Into which position that will ease the abdominal pain does the nurse assist the client? A. Prone B. Supine with the legs straight C. With the knees drawn up to the chest D. Side-lying with the head of the bed flat

C. With the knees drawn up to the chest

The nurse is conducting the initial assessment of a child with rheumatic fever. Which question does the nurse ask the parents to elicit information specific to the development of the disease? A. "Has he had any loss of appetite?" B. "Has he complained of a backache recently?" C. "Has he been excessively tired or lethargic?" D. "Has he had a sore throat in the last few months?"

D. "Has he had a sore throat in the last few months?"

A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates the need for further instruction? A. "I may feel cool while the cast is drying." B. "I shouldn't use anything to scratch underneath the cast." C. "If I smell any odor from the cast, I should call the doctor." D. "I can dry the cast faster if I use a hairdryer on the hot setting."

D. "I can dry the cast faster if I use a hairdryer on the hot setting."

The nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction? A. "I should wear a sock over my stump." B. "I can wash my leg with a mild soap." C. "I need to check my leg for irritation every day." D. "I'll put lotion on my leg a few times a day."

D. "I'll put lotion on my leg a few times a day."

The pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver? A. 15 B. 30 C. 50 D. 100

D. 100

A client's baseline vital signs are temperature 98°F (36.7°C) oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever of 103°F (39.4°C). Which respiratory rate would the nurse anticipate as part of the body's response to the change in client status? A. 12 breaths/min B. 16 breaths/min C. 18 breaths/min D. 22 breaths/min

D. 22 breaths/min

The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression-ventilation ratio is correct? A. 15:1 B. 15:2 C. 20:2 D. 30:2

D. 30:2

The nurse is working in the emergency department. Which client should be assessed first? A. A client with new-onset dizziness B. A client admitted with a recent ear injury C. A client who has been experiencing nausea and vomiting for 12 hours D. A client with new-onset atrial fibrillation with a rate of 118 beats/min

D. A client with new-onset atrial fibrillation with a rate of 118 beats/min

The emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first? A. Inserting a Foley catheter B. Initiating an intravenous (IV) line C. Cleansing the burn wound D. Administering 100% humidified oxygen

D. Administering 100% humidified oxygen

A client arrives at the emergency department with reports of a headache, hives, itching, and difficulty swallowing. The client states that he/she took ibuprofen 1 hour earlier and believes that he/she is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first? A. Administration of normal saline solution B. Administration of an intravenous (IV) glucocorticoid C. Administration of pain medication to relieve the client's headache D. Administration of a subcutaneous injection of epinephrine

D. Administration of a subcutaneous injection of epinephrine

The nurse attending a recertification course in basic life support (BLS) for health care professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant's pulse? A. Neck B. Wrist C. Behind the knee D. Antecubital fossa of the arm

D. Antecubital fossa of the arm

A client who sustained a fracture of the left arm requires the application of a plaster cast. What does the nurse tell the client that the procedure for applying the cast involves? A. Administering a local anesthetic to the fractured arm B. Soaking the left arm in a warm-water bath for 2 hours before cast application C. Debriding any open wounds and applying antibiotic ointment before the cast material is applied D. Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material

D. Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material

A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily? A. Placing the tube in warm water B. Hyperextending the head while inserting the tube C. Removing the tube if any resistance to insertion is met D. Asking the client to swallow as the tube is being advanced

D. Asking the client to swallow as the tube is being advanced

A nurse has a prescription to collect a 24-hour urine specimen from a client. Which measure should the nurse take during this procedure? A. Keeping the specimen at room temperature B. Saving the first urine specimen collected at the start time C. Discarding the last voided specimen at the end of the collection time D. Asking the client to void, discarding the specimen, and noting the start time

D. Asking the client to void, discarding the specimen, and noting the start time

A client who experienced the sudden onset of respiratory distress has been intubated with an endotracheal tube. After the tube is placed in the trachea, the nurse should take which immediate action? A. Tape the tube in place B. Send the client for a chest x-ray C. Note how far the tube has been inserted D. Auscultate both lungs for the presence of breath sounds

