Exit Exam - Small Packets Review

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The healthcare provider prescribes cephalexin 125 mg/5 mL oral suspension for a client who weighs 77 pounds. The recommended safe dose is 25 mg/kg/24 hours in 4 divided doses. Based on the client's weight, how many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

the nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge home. which reco... (select all) A. Inspect the skin for redness B. Avoid range of motion exercise C. Apply alcohol. to the stump after bathing D. Use a residual. limb shrinker E. Wash the stump with. soap and water

A,D,E

After administering a 12 ounce of nutritional supplement, 3 teaspoons of medications, and 129 (or 120) ml of water, the nurse should document the clients fluid intake as how many ml?

495

A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent? A) Age of the child B) Sibling position in family C) Stressful family events D) Parental discipline strategies

After successful alcohol detoxification, a client remarked to a friend, "I've tried to stop drinking but I just can't, I can't even work without having a drink." The client's belief that he needs alcoholindicates his dependence is primarily A) Psychological B) Physical C) Biological D) Social-cultural

Clients with mitral stenosis would likely manifest findings associated with congestion in the A) Pulmonary circulation B) Descending aorta C) Superior vena cava D) Bundle of Hi

The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find? A) Complaints of numbness and tingling in feet B) Wheezing noted when lung sound auscultated C) Excessive perspiration D) Difficulty sleeping

A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication

The charge nurse is planning assignments on a medical unit. Which client should be assigned to the unlicensed assistive personnel (UAP). A client with? A) Difficulty swallowing after a mild stroke B) an order of enemas until clear prior to colonoscopy C) an order for a post-op abdominal dressing change D) transfer orders to a long term facility

After an explosion at a factory one of the workers approaches the nurse and says "I am an unlicensed assistive personnel (UAP) at the local hospital." Which of these tasksshould the nurse assign to this worker who wants to help during the care of the woundedworkers? A) Get temperatures B) Take blood pressure C) Palpate pulses D) Check alertness

at the end of a preoperative teaching session on pain management technique " I just know I can't handle all the pain" which is the priority nursing problem A. Pain (acute) B. Knowledge deficit C. Anxiety D. Anticipatory grieving

A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care? A) Pain related to periosteal injury B) Impaired mobility related to bleeding C) Parental anxiety related to knowledge deficit D) Injury related to inter cranial hemorrhage

C. Parental anxiety related to knowledge deficit

An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be takenby the nurse is to: A) check the carotid pulse B) deliver 5 abdominal thrusts C) give 2 rescue breaths D) open the client's airway

In a child with suspected coarctation of the aorta, the nurse would expect to find A) Strong pedal pulses B) Diminishing carotid pulses C) Normal femoral pulses D) Bounding pulses in the arms

Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the health care provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse? A) Tell the parents to bring the child to the clinic for further evaluation B) Refer the school officials to printed materials about this viral illness C) Inform the teacher that the child is receiving antibiotics for the rash D) Explain that this rash is not contagious and does not require isolation

The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately? A) Irritability B) Slight edema at site C) Local tenderness D) Temperature of 102.5 F

The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? A. Regional relocation center for earthquake victims B. Vitamin supplements for high-risk pregnant women C. Lead screening for children in low income housing D. Case management and screening for clients with HIV

A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to A) A cerebral vascular accident B) Postoperative meningitis C) Medication reaction D) Metabolic alkalosis

A. A cerebral vascular accident

the nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video A. Open the roller clamp on the tubing B. Label the bag of IV solution C. Attach the tubing to the saline lock D. Flush the saline lock. with saline

A. Open the roller clamp on the tubing

The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 mL to be infused intravenously (IV) over 4 hours. The IV administration set delivers 10 gtt/mL. How many gtt/minute should the nurse regulate the infusion? (Enter numeric value only. If rounding is required, round to the nearest whole number?)

A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse? A) Listen quietly without comment B) Ask for further information on the spies C) Confront the client on a delusion D) Contact the government agency

The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered medications would most likely contribute to this change? A) Anticoagulant B) Liquid antacid C) Antihistamine D) Cardiac glycoside

Which finding would be the most characteristic of an acute episode of reactive airway disease? A) Auditory gurgling B) Inspiratory laryngeal stridor C) Auditory expiratory wheezing D) Frequent dry coughing

C. Auditory expiratory wheezing

A client who is a former actress enters the day room wearing a sheer night gown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which nursing action is the best in response to the client's attire? A) Gently remind her that she is no longer on stage B) Directly assist client to her room for appropriate apparel C) Quietly point out to her the dress of other clients on the unit D) Tactfully explain appropriate clothing for the hospital

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation? A. Potassium 3.5 mEq/L (3.5 mmol/L) B. Fingertips feel numb C. Sodium 135 mEq/L (135 mmol/L) D. Cervical spine stiffness

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? A. Monitor the amount of drainage from the client's incision B. Observe both lower extremities for redness and swelling C. Evaluate the client's ability to use an incentive spirometer D. Palpate all peripheral pulse points for volume and strength

The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate? A) Allow the infant to drink the liquid from a medicine cup B) Administer the medication with a syringe next to the tongue C) Mix the medication with the infant's formula in the bottle D) Hold the child upright and administer the medicine by spoon

The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? A) spaghetti B) watermelon C) chicken D) tomatoes

The provisions of the law for the Americans with Disabilities Act require nurse managers to A) Maintain an environment free from associated hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals D) Consider both mental and physical disabilities

While planning care for a preschool aged child, the nurse understands developmental needs. Which of the following would be of the most concern to the nurse? A) Playing imaginatively B) Expressing shame C) Identifying with family D) Exploring the playroom

An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next? A) Help the student to identify a specific problem B) Ask the parent to identify the major problem C) Ask the student to think of different alternatives D) Examine with the parent a variety of options

B) Ask the parent to identify the major problem

The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees F for a post surgical client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP? A) Encourage oral fluids for the temperature elevation B) Check temperature 15 minutes after hot liquids are taken C) Ask the client to drink only cold water and juices D) Chart this temperature elevation on the flow sheet

B) Check temperature 15 minutes after hot liquids are taken

A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach? A) The results of a standardized tool that measures depression B) Observation of affect and behavior C) Inquiry about use of alcohol D) Family history of emotional problems or mental illness

B) Observation of affect and behavior

Which of these observations made by the nurse during an excretory urogram indicate a complication? A) The client complains of a salty taste in the mouth when the dye is injected B) The client's entire body turns a bright red color C) The client states "I have a feeling of getting warm." D) The client gags and complains " I am getting sick."

B) The client's entire body turns a bright red color

A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? A) Light, pink urine B) occasional suprapubic cramping C) minimal drainage into the urinary collection bag D) complaints of the feeling of pulling on the urinary catheter

C) minimal drainage into the urinary collection bag

An important goal in the development of a therapeutic inpatient milieu is to A) Provide a businesslike atmosphere where clients can work on individual goals B) Provide a group forum in which clients decide on unit rules, regulations, and policies C) Provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions D) Discourage expressions of anger because they can be disruptive toother clients

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? A. Prepare the client for spinal anesthesia B. Empty the client's bladder using a straight catheter C. Convey to the client that birth is imminent D. Prepare the coach to accompany the client to delivery

The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding? A) Bounding pulse B) Rapid respirations C) Oliguria D) Neck veins are distended

The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions? A) 14 minutes B) 10 minutes C) 15 minutes D) Nine minutes

The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? A) Three apricots B) Medium banana C) Naval orange D) Baked potato

D) Baked potato

A client with a history of heart failure and type 1 diabetes mellitus is admitted with unstable angina. Which problem requires the most immediate Intervention by the nurse? a. Fluid volume excess. b. Acute anginal pain. c. Activity intolerance. d. Fatigue.

b. Acute anginal pain.

Which laboratory value should the nurse review prior to administering the initial dose of a statin medication? a. Serum electrolytes. b. Serum liver enzymes c. Capillary blood glucose. d. Complete blood count.

b. Serum liver enzymes

A pediatric home care nurse schedules a visit to the home of a 4-week-old newborn who had a low thyroxine (T4) and a high thyrold stimulating hormone (TSH) at birth, and was diagnosed with congenital hypothyroidism or cretinism. Which instruction is most important for the nurse to provide the parents of this child? a. Monitor the infant's daily intake and weekly weight. b. Offer a low sodium formula between breast feedings. c. Administer supplemental thyroid hormone daily. d. Stimulate the infant during feedings to ensure adequate intake.

c. Administer supplemental thyroid hormone daily.

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow up by the nurse? A. CT scan that was performed six months earlier B. Metal hip prosthesis was placed twenty years ago C. Report of client's sobriety for the last five years D. Takes metformin for type 2 diabetes mellitus

The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to A) Maintain previous calorie intake B) Keep a candy bar available at all times C) Reduce carbohydrates intake to 25% of total calories D) Keep a regular schedule of meals and snacks

The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self scheduling knowing that this method will A) Improve the quality of care B) Decrease staff turnover C) Minimize the amount of overtime payouts D) Improve team morale

When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first? A) Try to vigorously stimulate normal breathing B) Ask the RN to assess the vital signs C) Measure the pulse oximetry D) Continue to monitor respirations

When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency? A. History of intermittent claudication B. A positive Brodie-Trendelenberg test C. Ankle ulceration and edema D. A serum cholesterol level of 250 mg/dl (6.47 mmol/L)

A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0- to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to A) Ask the client about the refusal of certain pain medications B) Talk with the client's family about the situation C) Report the situation to the health care provider D) Document the situation in the notes

A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial administration of Digoxin to this client? A) Assess the apical pulse, counting for a full 60 seconds B) Take a radial pulse, counting for a full 60 seconds C) Use the pulse reading from the electronic blood pressure device D) Check for a pulse deficit

A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a fractured lower right leg 1 hour ago reports that the pain is getting worse. The nurse should recognize that the client may be developing which complication? A) Acute compartment syndrome B) Thromboembolitic complications C) Fatty embolism D) Osteomyelitis

A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse? A. Abdominal pain decreases when lying supine B. Pain last an hour and leaves the abdomen tender C. Right upper quadrant pain refers to right scapula D. Drink alcohol until intoxicated at least twice daily

The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? A) Stop the infusion B) Slow the rate of infusion C) Take vital signs and observe for further deterioration D) Administer Benadryl and continue the infusion

The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? A) Hourly urine output B) White blood count C) Blood glucose every 4 hours D) Temperature every 2 hours

The nurse is caring for a client with Parkinson's disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor? A) L-Dopa B) Cogentin C) Baclofen D) Benadryl

The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, whichaction should the nurse stressto the client as important? A) Avoid chocolate and cheese B) Take frequent naps C) Take the medication with milk D) Avoid walking without assistance

The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? A. Teach coughing and deep breathing exercises B. Assess the client's oral cavity for ulcerations C. Request thick nectar liquids for the client D. Monitor the client when using a straw for liquids

The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones

The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend A) Isometric B) Range of motion C) Aerobic D) Isotonic

A. Isometric

A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest." D) "The tube will seal the hole in your lung."

The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure? A) Standing and sitting B) In both arms C) After exercising D) Supine position

A client enters the emergency department unconscious via ambulance from the client's work place. What document should be given priority to guide thedirection of care for this client? A) The statement of client rights and the client self determination act B) Orders written by the health care provider C) A notarized original of advance directives brought in by the partner D) The clinical pathway protocol of the agency and the emergency department

A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? A) Bleeding time B) Platelet count C) Activated PTT D) Clotting time

A nurse and client are talking about the client's progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship? A) Pre-interaction B) Orientation C) Working D) Termination

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel. Which task should the nurse delegate to the UAP? A. Evaluate a client's mobility progress toward the plan of care B. Assess for side effects of administered pain medications C. Turn and reposition client with a total hip replacement D. Monitor an intravenous infusion rate on an established schedule

The nurse assess a client being treated for Herpes zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of the the treatment? (Select all that apply) A. Functional ability B. Skin integrity C. Pain scale D. Bowel sounds E. Heart sounds

A, B, C

A client who is hospitalized and recently diagnosed with Addison's disease is now confused and lethargic. Which actions should the nurse implement? (Select all that apply) A) Measure capillary glucose level B) Monitor cardiac telemetry pattern C) Reduce rate of intravenous fluid infusion D) Withhold next dose of corticosteroid E) Initiate fall risk precautions

A, B, E

A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? A) Cartoon stickers B) Large wooden puzzle C) Blunt scissors and paper D) Beach ball

A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? A) Flaccid paralysis B) Pupils fixed and dilated C) Diminished spinal reflexes D) Reduced sensory responses

In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings? A) Uterine atony B) Genital lacerations C) Retained placenta D) Clotting disorder

The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The first assessment the nurse should perform is A) Orientation to time, place and person B) Pulse oximetry C) Circulation to casted extremity D) Blood pressure

The nurse is performing a physical assessment on a toddler. Which of the following should be the first action? A) Perform traumatic procedures B) Use minimal physical contact C) Proceed from head to toe D) Explain the exam in detail

The nurse is teaching a client about precautions with Coumadin. The nurse should instruct the client to avoid foods with excessive amounts of which nutrient A) Calcium B) Vitamin K C) Iron D) Vitamin E

The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator

B) Perform a quick assessment of the client's condition

A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 -22. Based on this data, what is the first nursing action? A) Review other lab data B) Notify the health care provider C) Administer oxygen D) Calm the client

An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which order should be questioned by the nurse? A) Passive range of motion B) Replacement of factor VIII C) Aspirin for pain management D) Immobilization splint

During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results indicate a level of 11%. Based on this result, what teaching should the nurse emphasize? A) Rotation of injection sites B) Insulin mixing and preparation C) Daily blood sugar monitoring D) Regular high protein diet

The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75 mg IM every 4 weeks. The client begins developing a puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement? A. Monitor lying, sitting, and standing blood pressures B. Provide coaching in relaxation techniques C. Complete abnormal involuntary movement scales (AIMS) D. Discontinue all medications immediately

When caring for a client receiving warfarin sodium (Coumadin),which lab test would the nurse monitor to determine therapeutic response to the drug? A) Bleeding time B) Coagulation time C) Prothrombin time D) Partial thromboplastin time

The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention would be the best approach by the nurse manager? A) Confront the nurse about the suspicions in a private meeting B) Schedule a staff conference, without the nurse present, to collect information C) Consult the human resources department about the issue and needed actions D) Counsel the employee to resign to avoid investigation

C. Consult the human resources department about the issue and needed actions

A nurse is caring for a client with peripheral arterial insufficiency of the lower extremities. Which intervention should be included in the plan of care to reduce leg pain? A) Elevate the legs above the heart B) Increase ingestion of caffeine products C) Apply cold compresses D) Lower the legs to a dependent position

The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter? A) Heart rate B) Muscle tone C) Cry D) Color

The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse do first? A) Explain that the procedure will help him to get well B) Show a cartoon character with a blood pressure cuff C) Explain that the blood pressure checks the heart pump D) Permit handling the equipment before putting the cuff in place

during shift report, the charge nurse receives notice of several problems, which should the nurse address first? A. the census report has not been completed B. A client's wife has asked to. speak with the charge nurse C. One staff member has not reported to work D. A bucket of was was spilled in the hallway

Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? A) An adolescent diagnosed with sepsis 7 days ago with vital signs maintained within low normal B) A middle-aged woman documented to have had an uncomplicated myocardial infarction 4 days ago C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis D) A young adult in the second day of treatment for an overdose of acetaminophen

D) A young adult in the second day of treatment for an overdose of acetaminophen

The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? A) Weight reduction B) Stress management C) Physical exercise D) Smoking cessation

D. Smoking cessation

The nurse caring for a child with mononucleosis can expect a child to exhibit which symptoms? A. Positive Epstein-Barr, and malaise B. Ear pain and fever C. Elevated WBC and sedimentation rate D. Increased BUN and serum creatinine

A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? A) Lethargy B) Heat intolerance C) Diarrhea D) Skin eruptions

While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? A) Respiratory rate of 42 B) Lethargy for the past hour C) Apical pulse of 54 D) Coughing up copious secretions

which woman should the nurse consider at the highest risk for cervical cancer? A. History of unprotected sex with multiple partners B. postmenopausal for 5 years with intermittent vaginal secretions C. Taking. birth control pills after 40 years of age D. Multiparous delivery of infants more than 9pounds

The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mg/2.4 mL." How many mL should the nurse administer?

0.2

A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). which information should the nurse provide? A. Consume a high protein diet B. Increase physical activity C. Take vitamin supplements D. Obtain a prostatic-specific antigen blood level test

A new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority for the outcome of a positive experience with a mentor? A) Information is clarified as needed B) A teacher-coach role is taken by the mentor C) The mentor accepts feedback objectively D) The mentor is randomly assigned by administration

The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? A) Decreased urinary output B) Jugular vein distention C) Pleural effusion D) Bibasilar crackles

When teaching a client about the side effects of fluoxetine (Prozac), which of the following will be included? A) Tachycardia blurred vision, hypotension, anorexia B) Orthostatic hypotension, vertigo, reactions to tyramine rich foods C) Diarrhea, dry mouth, weight loss, reduced libido D) Photosensitivity, seizures, edema, hyperglycemia

C) Diarrhea, dry mouth, weight loss, reduced libido

A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? A) Obtain a 12-lead EKG B) Place client in high Fowler's position C) Lower the oxygen rate D) Take baseline vital signs

C) Lower the oxygen rate

A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note A) High protein B) Clear color C) Elevated sed rate D) Increased glucose

A. High protein

A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of whichelement? A) Sodium B) Potassium C) Phosphate D) Albumin

A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the "evil eye." The nurse should communicate to other personnel that the appropriate approach is to A) Touch the baby after looking at him B) Talk very slowly while speaking to him C) Avoid touching the child D) Look only at the parents

A. Touch the baby after looking at him

A nurse seeks to alter a provision of a state's Nurse Practice Act regarding nurse-client ratios, which the nurse believes to be unsafe. What action is most likely to impact a ruling by the state's Board of Nursing? a. Notify the state's Board about the matter anonymously. b. File a grievance at the medical center where the nurse is employed. c. Send a letter of concern to the American Nurses' Association. d. Consult with the appropriate state legislative representative.

d. Consult with the appropriate state legislative representative.

The nurse is reviewing a client's urinalysis results and identifies a specific gravity of 1.035. Which action should the nurse implement based on this finding? a. Explain that the urine finding is normal. b. Recommend the use of salt with meals. c. Tell client to report reduced urine output less than 1,000 mL/day. d. Instruct client to increase oral fluids to a minimum of 2,400 mL/day.

d. Instruct client to increase oral fluids to a minimum of 2,400 mL/day.

A client diagnosed with anorexia nervosa states after lunch, "I shouldn't have eaten all of that sandwich, I don't know why I ate it, I wasn't hungry." The client's comments indicate that the client is likely experiencing A) Guilt B) Bloating C) Anxiety D) Fear

A) Guilt

The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit? A) Lethargy B) Irritability C) Negative Moro D) Depressed fontanel

Three days after initiating parenteral fluids for a newborn with a ventricular septal defect (VSD), the nurse assesses an increase in heart rate and blood pressure. Which intervention is most important for the nurse to implement? A. View the graph of daily weights B. Restrict intake the oral fluids C. Assess bilateral lung sounds D. Decrease IV flow rate

While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age? A) 1 year of age B) 2 years of age C) 3 years of age D) 4 years of age

A 3 year-old child diagnosed as having celiac disease attends a daycare center. Which of the following would be an appropriate snack? A) Cheese crackers B) Peanut butter sandwich C) Potato chips D) Vanilla cookies

A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath bilateral 2+ pedal edema in an oxygen saturation on a room air of 89% which action should the nurse take first? A. Elevate the foot of the bed B. Restrict the client's fluids C. Begin supplemental oxygen D. Prepare client for hemodialysis

A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age? A) Jumping rope B) Tying shoelaces C) Riding a tricycle D) Playing hopscotch

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis? a. Bagel with jelly and skim milk. b. Granola bar and grapefruit juice. c. Egg whites, toast, and coffee. d. Bran muffin, mixed fruit, and orange juice.

a. Bagel with jelly and skim milk.

During the two-month well-baby visit, the mother complains that formula seems to stick to her baby's mouth and tongue. Which of the following would provide the most valuable nursing assessment? A) Inspect the baby's mouth and throat B) Obtain cultures of the mucous membranes C) Flush both sides of the mouth with normal saline D) Use a soft cloth to attempt to remove the patches

The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need for further teaching? A) "Nystatin should be given 4 times a day after my baby eats." B) "I will boil the nipples and pacifiers for twenty minutes." C) "I should be taking the medication prescribed for this infection." D) "The therapy can be discontinued when the spots disappear."

Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? A) Scratching the head more than usual B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking to the hair

A client arrives for an annual physical exam and complains of calf pain. The client's health history reveals peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms? A. Wire legs ever suddenly swollen, red, warm, and painful? B. Does calf pain occur when walking short distances? C. Did you receive treatment for weeping ulcers on your lower legs? D. Have you experienced ankle edema and varicose veins?

the nurse assesses a child in 90-90 skeletal traction. where should the nurse assess. for signs of compartment syndrome?

toes

A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirin toxicity? A) Serum potassium B) Protein intake C) Lactose tolerance D) Serum albumin

The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to A) Achieve harmony B) Maintain a balance of energy C) Respect life D) Restore yin and yang

The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to A) Dress the child warmly to avoid chilling B) Keep the child away from other children for the duration of the rash C) Clean the affected areas with tepid water and detergent D) Wrap the child's hand in mittens or socks to prevent scratching

The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) enhance absorption of the medication B) ensure that the entire dose of medication is given C) provide more even distribution of the drug D) prevent the drug from tissue irritation Skip

A 6 year-old female is diagnosed with recurrent urinary tract infections (UTI). Which one of the following instructions would be best for the nurse to tell the caregiver? A) Increase bladder tone by delaying voiding B) When laundering clothing, rinse several times C) Use plain water for the bath, shampooing hair last D) Have the child use antibacterial soaps while bathing

C. Use plain water for the bath, shampooing hair last

A 70 year-old post-operative client has elevated serum BUN, Hct, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is: A) Impaired gas exchange B) Metabolic acidosis C) Renal insufficiency D) Fluid volume deficit

A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? A) "I will only have to wear this for 6 months." B) "Ishould inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower."

The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor A. Arterial blood gasses B. Breath sounds C. Oxygen saturation D. Respiratory rate

The nurse's primary intervention for a client who is experiencing a panic attack is to A) Develop a trusting relationship B) Assist the client to describe his experience in detail C) Maintain safety for the client D) Teach the client to control his or her own behavior

The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? a. The client will express acceptance of their newly diagnosed health status. b. The nurse will encourage the client to walk thirty minutes everyday. c. The client's blood pressure readings will be less than 160/90 mmHg. d. The client's skin on the lower legs will be intact at the next clinical visit.

The PN reports that a client has a fingerstick glucose....and diaphoretic. what action should the charge nurse take? A. Assess the client for polyuria and polyphagia B. Give the client a glass of orange juice C. Notify the healthcare provider D. Collect a blood sample for hemoglobin A1C

During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first? a. The census report has not been completed. b. A client's wife has asked to speak with the charge nurse. c. One staff member has not reported to work. d. A bucket of water was spilled in the hallway.

118. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents

In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize A) Learning relaxation techniques B) Limiting alcohol use C) Eating smaller meals D) Avoiding passive smoke

Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time? A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand." B) "If the client is dizzy on standing, ask him to take some deep breaths." C) "Assist the client to the bathroom at least twice on this shift." D) "After you assist him to the chair, let me know how he feels."

A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand."

The nurse is caring for a seated client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement ? (Select all that apply) A. Loosen restrictive clothing B. Insert a bite block C. Ease the client to the floor D. Note the duration of the seizure E. Restrain the client

A, C, D

The nurse is assessing a newborn infant and observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. A priority maternal assessment by the nurse should be to ask about A) Alcohol use during pregnancy B) Usual nutritional intake C) Family genetic disorders D) Maternal and paternal ages

A. Alcohol use during pregnancy

. When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend? A) Biofeedback B) Deep breathing C) Distraction D) Imagery

A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A) "I cannot give this medication as it is written. I have no idea of what you mean." B) "Would you please clarify what you have written so I am sure I am reading it correctly?" C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful." D) "Please print in the future so I do not have to spend extra time attempting to read your writing."

The nurse is caring for a 10 month-old infant who is has oxygen via mask. It is important for the nurse to maintain patency of which of these areas? A) Mouth B) Nasal passages C) Back of throat D) Bronchials

The nurse is caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication? A) History of obesity B) Prescribed use of an MAO inhibitor C) Diagnosis of vascular disease D) Takes antacids frequently

When assessing a 6-month-old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? A. Crying B. Sitting upright C. Vomiting D. Straining on stool

When assessing an IV site that is used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse? A. Client uses the arm cautiously B. Red streak tracking the vein C. A sluggish blood return D. Spot of dried blood at insertion site

When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery after a myocardial infarction, which finding would be of greatest concern to the nurse? A) Sero sanginous drainage from gums B) Hematemesis C) Pink frothy sputum D) Slight red color at urine

the nurse is preparing to administer an IV dose of ciprofloxacin to a client....client data require the most immediate intervention by the nurse? A. Urine culture positive for MRSA B. Serum creatinine of 4.5 mg/dL C. Serum sodium of 145 mEq/L D. White blood cell count of 12,000 mm

An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids

B) Check the client's gag reflex

A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? A) Bleeding time B) Hemoglobin and hematocrit C) White blood cells D) Platelets

B) Hemoglobin and hematocrit

A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? A) Esophagitis B) Leukopenia C) Fatigue D) Skin irritation

B) Leukopenia

An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The nurse understands that which of the following is true in regards to giving immunizations to this child? A) Live vaccines are withheld in children with renal chronic illness B) The MMR vaccine should be given now, prior to the transplant C) An inactivated form of the vaccine can be given at any time D) The risk of vaccine side effects precludes giving the vaccine

B) The MMR vaccine should be given now, prior to the transplant

When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? (Select all that apply) A. Fresh vegetables with mayonnaise dip B. Fresh turkey slices and berries C. Chicken bouillon soup and toast D. Soda crackers and peanut butter E. Raw unsalted almonds and apples

B, C, E

A nurse is administering diazepam, a benzodiazepine, 10 mg IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which actions should the nurse implement when administering the medication? (Select all that apply) A) Protect medication from exposure to light B) Monitor for changes in level of consciousness C) Observe for onset of generalized bruising or bleeding D) Perform ongoing assessment of respiratory status E) Administer slowly over at least two minutes

B, D, E

A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to A) Administer pain medication B) Suction excessive tracheobronchial secretions C) Assist client to turn, deep breathe and cough D) Monitor oxygen saturation

B. Suction excessive tracheobronchial secretions

. A client in the third trimester of pregnancy reports that she feels some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take? A. Tell the client to begin nipple stimulation to prepare for breastfeeding B. Reschedule the client's prenatal appointment for the following day. C. Explain that this is normal secretion can be assessed at the next visit D. Recommend that the client star wearing a supportive brassiere

A mother wants to switch her 9 month-old infant from an iron fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse? A) Change the baby to whole milk B) Add chocolate syrup to the bottle C) Continue with the present formula D) Offer fruit juice frequently

The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects? A) Neurotoxicity B) Hepatomegaly C) Nephrotoxicity D) Ototoxicity

Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client? A) Venturi mask B) Partial rebreather mask C) Non-rebreather mask D) Simple face mask

Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required? A) pH below 7.3 B) Potassium of 5.0 C) HCT of 60 D) Pa O2 of 79%

A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first A) Focus on reality orientation to place and person B) Assist with the report of the client's complaint to the police C) Obtain more details of the client's claim of abuse D) Document the statement on the client's chart with a report to the manager

C) Obtain more details of the client's claim of abuse

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply) A) Take out dentures and place in a labeled cup B) Apply a body shroud C) Place a small pillow under the head D) Remove resuscitation equipment from the room E) Gently close the eye

C, D, E

A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need? A) Trust B) Initiative C) Independence D) Self-esteem

C. Independence

The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to A) Reports of difficulty falling and staying asleep B) Expression of persistent suicidal thoughts C) Lack of enjoyment in usual pleasures D) Reduced senses of taste and smell

C. Lack of enjoyment in usual pleasures

The nurse is assessing a client with a deep vein thrombosis. Which of the following signs and/or symptoms would the nurse anticipate finding? A) Rapid respirations B) Diaphoresis C) Swelling of lower extremity D) Positive Babinski's sign

C. Swelling of lower extremity

A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child? A) Hypothermia B) Edema C) Dyspnea D) Epistaxis

A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." The nurse's best response would be which of these statements? A) "I hear you saying that you have a fear for the loss of love." B) "You sound concerned that your partner will reject you." C) "Are you wondering about the effects on your sexuality?" D) "Are you worried that the surgery will change you?"

A hospitalized 8 month-old infant is receiving digoxin for the treatment of Tetralogy of Fallot. Prior to administering the next dose of medication, the parent reports that the baby has vomited one time, just after breakfast. The heart rate is 62. What is the initial response of the nurse? A) Give the dose after lunch B) Reduce the next dose by half C) Double the next dose D) Hold the medication

A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these mediations would the nurse anticipate the health care provider ordering? A) Oral Coumadin therapy B) Heparin 5000 units subcutaneously b.i.d. C) Heparin infusion to maintain the PTT at 1.5-2.5 times the control value D) Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value

The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? A) Protime (PT) and partial thromboplastin time (PTT) B) Red blood cell and white blood cell counts C) Blood urea nitrogen and creatinine clearance D) Liver enzymes(AST and ALT)

The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately? A) Vomiting of dark emesis B) Complaints of throat pain C) Apical heart rate of 110 D) Increased restlessness

The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L

Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? A) Assess for generalized edema B) Monitor for increased urinary output C) Encourage rest during hyperactive periods D) Note patterns of increased blood pressure

Which therapeutic communication skill is most likely to encourage a depressed client to vent feelings? A) Direct confrontation B) Reality orientation C) Projective identification D) Active listening

A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse would document this behavior as A) Perseveration B) Circumstantiality C) Neologisms D) Flight of ideas

D) Flight of ideas

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse? a. Takes metformin hydrochloride for type 2 diabetes mellitus. b. Report of client's sobriety for the last five years. c. CT scan that was performed six months earlier. d. Metal hip prosthesis was placed twenty years ago.

a. Takes metformin hydrochloride for type 2 diabetes mellitus.

A client is recieving a nitroglycerin infusion at 20mcg/min. The pharmacy dis ... nitroglycerin 75 mg in 250 mL of D5W. The nurse should program the infusion... mL/hr (enter a numeric value only)

answer: 4 Pump rate. is mL/hr (so we have to cover min to hr) the dose received =20 mcg/min=1200 mcg/hr=1.2 mg/hr to know how much mL in 1.2 mg, we used the fixed solution 75 mg in 250 mL as a reference 75 mg---250 mL 1.2 mg== X mL X= 1.2*250/75=4

An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement? a. Ask family members to remain with the client in the evening from 1700 to 2100 p.m. b. Ensure that the client is assigned to a room close to the nurses' station. c. Postpone administration of nighttime medications until after 2300 p.m. d. Administer a prescribed PRN benzodiazepine at the onset of a confused state.

The nurse provides dietary instructions about iron rich foods to a client with iron deficlency anemia. Which food selection made by the client indicates a need for additional instructions? a. Oranges. b. Kidney beans. c. Liver. d. Leafy green vegetables.

b. Kidney beans.

The nurse plans to administer a low dose prescription for dopamine to a cilent who is in septic shock. Which physiologic parameter should the nurse use to evaluate a therapeutic response to dopamine? a. Pupil response. b. Heart sounds. c. Urinary output. d. Temperature.

c. Urinary output.

A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is a. Difference in the intake and output b. Changes in the mucous membranes c. Skin turgor d. Weekly weight

A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to A) Notify the health care provider immediately B) Suggest in-patient psychiatric care C) Respect the client's confidential disclosure D) Phone the family to warn them of the risk

Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to ambulate a client for the first time after a colon resection? A) "Have the client sit on the side of the bed before helping the client to walk." B) "If the client is dizzy ask the client to take some slow, deep breaths." C) "Help the client to walk in the room as often as the client wishes." D) "When you help the client to walk, ask if any pain occurs."

Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin damage? A) Ninety-ninety B) Buck's C) Bryant D) Russell

A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"? A) "I don't remember anything about what happened to me." B) "I'd rather not talk about it right now." C) "It's all the other guy's fault! He was going too fast." D) "My mother is heartbroken about this."

A. "I don't remember anything about what happened to me"

The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions? A) Administration of cough suppressants B) Increasing oral fluid intake to 3000 cc per day C) Maintaining bed rest with bathroom privileges D) Performing chest physiotherapy twice a day

B. Increasing oral fluid intake to 3000 cc per day

A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy? A) Intraventricular hemorrhage B) Retinopathy of prematurity C) Bronchial pulmonary dysplasia D) Necrotizing enterocolitis

B. Retinopathy of prematurity

The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? A) Diminished bowel sounds B) Loss of appetite C) A cold, pale lower leg D) Tachypnea

C) A cold, pale lower leg

A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would A) Instruct the client to maintain a regular diet the day prior to the examination B) Restrict the client's fluid intake 4 hours prior to the examination C) Administer a laxative to the client the evening before the examination D) Inform the client that only 1 x-ray of his abdomen is necessary

C. Administer a laxative to the client the evening before the examination

The nurse would expect which eating disorder to have the greatest fluctuations in potassium? A) Binge eating disorder B) Anorexia nervosa C) Bulemia D) Purge syndrome

C. Bulemia

As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss

D) Hair loss

A client is ambulating with a two-wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, what action should the nurse implement? a. Offer to adjust the height of the walker. b. Encourage the client to continue using the walker as observed. c. Demonstrate more coordinated movement of the legs and walker. d. Explain the need to remove the wheels from the walker.

b. Encourage the client to continue using the walker as observed.

A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires Immediate Intervention by the nurse? a. Orientation to person and place only. b. Unequal bilateral hand grip strengths c. Pupillary changes to ipsilateral dilation. d. Left-sided facial drooping and dysphagia.

b. Unequal bilateral hand grip strengths

the nurse is teaching a client newly diagnosed with systemic lupus erythematosus (SLE).... accurate for the nurse to provide? A. the client can expect to progressively lose function in a fairly predict....... B. The disease is characterized by alternating periods of flare-ups and..... C. Once an. acute attack subsides, the client can. expect to feel fine.. D. Systemic lupus erythematosus (SLE) is a chronic, incurable, termin....

In conducting a pain assessment of a client with osteoarthritis, which action should the nurse include? a. Collect dietary history of calcium-rich food intake. b. Measure vital sign changes after physical activity. c. Ask if pain lessens with elevation of the extremity. d. Observe client during movement of affected joints.

d. Observe client during movement of affected joints.

Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby's diet. Which of the following should be added first? A) Cereal B) Eggs C) Meat D) Juice

Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect? A. Disrupted surfactant production B. Metabolic acidosis C. Aphasia and memory loss D. Deep sleep or coma

While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake

B) Administer acetaminophen as ordered as this is normal at this time

While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? A) "As you urinate more, you will need less medication to control fluid." B) "You will have to take this medication for about a year." C) "The medication must be continued so the fluid problem is controlled." D) "Please talk to your health care provider about medications and treatments."

C) "The medication must be continued so the fluid problem is controlled."

C) Activated PTT

The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? A) "I use a sliding scale to adjust regular insulin to my sugar level." B) "Since my eyesight is so bad, I ask the nurse to fill several syringes." C) "I keep my regular insulin bottle in the refrigerator." D) "I always make sure to shake the NPH bottle hard to mix it well."

D) "I always make sure to shake the NPH bottle hard to mix it well."

The nurse is planning care for an 8 year-old child. Which of the following should be included in the plan of care? A) Encourage child to engage in activities in the playroom B) Promote independence in activities of daily living C) Talk with the child and allow him to express his opinions D) Provide frequent reassurance and cuddling

A client admits to benzodiazepine dependence for several years. She is now inan outpatient detoxification program. The nurse must understand that a priority during withdrawal is A) Avoid alcohol use during this time B) Observe the client for hypotension C) Abrupt discontinuation of the drug D) Assess for mild physical symptoms

An older woman with a history of atrial fibrillation fell at home and fractured her left hip. She is currently taking warfarin 5 mg daily and has an international normalized ratio (INR) value of 5.0. Upon admission, which prescription should the nurse expect to implement? A. Administer Vitamin K injection B. Start continuous heparin infusion C. Continue warfarin at same dose D. Transfuse unit of packed red blood cells

A client being treated for hypertension returns to the community clinic for follow up. The client says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which of these is the best nursing diagnosis? A) Noncompliance related to medication side effects B) Knowledge deficit related to misunderstanding of disease state C) Defensive coping related to chronic illness D) Altered health maintenance related to occupation

A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills

A client who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment, the nurse observes that both breast are swollen, warm, and tender on palpation. Which instruction should the nurse provide? A. Apply ice to the breast for comfort B. Wear a loose-fitting bra during the day to prevent nipple irritation C. Run warm water over breast D. Express small amounts of milk from the breast to relieve pressure

A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement? a. Bring a bedside commode to the client. b. Stand on the client's right side as he walks. c. Walk directly behind the client to prevent a fall. d. Give the client a cane to hold in his right hand.

Which information is a priority for the RN to reinforce to an older client after intravenous pyelogram? a. Eat a light diet for the rest of the day b. Rest for the next 24 hours since the preparation and the test is tiring. c. During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days d. Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? A) Cheese sandwich with a glass of 2% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream

B) Sliced turkey sandwich and canned pineapple

A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child? A) Congenital cardiac defects B) An acute febrile illness C) Prolonged hypoxemia D) Severe multiple trauma

C. Prolonged hypoxemia

A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis A) Low serum albumin B) High serum cholesterol C) Abnormally low white blood cell count D) Elevated creatinine phosphokinase (CPK )

D. Elevated creatinine phosphokinase (CPK )

the nurse is caring for a client who is having a sickle cell crisis. what interventions should the nurse implement in this client's plan of care? A. Ensure adequate IV and oral fluid intake B. provide ice packs to major joint areas C. Space analgesics to prevent addiction to narcotics D. Re-enforce the imporatance of nutrional balance

The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)? A) Test blood sugar every 2 hours by accu check B) Review with family and client signs of hyperglycemia C) Monitor for mental status changes D) Check skin condition of lower extremities

A) Test blood sugar every 2 hours by accu check

while making rounds, the charge nurse notices that a young adult client....yesterday is sitting on the side of the bed leaning over the bed-side....oxygen at 2L/min via nasal cannula. the client is wheezing.....intervention should the nurse implement? A. Assist the client to lie in bed B. Administer a nebulizer treatment C. Call for an Ambu resucitaion bag D. Increase oxygen to 6 liters /min

A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath." B) "I have been coughing up foul-tasting, brown, thick sputum." C) "I have been sweating all day." D) "I feel hot off and on."

B) "I have been coughing up foul-tasting, brown, thick sputum."

Which statement best describes the effects of immobility in children? A) Immobility prevents the progression of language and fine motor development B) Immobility in children has similar physical effects to those found in adults C) Children are more susceptible to the effects of immobility than are adults D) Children are likely to have prolonged immobility with subsequent complications

B) Immobility in children has similar physical effects to those found in adults

a child newly diagnosed with sickle cell anemia (SCA) is being Discharged from..... is most important for the nurse to provide the parents prior to discharge? A. Signs of addiction to opioid pain medications B. Information about nonpharmaceutical pain. relief C. Referral for social services for the child and family D. Instructions about. how much fluid the child should drink daily

a client with bacterial meningitis is receiving phenytoin. which assessment finding....client is experiencing a therapeutic response to the medication? A. Decrease in intracranial pressure and cerebral edema B. Increased time ambulation between periods of rest C. Normal electroencephalogram after drug administration D. Absence of seizure activity for the duration of treatment

an adult client is admitted to the psychiatric until because of a daily..... hours or longer to complete. the client worries about staying clean and..... day area. this client's handwashing is an example of which clinical behavior? A. phobia B. Addiction C. Obsession D. Compulsion

an older client comes to the clinic with a family member. when....history, the client does not respond to questions in a clear manner. what should the nurse do first? A. provide a printed health care assessment form B. Ask the. family member. to anwer the quesitons C. Defer the health history until the client is less anxious D. Assess the surroundings for noise and distractions

in monitoring tissue perfusion in a client following an above-the-knee amputation.... the nurse include it in the plan of care? A. Assess the skin elasticity of the stump B. OBserve for swelling around the stump C. Note the amount and color of wound drainage D. Evaluate closest. proximal pulse

An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions? A) "How long have you been a UAP and what units you have worked on?" B) "What type of care do you give on the surgical unit and what ages of clients?" C) "What is your comfort level in caring for children and at what ages?" D) "Have you reviewed the list of expected skills you might need on this unit?"

D) "Have you reviewed the list of expected skills you might need on this unit?"

Which of these nursing diagnoses of 4 elderly clients would place one client at the greatest risk for falls? A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia

D) Altered patterns of urinary elimination related to nocturia

A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? A) Cut the child's hair short to remove the nits B) Apply warm soaks to the head twice daily C) Wash the child's linen and clothing in a bleach solution D) Application of pediculicides

D) Application of pediculicides

A client with cancer complains of fever, chills, malaise, and headache following administration of a colony- stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu-like symptoms? a. Monitor lab values for an increase in WBCs. b. Administer antiemetics before, during, and after therapy. c. Administer acetaminophen q4h. d. Monitor vital signs q4h for 24 hours.

c. Administer acetaminophen q4h.