D. Auscultate both lungs for the presence of breath sounds

The alarm on a client's cardiac monitor goes off, and the nurse rushes to the client's bedside and finds the client unconscious. After noting the following rhythm on the monitor, what does the nurse immediately do? A. Checks for a radial pulse B. Assesses the client's neurological status C. Increases the flow rate of the client's intravenous infusion D. Begins cardiopulmonary resuscitation (CPR)

D. Begins cardiopulmonary resuscitation (CPR)

The nurse is obtaining subjective data from the mother of a child admitted to the hospital with a diagnosis of intussusception. Which occurrence does the nurse expect the mother to report? A. Scleral jaundice B. Projectile vomiting C. Hard, pale stools D. Bloody mucus stools and diarrhea

D. Bloody mucus stools and diarrhea

A client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority? A. Ambulating the client B. Administering pain medication C. Encouraging copious fluid intake D. Checking for the return of the gag reflex

D. Checking for the return of the gag reflex

Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse include in the plan of care? A. Assessing the pin sites at least every 8 hours B. Removing the traction weights to provide skin care C. Applying lanolin to the skin of the right leg once per shift D. Checking the skin integrity of the right leg at least every 8 hours

D. Checking the skin integrity of the right leg at least every 8 hours

The nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which assessment finding indicates to the nurse that the client may be experiencing hypotonic contractions? A. Fetal hypoxia B. Discomfort with each contraction C. Increased frequency and longer duration of contractions D. Contractions that can be indented easily with fingertip pressure at their peak

D. Contractions that can be indented easily with fingertip pressure at their peak

A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? A. Document the findings B. Contact the primary health care provider C. Place the client in a supine position with the legs flat D. Cover the abdominal wound with a sterile dressing moistened with sterile saline solution

D. Cover the abdominal wound with a sterile dressing moistened with sterile saline solution

A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action? A. Reinsert the chest tube B. Contact the primary health care provider C. Transfer the client back to bed D. Cover the insertion site with a sterile occlusive dressing

D. Cover the insertion site with a sterile occlusive dressing

A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which signs/symptoms does the nurse anticipate that this client will exhibit? A. Increased heart rate and increased blood pressure B. Increased heart rate and decreased blood pressure C. Decreased heart rate and increased blood pressure D. Decreased heart rate and decreased blood pressure

D. Decreased heart rate and decreased blood pressure

A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. Which action should the nurse take first? A. Call a code B. Contact the primary health care provider C. Administer a bronchodilator D. Disconnect the suction source from the catheter

D. Disconnect the suction source from the catheter

A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should provide the client with which information about the test? A. The test may be painful B. The test takes 2 to 3 hours C. Food and fluids are not allowed for 4 hours after the test D. Dye is injected and may cause a warm flushing sensation

D. Dye is injected and may cause a warm flushing sensation

A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect? A. Diarrhea B. Dyspnea C. Headache D. Dysphagia

D. Dysphagia

A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which signs/symptoms does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth

D. Dysrhythmias and decreased respiratory rate and depth

A client is found to have viral hepatitis, and the nurse provides home care instructions to the client. What should the nurse tell the client to do? A. Maintain strict bed rest B. Limit the intake of alcohol C. Take acetaminophen for discomfort D. Eat small frequent meals that are low in fat and protein and high in carbohydrates

D. Eat small frequent meals that are low in fat and protein and high in carbohydrates

The primary health care provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication? A. Insert a Foley catheter in the client B. Prepare the client for insertion of a central IV line C. Administer the medication with the use of a macrodrip IV tubing set D. Ensure that the medication is diluted in an appropriate amount of normal saline solution

D. Ensure that the medication is diluted in an appropriate amount of normal saline solution

A nurse is providing discharge instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates what? A. Limit activity for 24 hours B. Take acetaminophen for discomfort C. Leave the eye patch in place until he has been seen by the primary health care provider D. Expect to experience pain, nausea, and vomiting after the procedure

D. Expect to experience pain, nausea, and vomiting after the procedure

The nurse is providing instructions to an unlicensed assistive personnel (UAP) about effective measures for communicating with a hearing-impaired client. What does the nurse instruct the UAP to do? A. Raise his/her voice when talking to the client B. Talk directly into the client's impaired ear C. Be cordial and smile when talking to the client D. Face the client when talking, keeping the hands away from the mouth