A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? a. Measure and document the client's urinary output. b. Request the client's reserved unit if packed red blood cells. c. Prepare the placement of a central venous catheter. d. Increase the infusion rate of Lactated Ringer's solution.

A client is recovering from a thyroidectomy. While monitoring the client's initial post operative condition, which of the following should the nurse report immediately? A) Tetany and paresthesia B) Mild stridor and hoarseness C) Irritability and insomnia D) Headache and nausea

A client with bacterial meningitis is receiving phenytoin. Which assessment finding indicates to the nurse that the client is experiencing a therapeutic response? A. Normal electroencephalogram after drug administration

A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client's behavior is a warning sign to indicate that the client may be A) headed for relapse B) feeling hopeless C) approaching recovery D) in need of increased socialization

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. Which effect is the nurse likely to note as a result of this increase in glaucoma surgeries? A. Decreased prevalence of glaucoma in the population

Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain? A. Upper body muscle strength B. Balance and posture C. Risk for disuse syndrome D. Pressure sore risk

The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is A) Urinary output of 30 ml per hour B) No complaints of thirst C) Increased hematocrit D) Good skin turgor around burn

The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A) Formula or breast milk B) Broth and tea C) Rice cereal and apple juice D) Gelatin and ginger ale

After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents

A) Abdominal x-ray

When conducting diet teaching for a client who is on a postoperative full fluid diet, which foods should the nurse encourage the client to eat?A. Lentils B. Potato soap C. Tea D. Cheese E. Whole grain breads

A,B,C

A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse? A) Suggest isometric exercises B) Maintain the client on bed rest C) Ambulate for several minutes D) Apply ice to the extremity

A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion

A depressed client is experiencing severe insomnia. The health care provider orders trazadone (Desyrel). The nurse tells the client to expect A) Improvement of acne B) Relief of insomnia C) Reduced arthritic pain D) Less nasal stuffiness

A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I've made some decisions about my life." What should be the nurse's initial response? A) "You've made some decisions." B) "Are you thinking about killing yourself?" C) "I'm so glad to hear that you've made some decisions." D) "You need to discuss your decisions with your therapist."

A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passes loose, watery stool. Which of these is a nursing priority? A) Hold the infant at frequent intervals. B) Assess for neonatal withdrawal syndrome C) Offer fluids to prevent dehydration D) Administer paregoric to stop diarrhea

An adult client is admitted to the emergency department after falling from the ladder. While waiting to have a computed tomography (CT) scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement? A. Review client's history for use of illicit drugs B. Explain the reason for using only non-narcotics C. Assess client's pupils for their reaction to light D. Request that the CT scan be done immediately

Dual diagnosis indicates that there is a substance abuse problem as well as a A) Cross addiction B) Mental disorder C) Disorder of any type D) Medical problem

The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age? A) Cooing B) Imitation of sounds C) Throaty sounds D) Laughter

The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to A) Determine oxygen saturation B) Measure forced expiratory volume C) Monitor atmosphere for presence of allergens D) Provide metered doses for inhaled bronchodilator

The recent increase in the reported cases of active tuberculosis (TB) in the United States is attributed to which factor? A) The increased homeless population in major cities B) The rise in reported cases of positive HIV infections C) The migration patterns of people from foreign countries D) The aging of the population located in group homes

The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? A) Practical nurse (PN) B) Registered Nurse (RN) C) Unlicensed assistive personnel (UAP) D) Volunteer

The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse's immediate attention A) "I have a burning sensation when I urinate." B) "I have soreness and aching in my muscles." C) "I am itching all over." D) "I have cramping in my stomach."

Which statement best describes time management strategies applied to the role of a nurse manager? A) Schedule staff efficiently to cover the needs on the managed unit B) Assume a fair share of direct client care as a role model C) Set daily goals with a prioritization of the work D) Delegate tasks to reduce work load associated with direct care and meetings

The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID A) Glycerine suppositories B) Fiber supplements C) Laxatives D) Stool softeners

C) Laxatives

The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect? A) Expiratory wheezes B) Blurred vision C) Acites D) Dilated pupils

C. Acites

A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first? a. Check the protein level in urine b. Have the client turn to the left side c. Take the temperature d. Monitor the urine output

The nurse is caring for a seated client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply) A. Insert a bite block B. Restrain the client C. Loosen restrictive clothing D. Note the duration of the seizureE. Ease the client to the floor

c,d,e

A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution at 18 units/kg/hr. The available solution is Heparin Sodium 25,000 units in 5% Dextrose injection 250mL. The nurse should program the infusion pump to deliver how many mL/hour? (enter numeric value only. If rounding is required, round to the nearest whole number)

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care? A. History of suicide attempts B. Feelings of disorientation C. Undiagnosed social anxiety symptoms (SAD) D. Family history of schizophrenia

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this clients plan of care? A. Observe color of urine B. Measure body temperature C. Assess skin turgor D. Check for pedal edema

A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is A) Central nervous system damage B) Moderate anemia C) Renal tubule damage D) Growth impairment

A. Central nervous system damage

The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is A) Advising client to restrict sodium intake B) Taking the blood pressure in the left arm C) Elevating her left arm above heart level D) Compressing the drainage device

In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing? A) White patches B) Green drainage C) Reddened tissue D) Eschar development

During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice? A) "I wonder who is paying for this trip to the hospital?" B) "I think she needs to go to the city hospital." C) "All those people indulge in large families!" D) "Doesn't she know there's such a thing as birth control?"

D) "Doesn't she know there's such a thing as birth control?"

A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A) Ask client to cough sputum into container B) Have the client take several deep breaths C) Provide a appropriate specimen container D) Assist with oral hygiene

D) Assist with oral hygiene

A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug. How should the nurse respond? a. "You may have an increased chance of having preeclampsia." b. "You may be at higher risk for having a spontaneous miscarriage." c. "This medication will have no effect on your unborn child." d. "You may experience postpartum hemorrhaging after delivery."

b. "You may be at higher risk for having a spontaneous miscarriage."

A client is being treated for hepatic failure. On examination, the client has a weight gain of 4.4 lbs (2kg) in 24 hours and an elevated pulse rate. Which intervention should the nurse include in the plan of care? a. Review arterial blood gases results. b. Assess for dependent pitting edema. c. Document abdominal girth. d. Record usual eating patterns.

b. Assess for dependent pitting edema.

A client is admitted with a diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care? A. Depression B. Peripheral neuropathy C. Confusion D. Right lower abdominal pain

A client with the syndrome of inappropriate antidiuretic hormone secretion ......which intervention is most important for the nurse to include in the plan of care A. initiate seizure precautions B. Assess neurological status every 8 hours C. Limit oral water intake D. Administer hypertonic IV fluids as prescribed

A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client states that he is tired of fighting his illness and is only continuing treatments because his family wants him to live. Which action should the nurse take? a. Notify the family that treatments have been discontinued. b. Arrange a meeting with the family, physician, and client. c. Ask the chaplain to discuss death issues with the client. d. Request a consultation with the hospital social worker.

A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at the parent-teacher meeting. What action is most important for the nurse to include in the meeting? a. Provide information on ways to increase activity for the family. b. Have several teachers talk about health risks associated with obesity. c. Distribute a shopping list of suggested healthy snack items. d. Determine the parents' degree of concern about their children's weight.

Which dietary instruction should the nurse include when teaching a client how to reduce episodes of Raynaud's syndrome? a. Reduce saturated fat intake. b. Increase calcium intake. c. Eliminate caffeine intake. d. Avoid hot beverages.

c. Eliminate caffeine intake.

A client tells the nurse that he Is "very nervous" about the surgery he is scheduled to have in the morning. Which action should the nurse implement first? a. Provide the client with distractions to decrease his anxiety. b. Explore the client's perception of the impending surgery. c. Notify the healthcare provider about the client's expressed fears and anxiety. d. Present the client with information about the surgical procedure.

c. Notify the healthcare provider about the client's expressed fears and anxiety.

A mother brings her 3-year-old son to the emergency room and tells the nurse that he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102° F (38.9°C. He is drooling and becoming increasingly more restless. What action should the nurse take first? a. Put a cold cloth on his head and administer acetaminophen. b. Assist the child to lie down and examine his throat. c. Notify the healthcare provider and obtain a tracheostomy tray. d. Listen to lung sounds and place him in a mist tent.

c. Notify the healthcare provider and obtain a tracheostomy tray.

While adding water to the chest tube drainage system, the nurse knocks over the container causing the blood to spill into the adjacent chamber. Which action should the nurse take? a. Increase suction to 30 cm. b. Assess tubing for fluctuation with respirations. c. Replace chest tube drainage system. d. Mark drainage in both chambers.

c. Replace chest tube drainage system.

A primigravida client being treated for preeclampsla with magneslum sulfate delivered a 7-pound infant four hours ago by cesarean delivery. Which nursing problem has the highest priority? a. Impaired parenting related to inexperience. b. Acute pain related to abdominal incision. c. Risk for injury related to uterine atony. d. Ineffective breastfeeding related to fatigue.

c. Risk for injury related to uterine atony.

A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. Which is the priority nursing problem for this client? a. Altered sleep pattern. b. Imbalanced nutrition: less than. c. Risk for injury. d. Disturbed thought processes.

c. Risk for injury.

A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant? a. Chickenpox b. Mumps c. Sore throat d. Influenza

c. Sore throat

A client arrives in the Emergency Department (ED) with a deep, full-thickness burn over the anterior surface of both upper legs. Which priority intervention should the nurse implement? a. Start IV antibiotics. b. Administer tetanus immunization. c. Give IV analgesia. d. Give an IV bolus of normal saline.

d. Give an IV bolus of normal saline.

A client in the third trimester of pregnancy com- plains of frequent nasal stiffness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?

d. Record the respiratory findings in the clients record as normal

A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be delayed? A) MMR B) Hib C) IPV D) DtaP

During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse? A) The client's self-report is the most important consideration B) Cultural sensitivity is fundamental to pain management C) Clients have the right to have their pain relieved D) Nurses should not prejudge a client's pain using their own values

The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding? A) Stand on 1 foot B) Catch a ball C) Skip on alternate feet D) Ride a bicycle

an older adult male who had an abdominal cholecystectomy has become....over the past 24 hours. he is found wandering into another client's room.....UAP. Which actions should the nurse implement? (select all) A. Review the client's most recent serum electrolyte value B. Assign the UAP to re-assess the client's risk for falls C. Report mental status change to the healthcare provider D. Apply soft upper limb restraints and raise all. four-bed rails E. Assess the client's breath sounds and oxygen saturation

A, C, E

Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called A) Craving B) Crashing C) Outward bound D) Nodding out

The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? A) Risk for dehydration B) Ineffective airway clearance C) Altered nutrition D) Risk for injury

Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160

While caring for a client, the nurse notes a pulsating mass in the client's peri umbilical area. Which of the following assessments is appropriate for the nurse to perform? A) Measure the length of the mass B) Auscultate the mass C) Percuss the mass D) Palpate the mass

Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt? A) "Addiction usually causes people to feel guilty. Don't worry, it is a typical response due to your drinking behavior." B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?" C) "Don't focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs." D) "You've caused a great deal of pain to your family and close friends, so it will take time to undo all the things you've done."

B. "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt"

A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to A) A social worker from the local hospital B) An occupational therapist from the community center C) A physical therapist from the rehabilitation agency D) Another client with diabetes mellitus and takes insulin

B. An occupational therapist from the community center

The new graduate nurse interviews for a position in a nursing department of a large health care agency, described by the interviewer as having shared governance. Which of these statements best illustrates the shared governance model? A) An appointed board oversees any administrative decisions B) Nursing departments share responsibility for client outcomes C) Staff groups are appointed to discuss nursing practice and client education issues D) Non-nurse managers supervise nursing staff in groups of units

B. Nursing departments share responsibility for client outcomes

A couple asks the nurse about risks of several birth control methods. What is he most appropriate response by the nurse? A) Norplant is safe and may be removed easily B) Oral contraceptives should not be used by smokers C) Depo-Provera is convenient with few side effects D) The IUD gives protection from pregnancy and infection

B. Oral contraceptives should not be used by smokers

The nurse is administering albuterol (Proventil) to a child with asthma. Which of the following assessments by the nurse indicate the need for an adjustment of the medication? A) Lethargy and fatigue B) Edema is the lower extremities C) Apical Pulse of 112 D) Temperature of 101 degrees Fahrenheit

The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? A) Narrowed QRS complex B) Shortened "PR" interval C) Tall peaked T waves D) Prominent "U" waves

The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan? A) Antibiotic therapy for 10 days B) Teach client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at bedside within the first 24 hours

The nurse should withhold which medication if the client's serum potassium level is 6.2 mEq/L or mmol/L (SI)? A. Metolazone B. Furosemide C. Spironolactone D. Hydrochlorothiazide

The nurse uses the DRG (Diagnosis Related Group) manual to A) Classify nursing diagnoses from the client's health history B) Identify findings related to a medical diagnosis C) Determine reimbursement for a medical diagnosis D) Implement nursing care based on case management protocol

C. Determine reimbursement for a medical diagnosis

The nurse is planning care for a client with increased intracranial pressure. The best position for this client is A) Trendelenberg B) Prone C) Semi-Fowlers D) Side-lying with head flat

C. Semi-Fowlers

The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? A) Confusion B) Loss of half of visual field C) Shallow respirations D) Tonic-clonic seizures

C. Shallow respirations

The nurse is assessing a newborn delivered at home by an admitted heroin addict. Which of the following would the nurse expect to observe? A) Hypertonic neuro reflex B) Immediate CNS depression C) Lethargy and sleepiness D) Jitteriness at 24-48 hours

the healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication? A. Difficulty locating the uterine fundus B. Excessive lochia C. Saturation of more than one pad per hour D. Hypertension

The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is A) A firm touch to the trapezius muscle or arm B) Pinching any body part C) Sternal rub D) Gentle pressure on eye orbit

D) Gentle pressure on eye orbit

An American Indian chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The attending nurse tells a colleague "I wonder if he has any idea how ridiculous he looks -- he's a grown man!" The nurse's response is an example of A) Discrimination B) Stereotyping C) Ethnocentrism D) Prejudice

D) Prejudice

During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention? A) Pleuritic pain on inspiration B) Dry mucus membranes in the mouth C) A decrease in respiratory rate from 34 to 24 D) Decrease in chest wall expansion

D. Decrease in chest wall expansion

Which behavioral characteristic describes the domestic abuser? A) Alcoholic B) Over confident C) High tolerance for frustrations D) Low self-esteem

D. Low self-esteem

When conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? (select all that apply.) a. Fruits without sauce b. Canned soup. c. Fresh or frozen vegetables without sauce. d. Cottage cheese. e. Pickled olives.

a, c

The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)? a. Measure the client's body weight each morning. b. Establish blood pressure parameters for client monitoring c. Evaluate a staff member providing wound care. d. Evaluate client teaching through return demonstration.

What would the nurse expect to see in a client who is experiencing symptoms of tardive dyskinesia? A) Rapid tongue movements B) Uncontrolled hand tremors during meals C) Behavioral changes D) Repetitive slapping movements

A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention? A) Lethargy B) Agitation C) Ataxia D) Hearing loss

A. Lethargy

The nurse would teach a client with Raynaud's phenomenon that it is most important to A) Stop smoking B) Keep feet dry C) Reduce stress D) Avoid caffeine

A. Stop smoking

A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate A) Non stress test B) Abdominal ultrasound C) Pelvic exam D) X-ray of abdomen

A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to? A) Stabilize thermoregulation B) Maintain alveolar surface tension C) Begin normal pulmonary blood flow D) Regulate intra cardiac pressure

A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond? A) With acceptance and views the victim's comment as an indication that their marriage is in trouble B) With fear of rejection causing increased rage toward the victim C) With a new commitment to seek counseling to assist with their marital problems D) With relief, and welcomes the separation as a means to have some personal time

Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child? A) "I know there is a problem since my baby is always constipated." B) "My child doesn't like many fruits and vegetables, but she really loves her milk." C) "I can't understand why my child is not eating as much as she did 4 months ago." D) "My child doesn't drink a whole glass of juice or water at 1 time."

Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)? A) Document skin turgor and color changes B) Test stool for occult blood and urine for glucose C) Suggest foods high in iron and those easily consumed D) Report mental status changes and the degree of mental clarity

On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the RN anticipate finding? A) Periorbital edema, absent light reflex and translucent tympanic membrane B) Irritability, rhinorrhea, and bulging tympanic membrane C) Diarrhea, retracted tympanic membrane and enlarged parotid gland D) Vomiting, pulling at ears and pearly white tympanic membrane

B. Irritability, rhinorrhea, and bulging tympanic membrane

A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client knowing that gradual emptying is preferred over complete emptying because it A) Reduces the potential for renal collapse B) Reduces the potential for shock C) Reduces the intensity of bladder spasms D) Prevents bladder atrophy

B. Reduces the potential for shock

A client is admitted for COPD. Which finding would require the nurse's immediate attention? A) Nausea and vomiting B) Restlessness and confusion C) Low-grade fever and cough D) Irritating cough and liquefied sputum

B. Restlessness and confusion

An 82 year-old client is prescribed eye drops for treatment of glaucoma. What assessment is needed before the nurse begins teaching proper administration of the medication? A) Determine third party payment plan for this treatment B) The client's manual dexterity C) Proximity to health care services D) Ability to use visual assistive devices

B. The client's manual dexterity

While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? A) They are able to make simple association of ideas B) They are able to think logically in organizing facts C) Interpretation of events originate from their own perspective D) Conclusions are based on previous experiences

B. They are able to think logically in organizing facts

A client states, "People think I'm no good, you know what I mean?" Which of these responses would be most therapeutic? A) "Well people often take their own feelings of inadequacy out on others." B) "I think you're good. So you see, there's one person who likes you." C) "I'm not sure what you mean. Tell me a bit more about that." D) "Let's discuss this to see the reasons to create this impression on people?"

A client who is 12 hour post-op becomes confused and says: "Giant sharks are swimming across the ceiling." Which assessment is necessary to adequately identify the source of this client's behavior? A) Cardiac rhythm strip B) Pupillary response C) Pulse oximetry D) Peripheral glucose stick

The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from... A) a tissue bank." B) a pig." C) my thigh." D) synthetic skin."

The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5. Which of the following would the nurse anticipate? A) Additional potassium will be given IV B) Blood for coagulation studies will be drawn C) Total parenteral nutrition (TPN) will be started D) Serum lipase levels will be evaluated

The nurse is planning care for a client during the acute phase of a sickle cell vaso- occlusive crisis. Which of the following actions would be most appropriate? A) Fluid restriction 1000cc per day B) Ambulate in hallway 4 times a day C) Administer analgesic therapy as ordered D) Encourage increased caloric intake

The nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's Syndrome? A) Rubeola B) Meningitis C) Varicella D) Hepatitis

Which activity can the RN ask an unlicensed assistive personnel(UAP)to perform? A) Take a history on a newly admitted client B) Adjust the rate of a gastric tube feeding C) Check the blood pressure of a 2 hours post operative client D) Check on a client receiving chemotherapy

Which of these parents' comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? A) I noticed a little lump a little above the belly button. B) The baby seems hungry all the time. C) Mild vomiting that progressed to vomiting shooting across the room. D) Irritation and spitting up immediately after feedings.

While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best? A) "That's OK, its all right to skip your medication now and then." B) "I will have to call your doctor and report this." C) "Is there a reason why you don't want to take your medicine?" D) "Do you understand the consequences of refusing your prescribed treatment?"

A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? A) Acceptance of the pregnancy B) Focus on fetal development C) Anticipation of the birth D) Ambivalence about pregnancy

C. Anticipation of the birth

A 15 year-old client with a lengthy confining illness is at risk for altered growth and development of which task? A) Loss of control B) Insecurity C) Dependence D) Lack of trust

C. Dependence

he nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by A) Inserting a fenestrated catheter with a whistle tip without suction B) Completing suction pass in 30 seconds with pressure of 150 mm Hg C) Hyper oxygenating with 100% O2 for 1 to 2 minutes before and after each suction pass D) Minimizing suction pass to 60 seconds while slowly rotating the lubricated catheter

C. Hyper oxygenating with 100% O2 for 1 to 2 minutes before and after each suction pass

A 67 year-old client is admitted with substernal chest pain with radiation to the jaw. His admitting diagnosis is Acute Myocardial Infraction (MI). The priority nursing diagnosis for this client during the immediate 24 hours is A) Constipation related to immobility B) High risk for infection C) Impaired gas exchange D) Fluid volume deficit

C. Impaired gas exchange

A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced manager should the new manager do initially? A) Set daily goals and establish priorities for each hour and each day. B) Ask for additional assistance when you feel overwhelmed. C) Keep a time log of your day in hourly blocks for at least 1 week. D) Complete each task before beginning another activity in selected instances.

C. Keep a time log of your day in hourly blocks for at least 1 week.

A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client? A) Prone B) Dorsal recumbent C) Semi-Fowler D) Supine

C. Semi-Fowler

A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would providethe best reality orientation for this client? A) "Good morning. Do you remember where you are?" B) "Hello. My name is Elaine Jones and I am your nurse for today." C) "How are you today? Remember, you're in the hospital." D) "Good morning. You're in the hospital. I am your nurse Elaine Jones."

A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? A) Bruising at the operative site B) Elevated heart rate C) Decreased platelet count D) No bowel movement for 3 days Skip

A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance? A. Respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory alkalosis

The charge nurse of a critical carry unit is informed at the beginning of the shift that lesss than the optical number of registered nurses will be working that shift and planning assignments which client should receive the most care hours by registered nurse (RN)? A. 48 year olds marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race B. 34 year old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter C. 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter D. An 82-year-old's client with Alzheimer's disease and newly fractured femur who has a Foley catheter and soft wrist restraint supplied

The nurse identifies several nursing problems for a client who is immobile and who has been experiencing fecal incontinence and diarrhea for several days. The client's spouse is the primary caregiver. In planning care, which problem has the highest priority? A. Impaired bed mobility B. Caregiver role strain C. Fluid volume deficit D. Bowel incontinence

The nurse is caring for an 81 year-old client with colorectal cancer. The client's pain has been managed until now with acetaminophen with codeine. Because of increased pain, intravenous morphine is added. What should the nurse recognize about the validity of this order? A) Inappropriate because of potential respiratory depression B) Appropriate despite the expected effect of mental confusion C) Inappropriate and demonstrates poor knowledge of pain control D) Appropriate pain management around-the-clock

The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? A. Core strengthening B. Aerobic exercise C. Weight-bearing exercise D. Muscle stretching and toning

the nurse developing a plan of care for a client who reports tingling of.....with peripheral vascular disease. which outcome should the nurse include? A. the client will express acceptance of their new diagnosis.. B. The nurse. will encourage the client to walk. thirty minutes.. C. The client's blood pressure readings will be less than 160/... D. The client's skin on the. lower legs. will be intact at the next ...

A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client's obstetric history by the nurse? A) Para 2, Gravida 1 B) Nulligravida 2, Para 1 C) Primagravida 1, Para 1 D) Gravida 2, Para 1

D. Gravida 2, Para 1

The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take? a. Complete an adverse occurrence report. b. Monitor for signs of bleeding. c. Obtain blood for coagulation studies. d. Notify the healthcare provider.

b. Monitor for signs of bleeding.

While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask? a. "Do you often have feeling of sadness?" b. "Are you having problems concentrating?" c. "Have you though about taking your life?" d. "What problems are you facing right now?"

The client with which type of wound is most likely to need immediate intervention by the nurse? a. Ulceration. b. Contusion. c. Laceration. d. Abrasion.

c. Laceration.

An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? a. Urine specific gravity is 1.040 b. Systolic blood pressure decreases 10 points when standing. c. The client denies being thirsty. d. Skin tenting occurs when the client's forearm is pinched.

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the education materials include which characteristics? (Select all that apply) A. Use common words with few syllables B. Printed using a 12-point type font C. Uses pictures to help illustrate complex ideas D. Contains a list with definitions of unfamiliar terms E. Written at a twelfth-grade reading level

A, C, D

A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse? A) "Focus on your sons' needs during the first days at home." B) "Tell each child what he can do to help with the baby." C) "Suggest that your husband spend more time with the boys." D) "Ask the children what they would like to do for the newborn."

A. "Focus on your sons' needs during the first days at home"

A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? a. Elevate the foot of the bed. b. Restrict the client's fluid. c. Begin supplemental oxygen. d. Prepare the client for hemodialysis.

A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? A) The muscles B) The cerebellum C) The kidneys D) The leg bones

A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include A) The escalation of fees with a decreased reimbursement percentage B) High costs of diagnostic and end-of-life treatment procedures C) Increased numbers of elderly and of the chronically ill of all ages D) A steep rise in health care provider fees and in insurance premiums

A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts ondeath and dying at this age? A) Death is personified as the bogeyman or devil B) Death is perceived as being irreversible C) The child feels guilty for the grandmother's death D) The child is worried that he, too, might die

An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by A) Tachypnea B) Acidic byproducts C) Vomiting and dehydration D) Hyperpyrexia

An unlicensed assistive staff member asks the nurse manager to explain the beliefs of a Christian Scientist who refuses admission to the hospital after a motor vehicle accident. The best response of the nurse would be which of these statements? A) "Spiritual healing is emphasized and the mind contributes to the cure." B) "The primary belief is that dietary practices result in health or illness." C) "Fasting and prayer are initial actions to take in physical injury." D) "Meditation is intensive in the initial 48 hours and daily thereafter."

At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states "My blood pressure is usually much lower." The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours B) check blood pressure again in 2 months C) see the health care provider immediately D) visit the health care provider within 1 week for a BP check

For which of the following mother-baby pairs should the nurse review the Coomb's test in preparation for administering RhO (D) immune globulin within 72 hours of birth? A) Rh negative mother with Rh positive baby B) Rh negative mother with Rh negative baby C) Rh positive mother with Rh positive baby D) Rh positive mother with Rh negative baby

The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A) A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago B) A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens- Johnson syndrome that morning D) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago

The nurse has been teaching an apprehensive primipara who has difficulty in initial nursing of the newborn. What observation at the time of discharge suggests that initial breast feeding is effective? A) The mother feels calmer and talks to the baby while nursing B) The mother awakens the newborn to feed whenever it falls asleep C) The newborn falls asleep after 3 minutes at the breast D) The newborn refuses the supplemental bottle of glucose water

The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding , the nurse should plan to A) Restrict visitors to immediate family B) Avoid arousal of the client except for family visits C) Keep client's hips flexed at no less than 90 degrees D) Apply a warming blanket for temperatures of 98 degrees Fahrenheit or less

The nurse is attending a workshop about caring for persons infected with Hepatitis. Which statement is correct when referring to the incidence rate for Hepatitis? A) The number of persons in a population who develop Hepatitis B during a specific period of time B) The total number of persons in a population who have Hepatitis B at a particular time C) The percentage of deaths resulting from Hepatitis B during a specific time D) The occurrence of Hepatitis B in the population at a particular time

The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention? A) Pulse oximetry of 85% B) Nocturia C) Crackles in lungs D) Diaphoresis

The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately? A) Fecal impaction B) Infrequent voiding C) Stress incontinence D) Burning with urination

The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention? A) Decrease in level of consciousness B) Loss of bladder control C) Altered sensation to stimuli D) Emotional lability

The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to A) Encourage the parents to enroll in cardiopulmonary resuscitation class B) Assist the parents to plan quiet play activities at home C) Stress to the parents that they will need relief care givers D) Instruct the parents to avoid contact with persons with infection

The parents of a child who has recently been diagnosed with asthma ask the nurse to explain the condition to them. The best response is "Asthma causes... A) the airway to become narrow and obstructs airflow." B) air to be trapped in the lungs because the airways are dilated." C) the nerves that control respiration to become hyperactive." D) a decrease in the stress hormones which prevents the airways from opening."

The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is A) Drink 3000 to 4000 cc of fluid each day for one month B) Limit fluid intake to 1000 cc each day for one month C) Increase intake of citrus fruits to three servings per day D) Restrict milk and dairy products for one month

Which of these statements best describes the characteristic of an effective reward- feedback system? A) Specific feedback is given as close to the event as possible B) Staff are given feedback in equal amounts over time C) Positive statements are to precede a negative statement D) Performance goals should be higher than what is attainable

A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A) Trichomoniasis B) Chlamydia C) Staphylococcus D) Streptococcus

A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure A) Right heart function B) Left heart function C) Renal tubule function D) Carotid artery function

A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? A) A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying B) A teenager who got a singed beard while camping C) An elderly client with complaints of frequent liquid brown colored stools D) A middle aged client with intermittent pain behind the right scapula

As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid A) Surfing B) Scuba diving C) Parasailing D) Swimming

In order to be effective in administering cardiopulmonary resuscitation to a 5 year- old, the nurse must A) Assess the brachial pulses B) Breathe once every 5 compressions C) Use both hands to apply chest pressure D) Compress 80-90 times per minute

Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach? A) Consider a liquid supplement to increase calories B) Discuss consequences of an unbalanced diet with the child C) Provide fruit, vegetable and protein snacks D) Encourage the child to keep a daily log of foods eaten

The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should A) Place a call to the client's health care provider for instructions B) Send him to the emergency room for evaluation C) Reassure the client's wife that the symptoms are transient D) Instruct the client's wife to call the doctor if his symptoms become worse

The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should A) Irrigate it as ordered with distilled water B) Irrigate it as ordered with normal saline C) Place the end of the tube in water to see if the water bubbles D) Withdraw the tube several inches and reposition it

The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? A) Tuberculin skin testing B) Sputum culture C) White blood cell count D) Chest x-ray

The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse's immediate attention? A) I have bad muscle spasms in my lower leg of the affected extremity. B) "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger." C) "I have to use the bedpan to pass my water at least every 1 to 2 hours." D) "It seems that the pain medication is not working as well today."

The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? A) "You need to regain your strength before attempting such exertion." B) "When you can climb 2 flights of stairs without problems, it is generally safe." C) "Have a glass of wine to relax you, then you can try to have sex." D) "If you can maintain an active walking program, you will have less risk."

The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care? A) Impaired skin integrity related to dependent edema B) Activity intolerance related to oxygen supply and demand imbalance C) Constipation related to immobility D) Risk for infection related to ineffective mobilization of secretions

The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response? A) Electrical energy fields B) Spinal column manipulation C) Mind-body balance D) Exercise of joints

The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered A) Expected B) Rude C) Professional D) Enjoyable

When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by A) Reduced oxygen capacity of cells due to lack of iron B) An imbalance between red cell destruction and production C) Depression of red and white cells and platelets D) Inability of sickle shaped cells to regenerate

Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A) angina at rest B) thrombus formation C) dizziness D) falling blood pressure

A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? A) Positive sweat test B) Bulky greasy stools C) Moist, productive cough D) Meconium ileus

A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is A) Maintain fluid and electrolyte balance B) Control nausea C) Manage pain D) Prevent urinary tract infection

A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? A) Gravida 4 para 2 B) Gravida 2 para 1 C) Gravida 3 para 1 D) Gravida 3 para 2

A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client? A) Moist mucous membranes B) Urinary frequency C) Poor skin turgor D) Increased blood pressure

A woman who delivered 5 days ago and had been diagnosed with preeclampsia calls the hospital triage nurse hotline to ask for advice. She states " I have had the worst headache for the past 2 days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next? A) Advise the client that the swings in her hormones may have that effect. However, suggest for her to call her health care provider within the next day. B) Advise the client to have someone bring her to the emergency room as soon as possible C) Ask the client to stay on the line, get the address and send an ambulance to the home D) Ask what the client has taken? How often? Ask about other specific complaints.

An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first? A) Lung sounds B) Urine output C) Level of alertness D) Appetite

An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest." B) A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?" C)An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room

During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to A) Increase fluids that are high in protein B) Restrict fluids C) Force fluids and reassess blood pressure D) Limit fluids to non-caffeine beverages

During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member? A) At least 2 full meals a day is eaten. B) We go to a group discussion every week at our community center. C) We have safety bars installed in the bathroom and have 24 hour alarms on the doors. D) The medication is not a problem to have it taken 3 times a day.

In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? A) Polyphagia B) Dehydration C) Bed wetting D) Weight loss

The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse is A) "The top layer of the skin is destroyed." B) "The skin layers are swollen and reddened." C) "All layers of the skin were destroyed in the burn." D) "Muscle, tissue and bone have been injured."

The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor? A) Sexually transmitted infection B) Exposure to teratogens C) Maternal hypertension D) Chromosomal abnormalities

The nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. What action should the nurse do first? A) Explain the stages of death and dying to the family B) Recommend an easy-to-read book on grief C) Assess the family's patterns for dealing with death D) Ask about their religious affiliations

The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When comparing findings to the Ballard scale, which situation may affect the score? A) Birth weight B) Racial differences C) Fetal distress in labor D) Birth trauma

The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be A) High calorie, low fat, low sodium B) High protein, low fat, low carbohydrate C) High protein, high calorie, unrestricted fat D) High carbohydrate, low protein, moderate fat

The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated A) "I can only wear cotton socks." B) "I cannot go barefoot around my house." C) "I will trim corns and calluses regularly." D) "I should ask a family member to inspect my feet daily."

The nurse is teaching a mother who will breast feed for the first time. Which of the following is a priority? A) Show her films on the physiology of lactation B) Give the client several illustrated pamphlets C) Assist her to position the newborn at the breast D) Give her privacy for the initial feeding

The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting." The nurse manager's leadership style is best described as A) Laissez-faire B) Autocratic C) Participative D) Group

When teaching a client with coronary artery disease about nutrition, the nurse should emphasize A) Eating 3 balanced meals a day B) Adding complex carbohydrates C) Avoiding very heavy meals D) Limiting sodium to 7 gms per day

Which action is most likely to ensure the safety of the nurse while making a home visit? A) Observation during the visit of no evidence of weapons in the home B) Prior to the visit, review client's record for any previous entries about violence C) Remain alert at all times and leave if cues suggest the home is not safe D) Carry a cell phone, pager and/or hand held alarm for emergencies

Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working? A) The client complains of discomfort at the IV insertion site B) The client states "I just can't get relief from my pain." C) The level of drug is 100 ml at 8 AM and is 80 ml at noon D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon

A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A) Prepare the child for x-ray of upper airways B) Examine the child's throat C) Collect a sputum specimen D) Notify the healthcare provider of the child's status

A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first? A) Place the child in the nearest bed B) Administer IV medication to slow down the seizure C) Place a padded tongue blade in the child's mouth D) Remove the child's toys from the immediate area

A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication? A) Weight gain of 5 pounds B) Edema of the ankles C) Gastric irritability D) Decreased appetite

A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child? A) Riding in a car B) Falling off a bed C) Electrical outlets D) Eating peanuts

A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre- operative client. Which action should the nurse take first? A) Raise the side rails on the bed B) Place the call bell within reach C) Instruct the client to remain in bed D) Have the client empty bladder

After the shift report in a labor and delivery unit which of these clients would the nurse check first? A) A middle aged woman with asthma and diabetes mellitus Type 1 has a BP of 150/94 B) A middle aged woman with a history of two prior vaginal term births is 2 cm dilated C) A young woman is a grand multipara has cervical dilation of 4 cm and 50% effaced D) An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum

The nurse admits an elderly Mexican-American migrant worker after an accident that occurred during work. To facilitate communication the nurse should initially A) Request a Spanish interpreter B) Speak through the family or co-workers C) Use pictures, letter boards, or monitoring D) Assess the client's ability to speak English

The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: "We are concerned about the possible occurrence of sudden infant deathsyndrome (SIDS)." In order to take appropriate action, the nurse must understand that A) The child is within the age group most susceptible to SIDS B) The peak age for occurrence of SIDS is 8 to 12 months of age C) The apnea monitor is not effective on a child in this age group D) 95% of SIDS cases occur before 6 months of age

The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to A) Excessive fetal weight B) Low blood sugar levels C) Depletion of subcutaneous fat D) Progressive placental insufficiency

What would the nurse expect to see while assessing the growth of children during their school age years? A) Decreasing amounts of body fat and muscle mass B) Little change in body appearance from year to year C) Progressive height increase of 4 inches each year D) Yearly weight gain of about 5.5 pounds per year

A client with human immunodeficiency virus (HIV) begins active labor at 38 weeks gestation and receives a prescription for zidovudine 2 mg/kg IV, to be administered over 1 hour. The client weighs 185 lbs. Based on the client's weight, how many mg should the nurse prepare to administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

168mg

A client with a gram-positive bacterial skin infection is receiving daptomycin 500 mg IV every 24 hours. The pharmacy delivers a secondary infusion of 0.9% Sodium Chloride with daptomycin 500 mg/100 mL to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter the numerical value only.)

200

. A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events B) Detaching or dissociating in this way postpones painful feelings C) This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflict D) To isolate the feelings in this way reduces conflict within the client and with others

A client who is admitted with complications related to hypopituitarism is diaphoretic and hypotensive. Which assessment finding warrants immediate intervention by the nurse? A. Lethargy

A middle - aged client , admitted to a critical care unit several weeks ago because of serious injuries sustained in a motor vehicle accident , is currently in stable condition Based on client's age and recent life - threatening crisis , which intervention should the nurse implement ? A. Encourage the client to reflect on personal goals and priorities B. Allow long periods of uninterrupted rest in order to reduce fatigue C. Discuss the cause of the accident with the client and his family D. Provide a routine schedule of activities to facilitate trust

An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? A) Stay with client and observe for airway obstruction B) Collect pillows and pad the side rails of the bed C) Place an oral airway in the mouth and suction D) Announce a cardiac arrest, and assist with intubation

When taking the client's blood pressure (BP), the nurse cannot hear the sounds through the stethoscope. Which action should the nurse take first? A) take the BP again in 2 minutes in the same arm B) retake the BP again immediately in the same arm C) use an electronic BP cuff on the other arm D) check to see if the stethoscope is plugged

When teaching a client about the use of sublingual nitroglycerin, the nurse should emphasize that which of these is the most common side effect? A) Headache B) Dry mouth C) Depression D) Anorexia

A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity? * A) Bradycardia B) Lethargy C) Irritability D) Vomiting

A. Bradycardia

The nurse is assessing a newborn the day after birth. A high pitched cry, irritability and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care? A) Reduce the environmental stimuli B) Offer formula every 2 hours C) Talk to the newborn while feeding D) Rock the baby frequently

A. Reduce the environmental stimuli

When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority? A) Risk for injury: hemorrhage B) Risk for injury related to peripheral neuropathy C) Altered nutrition: less than body requirements D) Fluid volume excess: ascites

A. Risk for injury: hemorrhage

The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is A) Pain B) Impaired gas exchange C) Cardiac output altered: decreased D) Fluid volume excess

A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present A) Temperature of 37.5 degrees Celsius with painful urination B) An open wound on their heel C) Insomnia and daytime fatigue D) Nausea with 2 episodes of vomiting

A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first? A) Notify the health care provider B) Administer the PRN dose of Albuterol C) Apply oxygen at 2 liters per nasal cannula D) Repeat the peak flow reading in 30 minutes

An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take? A. Prepare the client for an echocardiogram B. Document in the client's record C. Notify the healthcare provider D. Limit the client's fluids

The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment? A) Stressors in the home B) Medication compliance C) Exposure to hot temperatures D) Alcohol use

When walking past a client's room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention? A) "If we work together we can get all of the client care completed." B) "Since I am late for lunch, would you do this one client's glucose test?" C) "This client seems confused, we need to watch monitor closely." D) "I'll come back and make the bed after I go to the lab."

a new nurse preparing to irrigate an IV catheter is attaching a.....the charge nurse implement? A. Suggest the nurse use a 20-gauge needle B. Direct the nurse. to change the IV tubing C. Instruct the nurse to. remove the needle D. Prompt the nurse to apply povidone to the site

an older client is admitted to the hospital because of a recurring transient ischemic attack....assessments for the past 24 hours were within normal limits. one day after admission...becomes confused and combative indicating impaired mental status. what interventions should the nurse implement first? A. document. neurologic changes B. Reduce environmental stimuli C. Administer prescribed neuroleptic D. Review medications for interactions

The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? A) "I can't lie in 1 position for more than thirty minutes." B) "I am allergic to shrimp." C) "I suffer from claustrophobia." D) "I developed a severe headache after a spinal tap."

B) "I am allergic to shrimp."

When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula A) Every four to six hours B) Continuously C) In a bolus D) Every hour

B) Continuously

When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? (Select all that apply) A. Cheese B. Tea C. Lentils D. Whole grain breads E. Potato soup

B, C, E

A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? A) "There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional concerns that can be dealt with." C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." D) "You will work with a team of experts and also have access to a support group that the family can attend."