D. Face the client when talking, keeping the hands away from the mouth

A client is receiving intermittent bolus feedings by way of a nasogastric tube. In which position should the nurse place the client once the feeding is complete? A. Supine B. Head of bed flat C. Left lateral position D. Head of bed elevated 30 to 45 degrees

D. Head of bed elevated 30 to 45 degrees

The nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion? A. Monitoring urine output B. Monitoring bowel sounds C. Checking pedal pulses distal to the graft site D. Limiting elevation of the head of the bed to 45 degrees

D. Limiting elevation of the head of the bed to 45 degrees

A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? A. Check the client's blood pressure B. Check the oxygen saturation level C. Have the client take some deep breaths D. Lower the head of the bed slowly until the dizziness is relieved

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

A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client's room and quickly assesses the client. The client appears to be having respiratory difficulty. What should the nurse do first? A. Call a code B. Suction the client C. Call the anesthesiologist D. Manually ventilate the client, using a resuscitation bag

D. Manually ventilate the client, using a resuscitation bag

Mastitis is diagnosed in a client who recently gave birth. What does the nurse tell the woman? A. Wearing a bra will increase the discomfort B. Antibiotics are not usually used to treat this disorder C. Breastfeeding must be discontinued until the condition resolves D. Moist heat will increase circulation and may be used before the breasts are emptied

D. Moist heat will increase circulation and may be used before the breasts are emptied

A client in the post-anesthesia care unit has an as-needed prescription for ondansetron. Which occurrence would prompt the nurse to administer this medication to the client? A. Paralytic ileus B. Incisional pain C. Urine retention D. Nausea and vomiting

D. Nausea and vomiting

The nurse is assessing a client with AIDS for signs/symptoms of Pneumocystis jiroveci infection. Which sign/symptom of the infection is the earliest manifestation? A. Fever B. Dyspnea at rest C. Dyspnea on exertion D. Nonproductive cough

D. Nonproductive cough

A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing? A. Steak B. Veal C. Cheese D. Oranges

D. Oranges

A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding? A. Urine output of 40 mL/hr B. Blood pressure of 118/76 mm Hg C. Respiratory rate of 18 breaths/min D. Pallor and coolness of the right leg

D. Pallor and coolness of the right leg

A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client's neck primarily for which reason? A. It is unnecessary to use both hands B. Feeling dual pulsations may lead to an incorrect measurement C. Palpating both carotid pulses simultaneously could occlude the trachea D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop

D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop

A nurse is preparing for intershift report when an assistive personnel (AP) pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first? A. Call the primary health care provider B. Check the hourly urine output C. Check the IV site for infiltration D. Place the client in a modified Trendelenburg position

D. Place the client in a modified Trendelenburg position

The nurse is monitoring a client with deep vein thrombosis (DVT) for signs/symptoms of pulmonary embolism (PE). For which sign/symptom of PE, the most common, does the nurse assess the client? A. Cough B. Hemoptysis C. Diaphoresis D. Pleuritic chest pain

D. Pleuritic chest pain

The nurse is reviewing this rhythm strip from a cardiac monitor. Which type of abnormal beat does the nurse recognize? A. Sinus bradycardia B. Ventricular fibrillation C. Ventricular tachycardia D. Premature ventricular contractions (PVCs)

D. Premature ventricular contractions (PVCs)

A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important? A. Administering a sedative B. Encouraging fluid intake C. Administering an oral preparation of radiopaque dye D. Questioning the client about allergies to iodine or shellfish

D. Questioning the client about allergies to iodine or shellfish

A client has the following arterial blood gas (ABG) results: pH 7.51, PaCO231 mm Hg (4.12 kPa), PaO2 94 mm Hg (12.45 kPa), HCO3 24 mEq/L (24 mmol/L). Which acid-base disturbance does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

D. Respiratory alkalosis

The nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which finding does the nurse monitor the neonate most closely? A. Hypercalcemia B. Hyperglycemia C. Hypobilirubinemia D. Respiratory distress syndrome

D. Respiratory distress syndrome

A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which value, noted by the nurse reviewing the results, would be expected in this client at this time? A. Hemoglobin (Hb) 15 G/100 mL 14 to 18 g/100 mL, males; 12 to 16 g/100 mL, females B. Potassium (K+) 4 mEq/L C. Total calcium (Ca2+) 9 mg/dL D. Serum amylase 395 units/L