A child is treated with edetate calcium disodium (Calcium EDTA) for lead poisoning. Which of these should the nurse assess first ? A) Serum potassium level B) Blood calcium level C) Urinary output D) Deep tendon reflexes

A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in the plan of care within the initial 24 hours for this client? A) Wear masks with shields if potential splash B) Use disposable utensils and plates for meals C) Wear gown and gloves during client contact D) Provide soft easily digested food with frequent snacks

A client with hyperthyroidism is admitted to the postoperative unit after a subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse? A. T3 - uptake at 50% B. Glucose 150 mg/dL (8.32 mmol/L) C. Total calcium 5.0 mg/dL (1.25 mmol/L) D. Thyroxine 12 mcg/dL (154 mmol/L)

A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach? A) Vary the interview style for each candidate to learn different techniques B) Use simple questions requiring "yes" and "no" answers to gain definitive information C) Obtain an interview guide from human resources for consistency in interviewing each candidate D) Ask personal information of each applicant to assure meeting of job demands

A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation? A) Abnormal breath sounds B) Cyanosis of the lips C) Increasing pulse rate D) Pulse oximeter reading of 92%

A nurse is stuck in the hand by an exposed needle. What immediateaction should the nurse take? A) Look up the policy on needle sticks B) Contact employee health services C) Immediately wash the hands with vigor D) Notify the supervisor and risk management

A nurse who is working in the emergency department triage area is presented with four clients at the same time . The client presenting with which symptoms requires the most immediate intervention by the nurse A. One-inch bleeding laceration on the chin of a crying 5-year-old B. Low-grade fever, headache, and malaise for the past 72 hours C. Chest discomfort one hour after consuming large, spicy meals D. Unable to bear weight on the left foot, with swelling and bruising

A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn assessments suggests to the nurse that the infant has fetal alcohol syndrome? A) Growth retardation is evident B) Multiple anomalies are identified C) Cranial facial abnormalities are noted D) Prune belly syndrome is suspected

The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should A) Observe the child's behavior on at least 2 occasions B) Consult with the teacher about how to control impulsivity C) Compile a history of behavior patterns and developmental accomplishments D) Compare the child's behavior with classic signs and symptoms

While caring for a child with Reye's Syndrome, the nurse should give which action the highest priority? A) Monitor intake and output B) Provide good skin care C) Assess level of consciousness D) Assist with range of motion

C. Assess level of consciousness

A client has both a primary IV infusion in a secondary infusion of a medication. An infusion pump is available. The nurse needs to change the rate of the flow of the secondary infusion.

Click on the tube chamber just below the yellow bag

The nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which of the following must be emphasized? A) Rest in bed for an hour after taking medication B) Take the medication at the same time each day C) Keep the medication bottle in the refrigerator D) Carry the nitroglycerine with you at all times

A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have A) Scrotal discoloration B) Sustained painful erection C) Inability to achieve erection D) Heaviness in the affected testicle

A female client with chronic kidney disease and renal failure has an indwelling peritoneal catheter in ..... used for peritoneal dialysis. While bathing, the her abdominal dressing becomes wet. What action should the nurse take? a. Change the dressing. b. Reinforce the dressing. c. Flush the peritoneal dialysis catheter. d. Scrub the catheter with povidone-iodine.

While assessing a client who had a laparotomy the previous day, the nurse notices that 300 ml of dark red fluids has drained from the nasogastric tube In the last hour. Which action should the nurse take first? a. Determine the clients vital signs b. Monitor urinary output hourly. c. Notify the surgeon immediately. d. Assess the client's level of pain.

a. Determine the clients vital signs

A female client is admitted to the hospital with a diagnosis of right lower quadrant (RLQ) abdominal pain and a possible ectopic pregnancy. She tells the nurse that her pain is gone, but she is now experiencing a generalized abdominal aching. Her blood pressure has decreased and her pulse has Increased over the past two hours. While waiting for the healthcare provider to arrive, which intravenous solution is best for the nurse to initiate? a. Normal Saline (NS) at 20 mL/hour. b. Lactated Ringer's (LR) at 150 mL/hour. c. D5W/0.45 NS at 125 mL/hour. d. Dextrose 10% (D10W) at 83 mL/hour.

a. Normal Saline (NS) at 20 mL/hour.

A client who was recently diagnosed with anorexia nervosa collapses at an outpatient clinic. While taking the blood pressure, the client begins to demonstrate cloudy consciousness, stupor, and has slurred speech. The nurse obtains a blood glucose 50 mg/dL (2.77 mmol/L), heart rate of 116 beats/minute, and blood pressure of 88/50 mmHg.. Which intervention is most important for the nurse to implement? a. Position client with head flat and feet elevated b. Suggests obtaining a medical alert bracelet to be always worn. c. Encourage the client to eat low-carbohydrate and high-protein meals. d. Reinforce the need to continue the outpatient clinic therapy.

a. Position client with head flat and feet elevated

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding Is the nurse likely to obtain? a. Jugular vein distension. b. Fatigue. c. Hepatomegaly. d. Lower extremity edema.

b. Fatigue.

The nurse learns that a client does not know the purpose of the antipsychotic medication ziprasidone. How should the nurse best explain the purpose of this medication? a. This medication helps people with schizophrenia. b. This medication will help you think more clearly. c. This is an antipsychotic medication to calm you down. d. An antipsychotic medication promotes socialization.

b. This medication will help you think more clearly.

The nurse working in a disaster area assesses an adult client who has partial-thickness burns on the lower legs, or approximately 10% of the lower body. Which color of triage tag should the nurse place on this client? a. Black. b. Yellow. c. Red. d. Green.

b. Yellow.

The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit? A client: a. with pneumonia whose serum potassium level is 6.5 mg/dl. b. with atrial fibrillation, whose saline lock is infiltrated c. who is receiving a heparin infusion and has developed hematuria. d. with hypertension whose blood pressure is 230/118.

b. with atrial fibrillation, whose saline lock is infiltrated

A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse that the client is experiencing a therapeutic response to the phenytoin? a. Increased time of ambulation between periods of rest. b. Decrease in intracranial pressure and cerebral edema. c. Absence of seizure activity for the duration of treatment. d. Normal electroencephalogram after drug administration.

Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing..... had a pulmonary embolus. What action should the nurse take first? a. Bring the emergency crash cart to the bedside. b. Prepare a continuous heparin infusion per protocol. c. Provide supplemental oxygen. d. Notify the healthcare provider.

A woman is brought to the labor and delivery unit after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. Which action should the nurse perform first? a. Inspect the perineum for lacerations. b. Collect specimen for hemoglobin and hematocrit. c. Massage the fundus and give an oxytocin agent d. Place the infant to breast for bonding

c. Massage the fundus and give an oxytocin agent

A client with heart failure reports increased of shortness of breath. The nurse administered furosemide 20 mg intravenously 60 minutes ago. Which action is most important for the nurse to implement? a. Auscultate the lungs. b. Review serum potassium. c. Measure urine output. d. Administer albuterol via nebulizer.

c. Measure urine output.

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for them to explore further prior to the start of the procedure? a. Drank a glass of water in the past 2 hours. b. Reports left chest wall pain prior to admission. c. Verbalize a fear of being in a confined space. d. Experience facial swelling after eating crab.

The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age? A) Separation anxiety B) Fear of pain C) Loss of control D) Bodily injury

To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the A) Finger and toenail quicks B) Eyes C) Perianal area D) External ear canals

B. Eyes

A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort? A) Increase oral fluid intake B) Encourage visits from family and friends C) Keep conversations short D) Monitor vital signs frequently

A hospitalized 8 month-old is receiving gentamicin (Cidomycin). In monitoring the infant for drug toxicity, the nurse should review which laboratory results first? A) Blood urea nitrogen B) Thyroxin levels C) Growth hormone levels D) Platelet counts

. The nurse identifies an electrolyte imbalance, a weight gain of 4.4 lbs (2kg) in 24 hours and an elevated central venous pressure for a client with full thickness burns. Which intervention should the nurse implement? A. Auscultate for irregular heart rate B. Review arterial blood gasses results C. Measure ankle circumference D. Document abdominal girth

A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse? A) Elbow B) Mummy C) Jacket D) Clove hitch

The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to? A) Assess for abdominal distention B) Maintain infant in an upright position C) Begin formula feedings when infant is alert D) Pump the shunt to assess for proper function

The nurse is planning discharge for a 90 year-old client with musculoskeletal weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls? A) Place nightlight in the bedroom B) Wear eyeglasses at all times C) Install grab bars in the bathroom D) Teach muscle strengthening exercises

A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 20-40 mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug administration, what should the nurse do next? A) Give the medication as ordered B) Call the health care provider to clarify the dose C) Recognize that antibiotics are over-prescribed D) Hold the medication as the dosage is too low

A 2 year-old child is brought to the emergency department at 2:00 in the afternoon. The mother states: "My child has not had a wet diaper all day." The nurse finds the child is pale with a heart rate of 132. What assessment data should the nurse obtain next? A) Status of skin turgor B) Description of play activity C) History of fluid intake D) Dietary patterns

A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child? A) All lesions crusted B) Elevated temperature C) Rhinorrhea and coryza D) Presence of vesicles

A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? A) Notify the health care provider B) Readjust the traction C) Administer the ordered PRN medication D) Reassess the foot in fifteen minutes

A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client's medication administration record. The nurse should notify the health care provider if the client received which medication during the preceding 24 hours? A) digoxin (Lanoxin) B) diltiazam (Cardizem) C) nitroglycerine ointment D) metoprolol (Toprol XL)

A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A. Instructs about how much fluid the child should drink daily B. Signs of addiction to opioid pain medications C. Information about non-pharmaceutical pain relief measures D. Referral for social services for the child and family

The nurse is planning to administer otic drops to a 6 year-old child. Which of the following is the correct procedure? A) Hold the pinna up and back to instill the drops B) Place several drops in the outer ear C) Insert cotton in the outer ear after giving medication D) Assist the child to lie on the affected side afterwards

The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? A) Solid foods are introduced 1 at a time beginning with cereal B) Finely ground meat should be started early to provide iron C) Egg white is added early to increase protein intake D) Solid foods should be mixed with formula in a bottle

The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is A) Verify correct placement of the tube B) Check that the feeding solution matches the dietary order C) Aspirate abdominal contents to determine the amount of last feeding remaining in stomach D) Ensure that feeding solution is at room temperature

When counseling a 6 year old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder? A) Has no clear etiology B) May be associated with sleep phobia C) Has a definite genetic link D) Is a sign of willful misbehavior

A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take? A. Encourage the client to use cooler water and apply calamine lotion after soaking B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief C. Suggest that the client take brief showers and apply oil-based lotion after showering D. Explain that the symptoms are caused by liver damage and cannot be relieved.

A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for thenurse to remember when working with an interpreter is to A) Promote verbal and nonverbal communication with both the client and the interpreter B) Speak only a few sentences at a time and then pause for a few moments C) Plan that the encounter will take more time than if the client spoke English D) Ask the client to speak slowly and to look at the person spoken to

A client had arrived in the USA from a developing country 1 week prior. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS with a history of unintended weight loss, drug abuse, night sweats, productive cough and a "feeling of being hot all the time." The nurse should assign the client to share a room with a client with the diagnosis of A) Acute tuberculosis with a productive cough of discolored sputum for over three months B) Lupus and vesicles on one side of the middle trunk from the back to the abdomen C) Pseudomembranous colitis and C. difficile. D) Exacerbation of polyarthritis with severe pain

A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety related to pain

A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process? A) Disruption of fetal glucose supply B) Pancreatic insufficiency C) Maternal insulin dependency D) Reduced glycogen reserves

When interviewing the parents of a child with asthma, it is most important to gather what information about the child's environment? A) Household pets B) New furniture C) Lead based paint D) Plants such as cactus

An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first? A. Explore client's readiness to discuss the situation B. Discuss treatment options for abusive partners C. Report the finding. to the. police department D. Determine the frequency and type of clients abuse

An adult female tells the nurse that though she is afraid of her abusive boyfriend might one day kill her, she keeps hoping that he will change. Which action should the nurse take first? A. Explore the client's readiness to discuss the situation B. Determine the frequency and type of client's abuse C. Report the finding to the police department D. Discuss treatment options for abusive partners

The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fibrillation and heart failure -PN B) Client who had a major stroke 6 days ago - PN nursing student C) A child with burns who has packed cells and albumin IV running -charge nurse D) An elderly client who had a myocardial infarction a week ago - UAP

When providing nursing measures to relieve a 102-degree Fahrenheit fever in a toddler with an infection, what is the most effective intervention? A) Use medications to lower the temperature set point B) Apply extra layers of clothing to prevent shivering C) Immerse the child in a tub containing cool water D) Give a tepid sponge bath prior to giving an antipyretic

Which individual is at greatest risk for developing hypertension? A) 45 year-old African American attorney B) 60 year-old Asian American shop owner C) 40 year-old Caucasian nurse D) 55 year-old Hispanic teacher

A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being "too sick to return to work." The client is diagnosed as having somatoform disorder. In formulating a plan of care, the nurse must consider that the client's behavior A) Is controlled by their subconscious mind B) Is manipulative to avoid work responsibilities C) Would respond to psychoeducational strategies D) Could be modified through reality therapy

A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A) Should be taken in the morning B) May decrease the client's energy level C) Must be stored in a dark container D) Will decrease the client's heart rate

The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance? A) Assume a decision-making role B) Seek input from staff C) Use a non-directive approach D) Shared decision-making with others

After receiving chemotherapy, a client who weighs 154 pound (70 kg) develops febrile neutropenia. The healthcare provider prescribes filgrastim 5 mcg/kg SUBQ every 12 hours. The available vial is labeled, filgrastim 300 mcg/mL. Based on the client's weight, how many milliliters should the nurse administer? (Enter the numerical value only, If rounding is required, round to the nearest tenth.)

1.2

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)? A. Body mass index B. Breath sounds C. Self-description of pain D. Level of consciousness

A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement? A) Have respiratory support equipment available B) Immediately place her in the seclusion room C) Assess the client for anxiety and agitation D) Administer PRN dose of IM antipsychotic medication

The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should A) Review the medications the client is receiving B) Increase the formula infusion rate C) Increase the amount of water used to flush the tube D) Attach a rectal bag to protect the skin

The client with multiple sclerosis has an order to change the nasogastric tube. To promote safety when removing the tube, the nurse should A) ask the client to hold a breath B) offer sips of water C) bring the code cart to the bedside D) empty the tube of all drainage

A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right with the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees

A client is admitted to the hospital because of heart failure and digoxin toxicity. At home, the client was taking digoxin (Lanoxin) and furosemide (Lasix). Which symptom would the nurse anticipate finding on the initial assessment? A) Muscle weakness and cramping B) Confusion C) Blood in the urine D) Tinnitis

A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The most appropriate intervention for this client is A) Position client in upright position while eating B) Place client on a clear liquid diet C) Tilt head back to facilitate swallowing reflex D) Offer finger foods such as crackers or pretzels

The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube

A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action A) May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery C) Was appropriate in view of the client's history of violence D) Was necessary to maintain the therapeutic milieu of the unit

A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions? A) High Fowler's B) Supine C) Left lateral D) Low Fowler's

The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse? A) Decreased breath sounds in right lower lobe B) Aspiration of a residual of 100cc of formula C) Decrease in bowel sounds D) Urine output of 250 cc in past 8 hours

A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? A) Blood pressure 94/60 B) Heart rate 76 C) Urine output 50 ml/hour D) Respiratory rate 16

The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider? A) Height and weight percentiles vary widely B) Growth pattern appears to have slowed C) Recumbent and standing height are different D) Short term weight changes are uneven

A male client tells the nurse that he is concerned that he may have a stomach ulcer because he is experiencing heartburn and dull growing pain that is relieved when he eats. What is the best response by the nurse? A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer B. Assure the client that his symptoms may only reflect reflux since ulcer pain is not relieved with food C. instruct the client that these mild symptoms can generally be controlled with changes in diet D. Advise the client that he needs to seek immediate medical evaluation and treatment for these symptoms

A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements? A) In the initial 48 hrs avoid contact with children and pregnant women, and after urination or defecation flush the commode twice. B) Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice. C) Your family can use the same bathroom that you use without any special precautions. D) Drink plenty of water and empty your bladder often during the initial 3 days of therapy.

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains swab for COVID-19 testing. Which action is most important for the nurse to take? A. Place the nasal swab specimen for COVID-19 directly into a biohazard bag B. Move the client to a private room, keep the door closed, and initiate droplet precautions C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days

A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use? A. Ask the client to describe the pain B. Observe body language and movement C. Identity effective pain relief measures D. Provide a numeric pain scale

A client taking clopidogrel reports the onset of diarrhea . Which nursing action should the nurse implement first? A. Observe the appearance of the stool B. Assess the elasticity of the client's skin C. Review the client's laboratory values D. Auscultate the client's bowel sounds

A client who is receiving chemotherapy through a central line is admitted to the hospital with a diagnosis of sepsis. Which of the following nursing interventions should receive priority? A) Inspect all sites that may serve as entry ports for bacteria B) Place the client in reverse isolation C) Change the dressing over the site of the central line D) Restrict contact with persons having known, or recent, infections

The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body? A) Inspect the skin B) Auscultate breath sounds C) Evaluate muscle strength D) Investigate elimination patterns

The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time? A) Daily needs and concerns B) The overview cardiac rehabilitation C) Medication and diet guideline D) Activity and rest guidelines

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include: sodium 129 mEq/L (129 mmol/L), glucose 54 mg/dL (2.97 mmol/L), and potassium 5.3 mEq/L(5.3 mmol/L). When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication? A. Hydrocortisone B. Regular insulin C. Broad-spectrum antibiotic D. Potassium chloride

A client with a panic disorder has a new prescription for Xanax (Alprazolam). In teaching the client about the drug's actions and side effects, which of the following should the nurse emphasize? A) Short-term relief can be expected B) The medication acts as a stimulant C) Dosage will be increased as tolerated D) Initial side effects often continue

The healthcare provider prescribes digoxin elixir 125 mcg PO daily. The drug is available in a 60 ml. bottle labeled, "Digoxin elixir 0.05 mg/mL." How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

2.5 mL

A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias B) May lead to oliguria C) May cause irritability and anxiety D) Sometimes alters consciousness

A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 103/L). Which intervention is most important for the nurse to include in this client's plan of care? A. Assess urine and stool for occult blood B. Monitor for signs of activity intolerance C. Require visitors to wear respiratory masks D. Obtain client's temperature q4 hours

A combination multi-drug cocktail is being considered for an asymptomatic HIV -infected client with a CD4 cell count of 500. Which nursing assessment of the client is most crucial in determining whether therapy should be initiated? A. Willing to comply with complex drug schedules B. Maintains an adequate social support system C. Qualifies for a prescription assistance program D. States various side effects of retroviral agents

A couple experienced the loss of a 7 month-old fetus. In planning for discharge, what should the nurse emphasize? A) To discuss feelings with each other and use support persons B) To focus on the other healthy children and move through the loss C) To seek causes for the fetal death and come to some safe conclusion D) To plan for another pregnancy within 2 years and maintain physical health

A female client presents in the emergency department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask? A. Has she taken a bath since the rape occurred? B. Is the place where she lives a safe place? C. Does she knows the person who raped her? D. Did she report the rape to the police departmen?

The nurse plans to administer a bolus dose of IV Heparin based on the client's weight. The prescribed bolus dose is 100 units/kg. The client weighs 198 pounds. How many units of Heparin should the nurse administer? (Enter numeric value only.)

9000

the nurse is caring for a client admitted for evaluation of a descending aortic....documenting, the nurse hears the client screaming. the client tells the nurse that something inside is ripping and tearing. the client also reports dizziness...cause? A. Impending rupture of the aneurysm B. The client is having a panic attack C. clotting of the aneurysm D. THe client is hallucinating from the opioids

the nurse is preparing to gavage feed a premature infant through a.... tube, and the infant's HR drops to 60 beats/minute. Which action should the nurse take? A. postpone the feeding until the infant's vital signs to normal B. Continue the insertion since this is a typical response... C. Insert the feeding tube into the infant's nasal passage D. Pause and monitor for a continued drop in the heart

the nurse is preparing to send a client to the cardiac cath lab for elective....which intervention should the nurse implement before the client leaves the medical unit? A. Document that the client has remained NPO B. Confirm monitor reading in synchronous mode C. Notify the rapid response team of the transfer D. Secure cardioversion. pads on the client's chest

the nurse notices that a male client is particularly delusional one afternoon.... appears to be losing control of himself. which intervention is best for the nurse to implement? A. Move the client to a quiet place in the unit B. Encourage the client to use. the punching bag C. Use firmness and direct the. client. to sit. for awhile D. Suggest to the client that he take a walk

which intervention is most important for the nurse to include in the plan of care for a mechanically ventilated and is receiving continuous enteral feedings? A. Maintain the head of the bed elevated at 45 degrees B. Check the feeding tube placement q8 hrs C. Assess the gastric residual. volume q4. hours D. Obtain a chest x-ray PRN for adventitious lung sounds

which type of leukocyte is involved with allergic responses and destruction.. A. Eosinophils B. Neutrophils C. Lymphocytes D. Monocytes

A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client

A) A 79 year-old malnourished client on bed rest

A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins

A) An infant who has been identified to have botulism

A) Hold the tube feeding and notify the provider

A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements? A) In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice. B) Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice. C) Your family can use the same bathroom that you use without any special precautions. D) Drink plenty of water and empty your bladder often during the initial 3 days of therapy.

A) In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice.

after an unsuccessful resuscitation attempt, the nurse calls the family... the body before it is taken to the funeral home. which interventions should the nurse implement before the family enters the room? (select all) A. Gently close the eyes B. Remove resuscitation equipment from the room C. Take out dentures and place them in a labeled cup D. Apply a body shroud E. Place a. small pillow under the head

A, B, E

the nurse observes a client prepare a meal in the kitchen of a rehab facility.... behaviors indicate the client understands how to maintain balance safely? (select all) A. Brings a heavy can close to the body before lifting B. Locks knees while preparing food on the counter C. Widens stance while working near the sink D. Bends from the waist to pick trash off the floor E. Leans forward to pull a pan from a high shelf

A, C

The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? (Select all that apply) A. Frequent syncope B. Occasional nocturia C. Flat affect D. Blurred vision E. Frequent drooling

A, C, D

Which of these clients would the triage nurse request for the health care provider to examine immediately? A) A 5 month-old infant who has audible wheezing and grunting B) An adolescent who has soot over the face and shirt C) A middle-aged man with second degree burns over the right hand D) A toddler with singed ends of long hair that extends to the waist

A. A 5 month-old infant who has audible wheezing and grunting

Which of these tests with frequency would the nurse expect to monitor for the evaluation of clients with poor glycemic control in persons aged 18 and older? A) A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than 3-month intervals B) A glycosylated hemoglobin is to be obtained at least twice a year C) A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial assessment D) A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-month intervals after the initial assessment

A. A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than three-month intervals

With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select? A) An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago B) An adolescent admitted the prior night with Tylenol intoxication C) A middle aged client with an internal automatic defibrillator and complaints of "passing out at unknown times" admitted yesterday D) A school age child diagnosed with suspected bacterial meningitis and was admitted at the change of shifts

A. An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago

A confused client has been placed in physical restraints by order of the health care provider. Which task could be assigned to an unlicensed assistive personnel (UAP)? A) Assist the client with activities of daily living B) Monitor the clients physical safety C) Evaluate for basic comfort needs D) Document mental status and muscle strength

A. Assist the client with activities of daily living

The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that A) Circumcision is delayed so the foreskin can be used for the surgical repair B) This procedure is contraindicated because of the permanent defect C) There is no medical indication for performing a circumcision on any child D) The procedure should be performed as soon as the infant is stable

A. Circumcision is delayed so the foreskin can be used for the surgical repair

The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client complaint calls for immediate nursing action? A) Diaphoresis and shakiness B) Reduced lower leg sensation C) Intense thirst and hunger D) Painful hematoma on thigh

A. Diaphoresis and shakiness

An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age? A) Double the birth weight B) Triple the birth weight C) Gain 6 ounces each week D) Add 2 pounds each month

A. Double the birth weight

The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is A) "Eat a balanced diet for your age." B) "Increase your intake of protein and Vitamin A." C) "Decrease fatty foods from your diet." D) "Do not use caffeine in any form, including chocolate."

A. Eat a balanced diet for your age

A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority? A) Elevate leg on 2 pillows B) Apply support stockings C) Apply warm compresses D) Maintain complete bed rest

A. Elevate leg on 2 pillows

A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due to A) Insufficient oxygenation of the cardiac muscle B) Potential circulatory overload C) Left ventricular overload D) Electrolyte imbalance

A. Insufficient oxygenation of the cardiac muscle

A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should A) Expose the cast to air and turn the child frequently B) Use a heat lamp to reduce the drying time C) Handle the cast with the abductor bar D) Turn the child as little as possible

A. Expose the cast to air and turn the child frequently

A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness? A) Holistic healing B) Spiritual advising C) Herbal preparations D) Witchcraft potions

A. Holistic healing

For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate? A) Institute seizure precautions B) Weigh the child twice per shift C) Encourage the child to eat protein-rich foods D) Relieve boredom through physical activity

A. Institute seizure precautions

A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse's contribution and begins to find objections to the suggestion. The nurse manager's best response is to A) Let's move on to a new action that deals with the problem. B) I think you need to reserve judgment until after all suggestions are offered. C) Very well thought out. Your analytic skills and interest are incredible. D) Let's move to the 'what if...' as related to these objections for an exploration of spin off ideas.

A. Let's move to the 'what if...' as related to these objections for an exploration of spin off ideas.

The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report A) Loss of consciousness B) Feeding problems C) Poor weight gain D) Fatigue with crying

A. Loss of consciousness

A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as what type of side effect? A) Oculogyric crisis B) Tardive dyskinesia C) Nystagmus D) Dysphagia

A. Oculogyric crisis

A client comes into the community health center upset and crying stating "I will die of cancer now that I have this disease." And then the client hands the nurse a paper with one word written on it: "Pheochromocytoma." Which response should the nurse state initially? A) Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid). B) This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline. C) Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor. D) You probably have had episodes of sweating, heart pounding and headaches.

A. Pheochromocytomas usually aren''t cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid).

When teaching new parents to prevent Sudden Infant Death Syndrome (SIDS) what is the most important practice the nurse should instruct them to do? A) Place the infant in a supine or side lying position for sleep B) Do not allow anyone to smoke in the home C) Follow recommended immunization schedule D) Be sure to check infant every one hour

A. Place the infant in a supine or side lying position for sleep

A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which nursing approach should be the priority? A) Remove protective arm devices one at a time for short periods with supervision B) Initiate by mouth feedings when alert, with the return of the gag reflex C) Introduce to the parents how to cleanse the suture line with the prescribed protocol D) Position the infant on the back after feedings throughout the day

A. Remove protective arm devices one at a time for short periods with supervision

The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ("knocked out"). After recovering the tooth, the initial response should be to A) Rinse the tooth in water before placing it in the socket B) Place the tooth in a clean plastic bag for transport to the dentist C) Hold the tooth by the roots until reaching the emergency room D) Ask the child to replace the tooth even if the bleeding continues

A. Rinse the tooth in water before placing it in the socket

Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children? A) Sports and games with rules B) Finger paints and water play C) "Dress-up" clothes and props D) Chess and television programs

A. Sports and games with rules

A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to A) Suggest 3 to 4 warm sitz baths per day B) Cleanse the genitalia twice a day with soap and water C) Spray warm water over genitalia after urination D) Apply heat or cold to lesions as desired

A. Suggest 3 to 4 warm sitz baths per day

A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse's best explanation of these findings? A) These side effects are common and should subside in a few days B) The client is probably having an allergic reaction and should discontinue the drug C) Taking the lithium on an empty stomach should decrease these symptoms D) Decreasing dietary intake of sodium and fluids should minimize the side effects

A. These side effects are common and should subside in a few days

Which of these statements by the nurse is incorrect to use to reinforce information about cancers to a group of young adults? A)You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods. B) Prostate cancer is the most common cancer in American men with results to threaten sexuality and life. C) Colorectal cancer is the second-leading cause of cancer-related deaths in the United States. D) Lung cancer is the leading cause of cancer deaths in the United States. Yet it's the most preventable of all cancers.

A. You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods

A client's morning assessment includes bounding peripheral pulses , weight gain of 2 pounds (0.91 kg), pitting ankle edema , and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care? A. Maintain accurate intake and output. B. Administer prescribed diuretic C. Weigh client every morning D. Restrict daily fluid intake to 1500 mL

A depressed client in an assisted living facility tells the nurse that "life isn't worth living anymore." What is the best response to this statement? A) "Come on, it is not that bad." B) "Have you thought about hurting yourself?" C) "Did you tell that to your family?" D) "Think of the many positive things in life."

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? A. Auscultate for bowel sounds in all quadrants B. Ask the client about gastrointestinal pain C. Monitor the client's serum electrolyte levels D. Measure the client's fluid intake and output

Which intervention should the nurse include in the plan of care for a child with tetanus? A. Encourage coughing and deep breathing B. Minimize the amount of stimuli in the room C. Reposition from side to side every hour D. Open window shades to provide natural light

The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine areelevated. What dietary modifications are most appropriate? A) Decreased carbohydrates and fat B) Decreased sodium and potassium C) Increased potassium and protein D) Increased sodium and fluids

A school-aged child who weighs 42 pounds receives a post-tonsillectomy prescription..... IM to prevent post-op nausea. the med is available in 25 mg/ml.....should the nurse administer it? round

ANSWER= 0.4 1st convert weight weight in kg= 0.5 x19.09= 9.5454 mg amount per mL (use the fixed available med as a reference) 25mg==in 1mL 9.5mg-- in X mL X= 9.5 x 1 / 25= 0.38= 0.4

A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which A) Increase the heart rate B) Lead to dehydration C) Are considered aerobic D) May be competitive

A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate? A) Ambulate the client 4 hours after procedure B) Maintain client on NPO status for 24 hours C) Monitor vital signs D) Change dressing every 8 hours

The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms

. The nurse is reviewing the diagnostic tests prescribed for a client with a positive skin test. Which subjective findings reported by the client supports the diagnosis of tuberculosis? A. Barking cough and vomiting B. Mucopurulent cough and night sweats C. Dry cough and chest tightness D. Chronic cough and fatty stools

A 12-year-old client who had an appendectomy two days ago was receiving 0.9% normal saline at 50 mL/ hour. The client's urine specific gravity is 1.035. What action should the nurse implement? A. Assess bowel sounds in all quadrants B. Encourage popsicles influence of choice C. Evaluate postural blood pressure measurements D. Obtain a specimen for your analysis

A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse? A) Telfa dressing with antibiotic ointment B) Moist sterile non adherent dressing C) Dry sterile dressing that is occlusive D) Sterile occlusive pressure dressing

A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time? A) What are you taking for pain and does it provide total relief? B) What does the skin on the testicles look and feel like? C) Do you have any questions about your care? D) Did you know a consequence of epididymitis is infertility?

An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with aclear liquid diet, the client begins to cough. What should the nurse do next? A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids

hen reviewing the information , which statement should the nurse recognize as needing additional education? A. Report the presence of mucus in the urine B. Empty the pouch when it is half full C. Look at the stoma when replacing appliance D. Anticipate shrinking of the stoma

the nurse is planning to teach infant care and preventive measures for sudden infant death syndrome to a group of new parents. which information is most important for the nurse to provide? A. swaddle the infant in a blanket for sleeping B. Ensure that the infant's crib mattress is firm C. Place the infant. in a prone position whenever possible D. Prop the infant with a pillow when in a side-lying position

the nurse is preparing a hepatitis teaching program. which individual has the greatest .........prophylactic hepatitis B immunizations? A. A child daycare worker who has a history of type 2 DM B. An office worker who requires hemodialysis for chronic kidney disease C. A restaurant chef who was diagnosed one year ago with hepatitis D. A salesperson who travels internationally and eats food in foreign

the nurse is providing care for a child who is brought to the ED....to the leg from a barbed wire fence. the child has not received any tetanus.....in early signs of muscular rigidity with spasms and jaw clenching or trismus. what is the nurse's highest priority for this child? A. Suction oropharyngeal secretions B. Prepare for intubation with mechanical ventilation C. Minimize stimulation from sound, light, and touch D. Monitor IV infusions

when developing a teaching plan for a client with newly diagnosed type I DM, the nurse should explain that an.......which action should the nurse instruct the client to implement if this sign of DKA occurs? A. Resume normal physical activity B. Give a dose of regular insulin as prescribed C. Measure urine output over the next 24 hours D. Drink electrolytes fluid replacements

The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure? A) "He has been taking long naps for a week." B) "He has had an ear infection for the past 2 days." C) "He has been eating more red meat lately." D) "He seems to be going to the bathroom more frequently."

B) "He has had an ear infection for the past 2 days."

A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with A) A Dopamine drip IV with vital signs monitored every 5 minutes B) A myocardial infarction that is free from pain and dysrhythmias C) A tracheotomy of 24 hours in some respiratory distress D) A pacemaker inserted this morning with intermittent capture

B) A myocardial infarction that is free from pain and dysrhythmias

Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) B) A positive purified protein derivative with an abnormal chest x-ray C) A tentative diagnosis of viral pneumonia with productive brown sputum D) Advanced carcinoma of the lung with hemoptasis

B) A positive purified protein derivative with an abnormal chest x-ray

Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin

B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear

A client is receiving Total Parenteral Nutrition (TPN) via Hickman catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? A) Check that the catheter tip is intact B) Apply a pressure dressing to the site C) Monitor respiratory status D) Assess for mental status changes

B) Apply a pressure dressing to the site

B) Assess for dyspnea or stridor

The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? A) Blanch nail beds for color and refill B) Assess for post operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses

B) Assess for post operative arrhythmias

A client continuously calls out to the nursing staff when anyone passes the client's door and asks them to do something in the room. The best response by the charge nurse would be to A) Keep the client's room door cracked to minimize the distractions B) Assign one of the nursing staff to visit the client regularly C) Reassure the client that one staff person will check frequently if the client needs anything D) Arrange for each staff member to go into the client's room to check on needs every hour on the hour

B) Assign one of the nursing staff to visit the client regularly

The most effective nursing intervention to prevent atelectasis from developing in a post-operative client is to A) Maintain adequate hydration B) Assist client to turn, deep breathe, and cough C) Ambulate client within 12 hours D) Splint incision

B) Assist client to turn, deep breathe, and cough

The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? A) Decreased carbohydrates and fat B) Decreased sodium and potassium C) Increased potassium and protein D) Increased sodium and fluids

B) Decreased sodium and potassium

When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote A) Relaxation and sleep B) Deep breathing and coughing C) Incisional healing D) Range of motion exercises

B) Deep breathing and coughing

The nurse is teaching about non steroidal anti-inflammatory drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions? A) Reporting joint stiffness in the morning B) Taking the medication 1 hour before or 2 hours after meals C) Using alcohol in moderation unless driving D) Continuing to take aspirin for short term relief

B) Taking the medication 1 hour before or 2 hours after meals

A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that A) A referral is needed to the psychiatrist who is to provide the client with answers B) The client has a right to know about the prescribed medications C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

B) The client has a right to know about the prescribed medications

A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? A) grilled chicken sandwich and skim milk B) roast beef, mashed potatoes, and green beans C) peanut butter sandwich, banana, and iced tea D) barbecue beef, baked beans, and cole slaw

B) roast beef, mashed potatoes, and green beans

during discharge teaching, an overweight client with heart failure....nurse to review. which food choices included on the client's list should... (select all) A. Canned fruit. in heavy syrup B. Natural whole almonds C. Plain, air-popped popcorn D. Lightly salted potato chips E. Cheddar cheese cubes

B, C

the nurse is assessing a 3-month-old infant who had a pylorotomy yesterday....for pain based on which findings (select all) A. Peripheral pallor of the skin B. Increased pulse rate C. Clenched fists D. Restlessness E. Increased temperature F. Increased respiratory rate

B, C, D, F.

The nurse is interacting with a female client who is diagnostic with postpartum depression. Which findings should the nurse document as an objective sign of depression? (Select all that apply) A) Expresses suicidal thoughts B) Avoid eyes contact C) Reports feeling sad D) Has a disheveled appearance E) Interacts with felt effect

B, D, E

At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She asks about preconception diet changes. Which of the statements made by the nurse is best? A) "Include fibers in your daily diet." B) "Increase green leafy vegetable intake." C) "Drink a glass of milk with each meal." D) "Eat at least 1 serving of fish weekly."

B. "Increase green leafy vegetable intake"

A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale? A) "Nursing will help contract the uterus and reduce your risk of bleeding." B) "Breastfeeding twins will take too much energy after the hemorrhage." C) "The blood transfusion may increase the risks to you and the babies." D) "Lactation should be delayed until the "real milk" is secreted."

B. "Nursing will help contract the uterus and reduce your risk of bleeding"

The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins? A) B, D, and K B) A,D,andK C) A, C, and D D) A, B, and C

B. A,D,andK

To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would A) Assist the client to use the bedside commode B) Administer stool softeners every day as ordered C) Administer anti dysrhythmics prn as ordered D) Maintain the client on strict bed rest

B. Administer stool softeners every day as ordered

A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize A) They can expect the child will be mentally retarded B) Administration of thyroid hormone will prevent problems C) This rare problem is always hereditary D) Physical growth/development will be delayed

B. Administration of thyroid hormone will prevent problems

The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best response by the nurse should be that A) A child's bone is more flexible and can be bent 45 degrees before breaking B) Bones of children are more porous than adults and often have incomplete breaks C) Compression of porous bones produces a buckle or torus type break D) Bone fragments often remain attached by a periosteal hinge

B. Bones of children are more porous than adults and often have incomplete breaks

The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early indication of inadequate oxygen transport? A) Crackles in the lungs B) Confusion and restlessness C) Distended neck veins D) Use of accessory muscles

B. Confusion and restlessness

The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate? A) Non intention tremors and urgency with voiding B) Echolalia and a shuffling gait C) Muscle spasm and a bent over posture D) Intention tremor and jerky movement of the elbows

B. Echolalia and a shuffling gait

The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the "unfreezing" phase of change. With this approach and phase the nurse manager should A) Discuss with the staff how to deal with any defensive behavior B) Explain to the unit staff why change is necessary C) Assist the staff during the acceptance of the new changes D) Clarify what the changes mean to the community and hospital

B. Explain to the unit staff why change is necessary

The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data? A) Impaired gas exchange related to acute infection and sputum production B) Ineffective airway clearance related to sputum production and ineffective cough C) Ineffective breathing pattern related to acute infection D) Anxiety related to hospitalization and role conflict

B. Ineffective airway clearance related to sputum production and ineffective cough

On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's initial response should be to A) Give the client orientation materials and review the unit rules and regulations B) Introduce him/herself and accompany the client to the client's room C) Take the client to the day room and introduce her to the other clients D) Ask the nursing assistant to get the client's vital signs and complete the admission search

B. Introduce him/herself and accompany the client to the client's room

Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure togetherwith pulmonary capillary wedge pressure with a pulmonary artery catheter. This action by the nurse will assess A) Right ventricular pressure B) Left ventricular end-diastolic pressure C) Acid-Base balance D) Coronary artery stability

B. Left ventricular end-diastolic pressure

The community health nurse has been following the care for an adolescent with a history of morbid obesity, asthma, hypertension and is 22 weeks in to a pregnancy. Which of these lab reports sent to the clinic need to be called to the teens health care provider within the next hour? A) Hemoblobin 11 g/L and calcium 6 mg/dl B) Magnesium 0.8 mEq/L and creatinine 3 mg/dl C) Blood urea nitrogen 28 and glucose 225 mg/dl D) Hematocrit 33% and platelets 200,000

B. Magnesium 0.8 mEq/L and creatinine 3 mg/dl

While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action? A) Check vital signs B) Massage the fundus C) Offer a bedpan D) Check for perineal lacerations

B. Massage the fundus

The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first? A) Clear the area of any hazards B) Place the child on the side C) Restrain the child D) Give the prescribed anticonvulsant

B. Place the child on the side

A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal? A) Hot dog, carrot sticks, gelatin, milk B) Soup, blenderized soft foods, ice cream, milk C) Peanut butter and jelly sandwich, chips, pudding, milk D) Baked chicken, applesauce, cookie, milk

B. Soup, blenderized soft foods, ice cream, milk

A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output

A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevatedand is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors should wear gloves if they touch the client

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned about this regression in toileting. Which information should the nurse provide the parents? A. A retraining program will need to be initiated when the child returns home. B. Diapering will be provided since hospitalization is stressful to preschoolers .C. Children usually resume their toileting behaviors when they leave the hospital. D. A potty chair will be brought from home so he can maintain his toileting skills.

. A client is receiving enoxaparin 30 mg subcutaneously twice a day. In assessing for adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor? A. Glucose B. Calcium C. Platelet count D. White blood cell count

A 1 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? A) Use aseptic technique during dressing changes B) Maintain central line catheter integrity C) Monitor serum glucose levels D) Check results of liver function tests

A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to A) Limit milk and milk products B) Encourage bed activities and games C) Plan nursing care around lengthy rest periods D) Promote a diet rich in iron

A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values? A) Blood urea nitrogen B) Acid phosphatase C) Bilirubin D) Sedimentation rate

In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? A) Food B) Warmth C) Security D) Comfort

a college student brings a dorm roommate to the campus clinic because the... someone who is not present. the client tells the nurse that the voices are.....should the nurse ask the client next? A. "When did these voices begin" B. " have you. taken any hallucinogens?' C. "Are you planning to obey the voices?" D. " Do you believe the voices are real?"

following a total knee replacement, a client is discharged from the hospital.....reviewing discharge teaching, the client tells the nurse that he will avoid eating bananas and melons. how should the nurse respond? A. discuss necessary fluid restrictions as well as food restrictions B. Explain that no dietary restrictions are needed with warfarin C. Review teaching about the effects of foods rich in Vitamin K D. Provide a written list. of additional foods high in potassium

the nurse is assessing a first-day postpartum client. which finding is most important.. A. Blood pressure of 122/74 mm Hg. B. white blood count of 19,000 mm C. Moderate amount of foul-smelling lochia D. Oral temperature of 100.2 F

the nurse is caring for a client who is admitted to the ED...begins to experience a decreased level of consciousness and the ....vital signs changes indicate the client is manifesting Cushing's triad? A. Blood pressure of 80/40 mmHg, weak heart rate of 40, respirations of 10 breaths/min B. BLood pressure of 180/120 mmHg, weak heart rate, respirations of 18 breaths/min C. Blood pressure of 180/80 mmHg, bounding heart rate breaths/min with. apneic episodes D. Blood pressure of 90/60 mmHg, strong heart rate of 60, respirations of 16 breaths/min

the nursing staff on a medical unit includes an RN, PN, and UAP. which task should the charge nurse assign to the RN? A. administer PRN oral analgesics to a client with a history of chronic B. Transport a client who is receiving IV fluids to the radiology department C. Supervise a newly hired graduate nurse during an admission assessment D. Complete ongoing focused assessments of a client with wrist restraints

Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode? A) "I think all children should have their heads shaved." B) "I have been restricted in thought and harmed." C) "I have powers to get you whatever you wish, no matter the cost." D) "I think all of my contacts last week have attempted to poison me."