D. Serum amylase 395 units/L

The nurse is caring for a hospitalized child with a diagnosis of Kawasaki disease. During the subacute phase, what does the nurse monitor the child closely for? A. Bleeding B. A high fever C. Failure to thrive D. Signs/symptoms of congestive heart failure (CHF)

D. Signs/symptoms of congestive heart failure (CHF)

A client who has sustained a myocardial infarction is scheduled to have an echocardiogram. Which measure should the nurse take before the procedure? A. Imposing nothing-by-mouth (NPO) status for 4 hours B. Asking the client to sign an informed consent form C. Asking the client about a history of allergy to iodine or shellfish D. Telling the client that the procedure is painless and takes 30 to 60 minutes to complete

D. Telling the client that the procedure is painless and takes 30 to 60 minutes to complete

A woman has been scheduled for a routine mammogram. The nurse should provide the client with which information about the test? A. That mammography takes about 1 hour B. Not to eat or drink on the morning of the test C. That there is no discomfort associated with the procedure D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test

D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test

The nurse provides home care instructions to a client after a scleral buckling procedure. What should the nurse tell the client? A. To maintain strict bedrest for 48 hours B. To expect bloody drainage on the eye dressing C. That vision will be perfectly clear immediately after surgery D. That redness and swelling of the eyelids and conjunctiva are expected

D. That redness and swelling of the eyelids and conjunctiva are expected

A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first? A. The client's vital signs B. The amount of drainage C. The client's lung sounds D. The chest tube connections

D. The chest tube connections

A nurse provides information to a client who is scheduled for cardiac catheterization to rule out coronary occlusion. The nurse should provide which information to the client? A. The procedure is performed in the operating room B. It is necessary to lie quietly on a hard x-ray table for about 4 hours C. The room is bright and well lit, and it is best to keep the eyes closed D. The client may have feelings of warmth or flushing during the procedure

D. The client may have feelings of warmth or flushing during the procedure

A client has made an appointment for her annual Papanicolaou test (a.k.a. Pap smear). The nurse who schedules the appointment should provide which information to the client? A. Vaginal douching is required an hour before the test B. Spicy foods should not be eaten on the day of the test C. The test has absolutely no discomfort associated with it D. The test cannot be performed while the client is menstruating

D. The test cannot be performed while the client is menstruating

A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to contact the orthopedic specialist? A. The traction knots are intact. B. The traction weights are hanging freely. C. The clamps on the traction frame are tight. D. The traction ropes are unable to move over the pulleys.

D. The traction ropes are unable to move over the pulleys.

A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should provide the client with which information? A. To resume full activity the next day B. Not to eat or drink anything until the next morning C. To keep the shoulder completely immobilized for the rest of the day D. To report to the primary health care provider the development of fever or redness and heat at the site

D. To report to the primary health care provider the development of fever or redness and heat at the site

The nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first? A. Calling the primary health care provider B. Reinserting the implant into the client's vagina C. Picking up the implant with gloved hands and placing it in sterile water D. Using long-handled forceps to place the implant in a lead container

D. Using long-handled forceps to place the implant in a lead container

The nurse is administering care to a client with angina pectoris who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse notes the rhythm shown here. How does the nurse interpret the rhythm? A. Atrial fibrillation B. Sinus tachycardia C. Sinus bradycardia D. Ventricular tachycardia

D. Ventricular tachycardia

The nurse is caring for a client who is being treated for congestive heart failure related to excessive fluid volume. Which assessment finding causes the nurse to determine that the client's condition has improved? A. Dyspnea B. 1+ edema in the legs C. Moist crackles in the lower lobes of the lungs D. Weight loss of 4 lb (1.8 kg) in 24 hours

D. Weight loss of 4 lb (1.8 kg) in 24 hours

The nurse is caring for a child with newly diagnosed type 1 diabetes mellitus who is receiving insulin. The child suddenly exhibits tachycardia and begins to sweat and tremble, and the nurse determines that the child is experiencing a hypoglycemic reaction. What should the nurse immediately give the child? A. A sugar cube B. A teaspoon of sugar C. ½ cup (118 mL) of diet cola D. ½ cup (118 mL) of fruit juice

D. ½ cup (118 mL) of fruit juice