C) "I have powers to get you whatever you wish, no matter the cost."

A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client's drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be A) "These pills aren't antacids since they are all different." B) "Some teenagers use pills to lose weight." C) "Tell me about your week prior to being admitted." D) "Are you taking pills to change your weight?"

C) "Tell me about your week prior to being admitted."

The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process? A) Assist a client post cerebral vascular accident to ambulate B) Feed a 2 year-old in balanced skeletal traction C) Care for a client with discharge orders D) Collect a sputum specimen for acid fast bacillus

C) Care for a client with discharge orders

C) Dyspnea

The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN? A) Test a stool specimen for occult blood B) Assist with the ambulation of a client with a chest tube C) Irrigate and redress a leg wound D) Admit a client from the emergency room

C) Irrigate and redress a leg wound

The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? A) It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes. B) In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent D) Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to2 weeks

C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent

A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse? A) Relieve the nurse performing CPR B) Go get the code cart C) Participate with the compressions or breathing D) Validate the client's advanced directive

C) Participate with the compressions or breathing

The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 D) Client is unable to speak

C) Pulse oximetry of 88

The nurse is teaching a 27 year-old client with asthma about management of their therapeutic regime. Which statement would indicate the need for additional instruction? A) "I should monitor my peak flow every day." B) "I should contact the clinic if I am using my medication more often." C) "I need to limit my exercise, especially activities such as walking and running." D) "I should learn stress reduction and relaxation techniques."

C. "I need to limit my exercise, especially activities such as walking and running"

The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers. Which of these comments by the student indicates a need for clarification of information? A) "The infant will get the hepititis B vaccine (HepB) and the hepatitis B immune globulin within 12 hours at birth at separate injection sites." B) "The second dose can be given at 1 to 2 months of age." C) "The third dose should be given at least 16 weeks from the second dose." D) "The last dose in the series is not to be given before age 24 weeks."

C. "The third dose should be given at least 16 weeks from the second dose"

The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds A) "The complaints of at least 3 common findings." B) "The absence of any opportunistic infection." C) "CD4 lymphocyte count is less than 200." D) "Developmental delays in children."

C. CD4 lymphocyte count is less than 200

In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next? A) Take the client's respirations, blood pressure (BP), temperature and then pupillary responses B) Place the client into the bed and administer the ordered PRN analgesic C) Check the client for bladder distention and the client's urinary catheter for kinks D) Turn the television off and then assist client to use relaxation techniques

C. Check the client for bladder distention and the client's urinary catheter for kinks

The mother of an infant born with hypospadias is concerned because she has been told that her child cannot be circumcised according to her Jewish faith tradition. Which response is best for the nurse to provide? a. "Your faith is important, but correcting this problem is priority for your son." b. "Circumcising the penis now may contribute to frequent urinary infections." c. "During the surgery part of the foreskin is used to repair the meatus." d. "I understand your concern. Would you like to talk to the pediatrician?"

C. During the surgery part of the foreskin is used to repair the meatus. Infants born with hypospadias may require using the foreskin (D) in surgical correction of the meatus so circumcision is deferred until this time. In Jewish tradition, circumcision is usually conducted on the 8th day of life, but the desirable time for surgical repair of the meatus is 6-12 months of age.

An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first? A) Review the client's weight pattern over the year B) Ask the mother to record her diet for the last 24 hours C) Encourage her to talk about her view of herself D) Give her several pamphlets on postpartum nutrition

C. Encourage her to talk about her view of herself

The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching? A) Change the pillow covers every month B) Wash bed linens in warm water with a cold rinse C) Wash and rinse the bed linens in hot water D) Use air filters in the furnace system

C. Wash and rinse the bed linens in hot water

A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure? A) Playing with toys in a back yard flower garden B) Eating small amounts of grass while playing "farm" C) Playing with cars on the pavement near burning leaves D) Throwing a ball to a neighborhood child who has poison ivy

C. Playing with cars on the pavement near burning leaves

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the A) Surgical repair of a diseased coronary artery B) Placement of an automatic internal cardiac defibrillator C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow D) Non- invasive radiographic examination of the heart

C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow

A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to A) Convince the client that the hospital staff is trying to help B) Help the client to enter into group recreational activities C) Provide interactions to help the client learn to trust staff D) Arrange the environment to limit the client's contact with other clients

C. Provide interactions to help the client learn to trust staff

During the beginning shift assessment of a client with asthma and is receiving oxygen per nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding? A) Pulse oximetry reading of 89% B) Crackles at the base of the lungs on auscultation C) Rapid shallow respirations with intermittent wheezes D) Excessive thirst with a dry cracked tongue

C. Rapid shallow respirations with intermittent wheezes

The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart? A) Right ventricle, left ventricle, right atrium, left atrium B) Left ventricle, right ventricle, left atrium, right atrium C) Right atrium, right ventricle, left atrium, left ventricle D) Right atrium, left atrium, right ventricle, left ventricle

C. Right atrium, right ventricle, left atrium, left ventricle

A 74 year-old male is admitted due to inability to void. He has a history of an enlarged prostate and has not voided in 14 hours. When assessing for bladder distention, the best method for the nurse to use is to assess for A) Rebound tenderness B) Left lower quadrant dullness C) Rounded swelling above the pubis D) Urinary discharge

C. Rounded swelling above the pubis

While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately? A) Jaundice evident at 26 hours B) Hematocrit of 55% C) Serum bilirubin of 12mg D) Positive Coomb's test

C. Serum bilirubin of 12mg

Which tasks, if delegated by the new charge nurse to a unlicensed assistive personnel (UAP), would require intervention by the nurse manager? A) To help an elderly client to the bathroom. B) To empty a foley catheter bag. C) To bathe a woman with internal radon seeds. D) To feed a 2 year-old with a broken arm.

C. To bathe a woman with internal radon seeds.

A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? A) Ask the teenager to wait until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained from thepartner C) Refer the teenager to a community pediatric hospital emergency department D) Proceed with the triage process in the same manner as any adult client

150. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? A) Have the client cough into a tissue and dispose in a separate bag B) Instruct the client to cover the mouth with a tissue when coughing C) Reinforce for all to wash their hands before and after entering the room D) Place client in a negative pressure private room and have all who enter the room use masks with shields

A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? A) "I knew this would happen. I've been eating too much red meat lately." B) "I really enjoyed my fishing trip yesterday. I caught 2 fish." C) "I have really been working hard practicing with the debate team at school." D) "I went to the health care provider last week for a cold and I have gotten worse."

An adult client is admitted to the emergency department after falling from a ladder. While waiting to have a computer tomography (CT) scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement? A. Assess clients peoples for their reaction to light B. Request that the CT scan beats immediately C. Review client's history for use of illicit drugs D. Explain the reason for using only non-narcotics

Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy? A) Permission to videotape B) Salivary pH C) Mini-mental status exam D) Pre-anesthesia work-up

Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? A) An adolescent diagnosed with sepsis 7 days ago with vital signs maintained withinlow normal B) A middle-aged woman documented to have had an uncomplicated myocardialinfarction 4 days ago C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis D) A young adult in the second day of treatment for an overdose of acetometaphen

Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia

While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocial skill? A) Stubborn behavior B) Rejection of parents C) Frustration with adults D) Assertion of control

a new mother on the postpartum unit runs out of the room screaming ther her newborn infant's crib is empty and the. baby is missing. which action should the nurse take first? A. Determine if the newborn is in the nursery B. Activate the lockdown procedure C. Ask the mother if any visitors were expected to arrive D. Match. ID bands of all infants and mothers on the. unit

a nurse working on an endocrine unit should see which client first? A. An older client with Addison's disease whose current blood sugar level is 62 mg/dL B. An adult with a blood sugar of 384 mg. dL (21.31 mmol/L) and a urine output of 350 C. An adolecent male with. type I DM who is arguing about. his insulin dose D. A client talking about corticosteroids who have become disoriented in the last two hours.

an 11 yo client is admitted to the mental health unit after trying to run away from home and threatening....and plans to ask the client to verbalize three ways to deal with stress. which activity is best to establish rapport? A. Bring the client to the team meeting to discuss the treatment plan B. Explain the purpose of each medication the client is currently taking C. Ask the client to write feelings in a journal and then review it together D. Play a board game with the client and. begin talking about stressors.

the nurse is assigned to care for a client diagnosed with psoriasis.... the client's psychosocial need for acceptance? A. Encouraging the client to join a support group B. Wearing gloves when interviewing the client C. Allowing the client to ventilate feelings D. Shaking the clients hand during an introduction

Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness

D) A preschooler with intermittent episodes of alertness

Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? A) Be with a client who self-administers insulin B) Cleanse and dress a small decubitus ulcer C) Monitor a client's response to passive range of motion exercises D) Apply and care for a client's rectal pouch

D) Apply and care for a client's rectal pouch

The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of A) Anonymity B) Beneficence C) Justice D) Autonomy

D) Autonomy

A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage

D) Continue to monitor the rate of drainage

A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to A) Ask to not be assigned to this client or to work on another unit B) Tell the client that such behavior is inappropriate C) Inform the client that hospital policy prohibits staff to date clients D) Discuss the boundaries of the therapeutic relationship with the client

D) Discuss the boundaries of the therapeutic relationship with the client

A middle aged woman talks to the nurse in the health care provider's office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? A) I am one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occurs more frequently. B) My fibroids are noncancerous tumors that grow slowly. C) My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention and constipation. D) Fibroids that cause no problems still need to be taken out.

D) Fibroids that cause no problems still need to be taken out.

A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements? A) I am sorry. Referral information can only be provided by the client's health care providers. B) "I can never give any information out by telephone. How do I know who you are?" C) Since this is a referral, I can give you the this information. D) I need to get the client's written consent before I release any information to you.

D) I need to get the client's written consent before I release any information to you.

A client who is thought to be homeless is brought to the emergency department by police. The client is unkempt, has difficulty concentrating, is unable to sit still and speaks in a loud tone of voice. Which of these actions is the appropriate nursing intervention for the client at this time? A) Allow the client to randomly move about the holding area until a hospital room is available B) Engage the client in an activity that requires focus and individual effort C) Isolate the client in a secure room until control is regained by the client D) Locate a room that has minimal stimulation outside of it for admission process

D) Locate a room that has minimal stimulation outside of it for admission process

Although non steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects? A) Urinary incontinence B) Constipation C) Nystagmus D) Occult bleeding

D) Occult bleeding

The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C) Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings

D) Pale, thin arms and legs, uninterested in surroundings

The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? A) Have the client cough into a tissue and dispose in a separate bag B) Instruct the client to cover the mouth with a tissue when coughing C) Reinforce for all to wash their hands before and after entering the room D) Place client in a negative pressure private room and have all who enter the room use masks with shields

D) Place client in a negative pressure private room and have all who enter the room use masks with shields

A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a A) Chest x-ray B) Blood culture C) Sputum culture D) PPD intradermal test

D. PPD intradermal test

A client admitted with a liver abscess is scheduled for surgical evacuation and drainage of the abscess tomorrow morning. Nursing assess .... Client's abdominal pain has increased from 4 to 8 on a 10-point scale in the last four hours. What is priority nursing action? a. Notify the surgeon of increasing abdominal pain. b. Administer the nest scheduled dose of antibiotic. c. Encourage the client to cough and deep breath. d. Assess for a change in the client's bowel sounds.

A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? a. Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. b. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. c. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. d. The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.

After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? a. File a detailed incident report with the specific hiring facility. b. Warn the colleague that their actions are unprofessional. c. Comment anonymously about the action of a staff discussion board. d. Communicate the colleague's actions to the unit charge nurse.

An adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the - 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? a. Add sterile water to the suction control chamber. b. Give blood from the collection chamber as autotransfusion c. Manipulate blood in tubing to drain into chamber. d. Increase wall suction to eliminate fluctuation in water seal.

The nurse identifies an electrolyte imbalance, an elevated pulse rate, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with chronic kidney disease. What intervention should the nurse include in the plan of care? a. Monitor serum electrolytes daily. b. Provide only distilled water. c. Document abdominal girth. d. Perform range of motion exercises.

A client is taken to the urgent care clinic after fainting while exercising at the gym. The client is weak, pale, and diaphoretic. Which intervention should the nurse implement first? a. Check blood glucose level. b. Auscultate heart sounds. c. Offer an oral hydration drink. d. Perform a 12-lead electrocardiogram.

a. Check blood glucose level.

The nurse is assessing the mood of a depressed male client. When asked how he feels, the client looks down and states, "I don't know I just can't think " Which activity should the nurse suggest that this client perform? a. Complete a written self-esteem assessment. b. Review the client handbook about unit therapies c. Set daily goals in the community meeting. d. Read, "The Depression Recovery Book."

a. Complete a written self-esteem assessment.

An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan? a. Decreased abdominal girth. b. Prothrombin time within normal limits. c. Improved level of consciousness. d. Clear, dark amber-colored urine.

a. Decreased abdominal girth.

A client who is an avid hiker expresses concern about losing too much potassium while hiking. In teaching the client to prepare potassium-rich snack mix the nurse should encourage the cllent to include which items? (Select all that apply.) a. Dried apricots. b. Seedless raisins. c. Lightly salted peanuts. d. Dried bananas. e. Dried apples.

a. Dried apricots. b. Seedless raisins. d. Dried bananas.

Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client's right radial pulse. Which action should the nurse take first? a. Elevate the client's right hand on one or two pillows. b. Notify the healthcare provider of the finding immediately. c. Measure the client's blood pressure and apical pulse rate. d. Complete a neurovascular assessment of the right hand.

a. Elevate the client's right hand on one or two pillows.

The mother of a one-month-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond? a. Position the infant on the stomach occasionally when awake and active. b. Turn the infant on the left side braced against the crib when sleeping. c. Prop the infant in a sitting position with a cushion when not sleeping. d. Place a small pillow under the infant's head while lying on the back.

a. Position the infant on the stomach occasionally when awake and active.

The nurse finds a female client crying quietly in her room. What action should the nurse take first? a. Pull up a chair and sit beside the client. b. Review the client's record before attempting to intervene. c. Provide the client privacy and quietly close the door. d. Ask the client why she is crying

a. Pull up a chair and sit beside the client.

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior? a. Silence allows the client to reflect on what was said. b. The nurse is respecting the client's loss. c. The nurse is stating disapproval of the statement. d. Silence is reflecting the client's sadness.

a. Silence allows the client to reflect on what was said.

An adolescent receives a prescription for an injection of s-matriptan succinate 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/ 0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.

answer: 0.33 the dose is 4 mg ( we want to know how much mL. to get this amount of. dose) our reference is the avialability vial (6 mg in 0.5 mL) 6 mg --- 0.5 mL 4mg --- X mL X=4* 0.5 / 6 = 0.3333333= 0.33

An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse a copy of the client's living will. Which action should the nurse take? a. Facilitate a family meeting with the palliative care team. b. Notify the healthcare provider of the client's wishes. c. Place a certified copy of the living will in the client's record. d. Alert the nursing staff of the client's don't resuscitate status.

An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first? a. Document neurologic changes. b. Reduce environmental stimuli. c. Administer prescribed neuroleptic. d. Review medications for interactions.

The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? a. Nausea and vomiting b. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) c. Diffuse macular rash d. Muscle tenderness

An older client has been diagnosed with chronic venous insufficiency. To promote venous return, which action should the nurse encourage the client to take? a. Sit at the side of the bed for 15 minutes before standing. b. Wear cotton socks and enclosed toe shoes whenever outside. c. Lie down in bed 2 times a day. d. Drink 8 to 10 ounces of water a day.

b. Wear cotton socks and enclosed toe shoes whenever outside.

A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 to 125 mEg/L or mmol/L (SI). Based on this finding, which intervention should the nurse implement? a. Withhold next scheduled dose of treatment. b. Maintain the prescribed fluid restriction. c. Increase neurologic checks to every 2 hours. d. Assess for increasing fluid volume overload.

b. Maintain the prescribed fluid restriction.

During the admission assessment, the nurse identifies multiple bruises at various stages of heating on a client recently diagnosed with aplastic anemia. The nurse reviews the client's stat serum laboratory values which reveal platelets 50,000/mm° (5 x 10°L), white blood cells 3,000/mm° (3 % 10°/L.), and red bloods cells 2.5 million/mm? (2.5 x 10*°). Which actions should the nurse Implement? (Select all that apply.) a. Implement contact precautions. b. Monitor for signs of bleeding. c. Provide a soft-bristle tooth brush. d. Initiate sepsis protocol Infuse blood products as prescribed.

b. Monitor for signs of bleeding. c. Provide a soft-bristle tooth brush. d. Initiate sepsis protocol Infuse blood products as prescribed.

The nurse determines that an older female client has kyphosis, has lost two inches of height in the last three years, and has a recent history of spinal vertebral fractures. What underlying pathology explains these manifestations? a. Rate of bone resorption that exceeds rate of bone deposition. b. Progressive weakening of the muscle fibers of the lower back. c. Deterioration of the myelin sheath surrounding nerve fibers. d. Vertebral compression caused by increased bone density.

b. Progressive weakening of the muscle fibers of the lower back.

A client uses triamcinolone, a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report Increased erythema with purulent exudate at the site. Which action should the nurse implement? a. Explain that the client needs to complete all prescribed doses of the medication. b. Schedule an appointment for the client to see the healthcare provider, c. Instruct the client to continue the ointment until all erythema is relieved. d. Advise the client to apply plastic wrap over the ointment to promote healing.

b. Schedule an appointment for the client to see the healthcare provider,

The nurse is teaching a husband how to care for his wife who recently had a stroke and has residual weakness on her right side. What style shoes should the nurse recommend the client wear when ambulating with her husband's assistance? a. Slip-on rubber shower shoes. b. Tennis shoes with Velcro. c. Rubber soled slippers. d. Leather soled loafers.

b. Tennis shoes with Velcro.

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "kill, kill." What question should the nurse ask the client next? a. "When did these voices begin?" b. "Have you taken any hallucinogens?" c. "Are you planning to obey the voices?" d. "Do you believe the voices are real?"

After several months of chronic fatigue, morning stiffness, and join pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to taking prednisone? a. Take prednisone doses before meals on an empty stomach. b. Wear sunglasses when exposed to bright sunlight. c. If sequential doses are missed, notify the healthcare provider. d. Schedule a monthly laboratory visit for a complete blood count.

The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? a. Diminished bowel sounds b. Loss of appetite c. A cold, pale lower leg d. Tachypnea

A client with uremia is experiencing uremic frost. Which action should the nurse Implement? a. Provide frequent skin care and apply lotion. b. Evaluate bony prominences for breakdown. c. Explain that hemodialysis is needed. d. Monitor the client's oral fluid intake.

c. Explain that hemodialysis is needed.

When using a Yankauer oral-tip catheter to suction a client's oropharynx, which action should the nurse take before inserting the catheter into the oropharynx? a. Assess the nares for a deviated septum. b. Apply suction by occluding the port. c. Turn on the continuous suction device. d. Ask the client to begin swallowing.

c. Turn on the continuous suction device. Rationale: The continuous suction device should be turned on (B) prior to inserting the Yankauer tip or tonsillar tip catheter into the client's mouth so that suction can be applied as soon as it is in place. (A) is an action implemented prior to nasogastric tube (NGT) placement. (C) should be assessed prior to insertion of a nasal suction catheter or NGT. Suction should not be applied while a catheter is inserted (D) because it can traumatize tissue and remove oxygen in the upper airways.

A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? a. Recommend he avoid fast food restaurants until he is familiar with his prescribed diet. b. Advise him to take his own food with him when going to fast food restaurants with his friends. c. Encourage him to find activities to do with his friends that do not involve eating. d. Assist him in identifying popular fast foods that are within his meal plan for diabetes.

The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex. Which action should the nurse lake in response to the finding? a. Ask the client to describe recent alcohol use. b. Keep the client's feet elevated when in bed. c. Assess the client's muscle strength and tone d. Complete thorough neurologic assessment

d. Complete thorough neurologic assessment

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. What instruction should the nurse give the parents if their child becomes pale, cool, and lethargic? a. Assist the child to a recumbent position. b. Provide a quiet time by holding or rocking the toddler. c. Encourage oral electrolyte solution intake. d. Contact their healthcare provider immediately.

d. Contact their healthcare provider immediately.

While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the alr valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next? a. Reposition the stethoscope in the antecubital fossae over the palpable brachial pulse point. b. Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading. c. Inflate the cuff quickly to a higher mm of Hg reading than the previously auscultated systolic sound d. Continue the blood pressure assessment until the last Korotkoff sound is heard.

d. Continue the blood pressure assessment until the last Korotkoff sound is heard.

As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids based on which pathophysiological process? a. Removing gastric secretions and to relieve abdominal distention. b. Reducing hydrochloric acid secretion. c. Restoring and maintaining a positive fluid balance. d. Decreasing the formation and secretion of pancreatic enzymes.

d. Decreasing the formation and secretion of pancreatic enzymes.

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate Is 14 breaths/minute. Which action should the nurse implement? a. Encourage the client to take deep breaths. b. Increase the liter flow of oxygen. c. Remove the mask to deflate the bag. d. Document the assessment data.

d. Document the assessment data.

A client who takes nonsteroidal antiinflammatory drugs (NSAIDs) every day for rheumatoid arthrits Is being treated for anemia. Which intervention is most important for the nurse to include in the plan of care? a. Offer dietary selections rich in iron. b. Monitor liver function test results. c. Protect skin from bruising. d. Observe for gastrointestinal bleeding.

d. Observe for gastrointestinal bleeding.

The charge nurse is making assignments on an in-patient psychiatric unit. The staff consists of two psychiatric technicians and one practical nurse (PN). Which team assignment is best to assign to the PN? a. Detoxification precaution check lists. b. Routine morning vital signs and weights. c. Administration of routine medications. d. One-on-one observation of a suicidal client.

d. One-on-one observation of a suicidal client.

Prior to obtaining an axillary temperature, the nurse should perform which action? a. Check the last oral temperature reading. b. Position the client's arm at heart level. c. Ask when the client last ate or drank. d. Place a protective sheath over the thermometer.

d. Place a protective sheath over the thermometer.

The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action? A) Periorbital edema B) Dizziness spells C) Lethargy D) Shortness of breath

The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? A) Apply dressing using sterile technique B) Improve the client's nutrition status C) Initiate limb compression therapy D) Begin proteolytic debridement

The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client? A) Instruct the client to wear a high efficiency particulate air mask in public places. B) Ask a family member to supervise daily compliance C) Schedule weekly clinic visits for the client D) Ask the health care provider to change the regimen to fewer medications

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (Select all that apply) a. Brings a heavy can close to body before lifting. b. Locks knees while preparing food on the counter. c. Widens stance while working near the sink. d. Bends from the waist to pick trash off the floor. e. Leans forward to pull a pan from a high shelf.

a, b

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) a. Headache and tremors b. Irregular heart rate c. Skin hyperpigmentation d. Postural hypotension e. Pallor and diaphoresis

a, b, e

The nurse is teaching a primigravida about preeclampsia. Which finding are indicators of preeclampsia and should be reported to the healthcare provider? (select all that apply.) a. Blurred vision b. Headache c. Lack of appetite. d. Urinary frequency. e. Chills and fever. f. Swollen hands.

a, b, f

A client is hospitalized for treatment of a myasthenic crisis and is concerned about what may have caused this illness. The client states, "I just had a little case of the sniffles and a bit of a sore throat and wham! Suddenly I couldn't get out of bed or do anything." Which response Is best for the nurse to provide this client? a. "Muscle weakness is an early sign of crisis and means that you need more rest." b. "The crisis may have been triggered by your cold. I bet it can feel pretty scary.' c. "You probably just did too much at one time. You need to pace your activities." d. "It was probably an overdose of your medication. Did you take a double dose?"

a. "Muscle weakness is an early sign of crisis and means that you need more rest."

A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral atrial disease. Which question should the nurse ask the client about expected finding related to chronic arterial symptoms? a. Were your legs ever suddenly swollen, red, warm, and painful? b. Does the calf pain occur when walking short distances? c. Did you receive treatment for weeping ulcers on lower legs? d. Have you experienced ankle edema and varicose veins?

A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce with the client? a. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) b. It is critical to report promptly to your health care provider any findings of peptic ulcers c. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors d. With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine

A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement? a. Suggest the nurse use a 20-gauge needle. b. Direct the nurse to change the IV tubing. c. Instruct the nurse to remove the needle. d. Prompt the nurse to apply povidone to the site.

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms? a. Positive Epstein-Barr, and malaise. b. Ear pain and fever. c. Elevated WBC and sedimentation rate. d. Increased BUN and serum creatinine.

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? a. Keep the nails trimmed short. b. Apply baby lotion to the skin twice daily. c. Bathe the child daily with bath oil. d. Allow the child to wear only 100% cotton clothing.

The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? a. Assess the client's oral cavity for ulcerations. b. Monitor the client when using a straw for liquids. c. Teach coughing and deep breathing exercises. d. Request thick nectar liquids for the client.

When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate invention? (Select all that apply) A. Sloughing tissue around wound edges B. Complaint of increased pain and pressure C. Change in the quality of the peripheral pulses. D. Loss of sensation to the left lower extremityE. Weeping serosanguineous fluid from wounds

b,c,d

The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat gout? a. "I need to take the prescribed amount of the drug to get rid of my gout." b. "I need to take this drug every day to keep from having any flareups." c. "The pain and swelling can be controlled by taking this drug every day. d. "I should take this drug when I have gout attacks to reduce symptoms."

b. "I need to take this drug every day to keep from having any flareups."

Penicillin G procaine 240,000 units intramuscularly is prescribed for a 4-year-old child who has a streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2 mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

0.4 mL

A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? A) Gastric lavage PRN B) Acetylcysteine (mucomyst) for age per pharmacy C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open D) Activated charcoal per pharmacy

A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find? A) S3 heart sound B) Thready pulse C) Flattened neck veins D) Hypoventilation

A client has been taking alprazolam (Xanax) for 3 days. Nursing assessment should reveal which expected effect of the drug? A) Tranquilization, numbing of emotions B) Sedation, analgesia C) Relief of insomnia and phobias D) Diminished tachycardia and tremors associated with anxiety

What is the most important aspect to include when developing a home care plan for a client with severe arthritis? A) Maintaining and preserving function B) Anticipating side effects of therapy C) Supporting coping with limitations D) Ensuring compliance with medications

The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period? A) Estrogen replacement therapy B) 10% less than ideal body weight C) Hypersensitivity to heparin D) History of hepatitis

The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? A) "My pain is deep in my chest behind my sternum." B) "When I sit up the pain gets worse." C) "As I take a deep breath the pain gets worse." D) "The pain is right here in my stomach area."

a client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. in what.....the actions in order of priority. with the highest priority first, and least priority last or a the bottom(Select all) 1. stop the infusion 2. Assess vital signs 3. Contact the healthcare. provider 4. Document reaction to the drug 5. initiate an adverse event report

1. stop the infusion 2. Assess vital signs 3. Contact the healthcare. provider 4. Document reaction to the drug 5. initiate an adverse event report

The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result in metabolic acidosis? A) Severe diarrhea for 24 hours B) Nausea with anorexia C) Alternating constipation and diarrhea D) Vomiting for over 48 hours

A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority? A) Counsel the woman to consent to HIV screening B) Perform tests for sexually transmitted diseases C) Discuss her high risk for cervical cancer D) Refer the client to a family planning clinic

A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? A) Protamine B) Amicar C) Imferon D) Diltiazem

A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is A) Start a peripheral IV B) Initiate closed-chest massage C) Establish an airway D) Obtain the crash cart

A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse? A) Avoid Alka-Seltzer because it contains aspirin B) Take Alka-Seltzer at a different time of day than the warfarin C) Select another antacid that does not inactivate warfarin D) Use on-half the recommended dose of Alka-Seltzer

A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500 mg PO every 12 hours. When the client requests an afternoon snack, which dietary choice should the nurse provide? A. Cinnamon applesauce B. Vanilla-flavored yogurt C. Calcium-fortified juice D. Low-fat milk

Therapeutic nurse-client interaction occurs when the nurse A) Assists the client to clarify the meaning of what the client has said B) Interprets the client's covert communication C) Praises the client for appropriate feelings and behavior D) Advises the client on ways to resolve problems

The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in A) Calcium B) Fiber C) Sodium D) Carbohydrate

To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion

A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are A) Brittle hair, lanugo, amenorrhea B) Diarrhea, nausea, vomiting, dental erosion C) Hyperthermia, tachycardia, increased metabolic rate D) Excessive anxiety aboutsymptoms

A client with rheumatoid arthritis ( RA ) starts a new prescription for subcutaneously once weekly . The nurse should emphasize the importance of reporting which problem to the healthcare provider A. Joint stiffness B. Persistent fever C. Headache D. Increased hunger and thirst

What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention? A) Set good examples themselves B) Protect their child from outside influences C) Make sure their child understands all the safety rules D) Discuss the consequences of not wearing protective devices

A mother telephones the clinic and says "I am worried because my breast-fed 1 month-old infant has soft, yellow stools after each feeding." The nurse's best response would be which of these? A) This type of stool is normal for breast fed infants. Keep doing as you have. B) The stool should have turned to light brown by now. We need to test the stool C) Formula supplements might need to be added to increase the bulk of the stools. D) Water should be offered several times each day in addition to the breast feeding.

A female client with a history of heart failure ( HF ) arrives at the clinic after what she describes as a very long trip . Following the initial physical assessment and chart review , which priority action should the nurse implement ? (Click on each chart tab for additional information . Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record). A. Administer the prescribed diuretic B. Give a potassium supplement C. Reteach medication regimen D. Auscultate lung and heart sounds

The healthcare provider prescribes penicillin G benzathine 2,400,000 units intramuscularly for a client who has a postoperative wound infection . The prefilled syringe is labeled , penicillin G benzathine 1,200,000 units / 2 mL How many mL should the nurse administer to this client ? ( Enter numerical value only rounded to the nearest whole number

The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care? A) Risk for injury B) Self care deficit C) Alteration in comfort D) Alteration in mobility

A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement ? A. Suggest the nurse use a 20-gauge needle B. Instruct the nurse to remove the needle C. Direct the nurse to change the IV tubing D. Prompt the nurse to apply povidone to the site

The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention? A) Temperature of 102 degrees Fahrenheit B) Pulse rate of 98 beats per minute C) Respiratory rate of 32 D) Blood pressure of 90/50

What is the major developmental task that the mother must accomplish during the first trimester of pregnancy? A) Acceptance of the pregnancy B) Acceptance of the termination of the pregnancy C) Acceptance of the fetus as a separate and unique being D) Satisfactory resolution of fears related to giving birth

Handshaking is the preferred form of touch or contact used with clients in a psychiatric setting. The rationale behind this limited touch practice is that A) Some clients misconstrue hugs as an invitation to sexual advances B) Handshaking keepsthe gesture on a professional level C) Refusal to touch a client denotes lack of concern D) Inappropriate touch often results in charges of assault and battery

A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client? A) Capillary refill less than 3 seconds B) Pale mucous membranes C) Respirations 36 breaths per minute D) Complaints of fatigue when ambulating

In addition to standard precautions, a nurse should implement contact precautions for which client? A) 60 year-old with herpes simplex B) 6 year-old with mononucleosis C) 45 year-old with pneumonia D) 3 year-old with scarlet fever

What is the major purpose of community health research? A) Describe the health conditions of populations B) Evaluate illness in the community C) Explain the health conditions of families D) Identify the health conditions of the environment

A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THEABDOMEN? The best response by the nurse would be which of these statements? A) "Touching the abdomen could cause cancer cells to spread." B) "Examining the area would cause difficulty to the child." C) "Pushing on the stomach might lead to the spread of infection." D) "Placing any pressure on the abdomen may cause an abnormal experience."

A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to? A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcement of the manipulative behavior C) Confront the client about the negative effects of behaviors on otherclients and staff D) Develop a behavior modification plan that will promote more functional behavior

A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at a parent teacher meeting. What action is most important for the nurse to include in the meeting? A. Provide information on ways to increase activity for the family B. Have several teachers talk about health risks associated with obesity C. Distribute a shopping list of suggested healthy snack items D. Determine the parents degree of concern about...

A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action? A) Report this immediately to the nurse manager B) Confront the nurse about the suspected drug use C) Sign the narcotic sheet and document the event in an incident report D) Counsel the colleague about the risky behaviors

A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs wereT-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min.Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit. C) Cervical dilation of 4 D) BP 138/88

A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan, the nurse should teach the parents to report which sign of overdose? A. Bradycardia B. Tachypnea C. Hypertension D. Coughing

A toddler presenting with a history oof intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting of milk products arrives to the clinic accompanied by the parents. Which type of testing should the nurse provide education to the toddler's family about? A. Serum immunoglobulin E (IgE) B. Intradermal test C. Atopy patch test D. Placebo-controlled food challenge

A young adult visits the client reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan? A. Consumes 10 or more drinks of alcohol every weekend B. Snacks on foods with very high salt content on a daily basis C. Exercise vigorously every evening right before going to bed D. Recently became a vegetarian and eats a lot of high fiber foods.

A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? A. Explain that counseling will be provided to give her information about her cancer. B. Offer assurance that there are a variety of effective treatments for breast cancer C. Gather additional information about the client's family history for all types of cancer D. Provide information about survival rates for women who. have the genetic mutation

A young male client is admitted to rehabilitation following a right above - knee amputation (AKA) for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse , stating that his " right foot is aching. " The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement? A. Encourage discussion of feelings about the loss of his limb B. Administer a prescription for gabapentin, a neuroleptic agent C. Teach the client how to wrap the stump with an elastic bandage D. Offer to assist the client to a quieter location so he can relax.

Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical? A) Liver function B) Kidney function C) Blood sugar D) Cardiac enzymes

After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information and a uniform packet. Which action should the nurse take? A. File a detailed incident report with the specific hiring facility B. Why did the colleague that their actions are unprofessional C. Comment anonymously about the action on a staff discussion board D. Communicate the colleague's actions to the unit charge nurse

Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? A) Risk for injury B) Risk for knowledge deficit C) Altered thought process D) Disturbance in self-esteem

An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider? A) Slurred speech B) Incontinence C) Muscle weakness D) Rapid pulse

An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first? A) Potassium levels B) Blood pH C) Magnesium levels D) Blood urea nitrogen

An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the -10 cm H2O mark with fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? A. Add sterile water to the suction control chamber B. Give blood from the collection chamber as autotransfusion C. Manipulate blood in tubing to drain into the chamber D. Increase wall suction to eliminate fluctuation in water seal

An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) administer the medication in 2 separate injections B) give the medication in the dorsal gluteal site C) call to get a smaller volume ordered D) check with pharmacy for a liquid form of the medication skip

An older woman who has difficulty hearing is being discharged from day surgery following cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care? A. Have the client vocalize the instructions provided B. Ensure that someone will stay with a client for 24 hours C. Speak clearly and face the client for lip reading D. Provide written instructions for eye drop administration

An unlicensed assistive personnel (UAP) is a sign to provide personal care for a client whose prescribed activity is bed rest in a bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? A. Determine the client's level of mobility and need for assistance B. Instruct the UAP that all clients deserve equal care C. Advise the client to maintain bedrest so that safety can be insured D. Assign another UAP to care for the client

As the RN responsible for a client in isolation, which can be delegated to the PN? A) Reinforcement of isolation precautions B) Assessment of the client's attitude about infection control C) Evaluation of staffs' compliance with control measures D) Observation of the client's total environment for risks

Clients taking which of the following drugs are at risk for depression? A) Steroids B) Diuretics C) Folic acid D) Aspirin

Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that it A) Considers client and staff needs B) Conserves time for planning C) Frees the nurse manager to handle other priorities D) Allows for requests about special privileges

During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client's knees. The best action for the nurse to take is to A) Ask the client for more information about the nature of the bruises B) Ask the client and then the family about the findings C) Report the bruising to social services to follow-up D) Document the findings on the admission sheet

Following surgery for placement of a ventriculoperitoneal (VP) shunt as treatment for hydrocephalus, the parents question why the infant has a small abdominal incision. The best response by the nurse would be to explain that the incision was made in order to A) Pass the catheter into the abdominal cavity B) Place the tubing into the urinary bladder C) Visualize abdominal organs for catheter placement D) Insert the catheter into the stomach

On admission to the ambulatory surgery unit, the nurse notices the client's painted finger nails. On reviewing the pre-op orders, the nurse notes that pulse oximetry has been ordered. Which statement by the nurse is appropriate? A) "In order to measure your oxygen level, please remove the polish from at least 2 nails." B) "If you do not remove all your polish, I will request a needle stick to test oxygen levels." C) "I am sorry. All your nail polish must go off." D) "I will ask your provider if we must ruin those beautiful nails."

The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)? A) A client with peripheral vascular disease and an ulceration of the lower leg. B) A pre-operative client awaiting adrenalectomy with a history of asthma C) An elderly client with hypertension and self-reported noncompliance D) A new admission with a history of transient ischemic attacks and dizziness

The client referred for a mammography questions the nurses about the cancer risks from radiation exposure. What is the appropriate response by the nurse? A) The radiation from a mammography is equivalent to 1 hour of sun exposure. B) You have nothing to worry about; it is less than tanning in the nude. C) A chest x-ray gives you more radiation exposure. D) Exposure to mammography every 2 years is not dangerous.

The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement? A. Encourage family members to cook meals outdoors and bring the cooked foot inside B. Assess the client's mucous membranes and report the findings to the healthcare provider C. Advise the client to replace cooked foods with a variety of different nutritional supplements D. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting

The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is A) "You think that someone wants to poison you?" B) "Why do you think the food is poisoned?" C) "These feelings are a symptom of your illness." D) "You're safe here. I won't let anyone poison you."

The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated to the findings in the infant? A) DTaP B) Hepatitis B C) Polio D) H. Influenza

The mother of a 2-day-old infant girl expresses concern about a "flea bite" type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer? A. This is a common newborn rash that will resolve after several days B. The rash is due to distended oil glands that will resolve in a few weeks C. The healthcare provider is being notified about the rash D. This rash is characteristic of a medication reaction

The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse? A) "Folic acid should be taken before and after conception." B) "Multivitamin supplements are recommended during pregnancy." C) "A well balanced diet promotes normal fetal development." D) "Increased dietary iron improves the health of mother and fetus."

The nurse admits a client with hypertension who complains of dizziness after taking diltiazem (Cardizem). Which of the following is the most important information for the nurse to assess? A) Schedule for taking medicine B) Daily intake of potassium C) Activity and rest patterns D) Baseline heart rate

The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 750 mg/dL. When assessing the client, what is the priority? A. Assess for signs of fluid volume deficit B. Observe wound drainage characteristics C. Measure the level of pain. D. Determine when the client last ate

The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action? A) Leave the room and return five minutes later and give the medicine B) Explain to the child that the medicine must be taken now C) Give the medication to the father and ask him to give it D) Mix the medication with ice cream or applesauce

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound . A high protein diet is encouraged to promote wound healing . Which lunch choice by the client indicates that the teaching was effective? A. A tuna fish sandwich with chips and ice cream B. A salad with three kinds of lettuce and fruit C. A peanut butter sandwich with soda and cookies D. Vegetable soup, crackers, and milk.

The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding? A) Hold a rattle B) Bang two blocks C) Drink from a cup D) Wave "bye-bye"

The nurse is assessing a client who reports falling 2 days ago and has a history of gouty arthritis that is controlled with allopurinol. The client states the left knee is swollen and extremely painful to touch. Which instruction should the nurse include in the discharge teaching? A. Decrease consumption of red meat and most seafood B. Substitute natural fruit juices for carbonated drinks C. Limit use of mobility equipment to avoid muscle atrophy D. Use electric heating pad when pain is at its worse

The nurse is assessing a client who returns to the unit after a thoracentesis in the procedure room. Which finding should the nurse report to the healthcare provider immediately? A. Diminished breath sounds over the trocar insertion site B. Equal bilateral chest extension C. Scattered crackles unchanged from baseline D. Respiratory rate of 22 breaths/minute

The nurse is assigning rooms for four clients, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The client with which condition should be assigned the only private room available? A. Bacterial meningitis B. Viral encephalitis C. Septic shock D. Brain abscess

The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child? A) Using a moist soft brush or cloth to clean teeth and gums B) Swabbing teeth and gums with flavored mouthwash C) Offering a bottle of water for the child to drink D) Brushing with toothpaste and flossing each tooth

The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two-word phrases. Which assessment should the nurse administer? A. The modified checklist for autism in toddlers (M-CHAT) B. Psychology systems questionnaire (PHQ-2) C. Behavioral style question (BSQ) D. The ages and stages questionnaire (ASQ)

The nurse is caring for a 4 year-old admitted after receiving burns to mor than 50% of his body. Which laboratory data should be reviewed by the nurse as apriority in the first 24 hours? A) Blood urea nitrogen B) Hematocrit C) Blood glucose D) White blood count

The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to A) Check for subcutaneous emphysema in the upper torso B) Reposition the client to a position of comfort C) Call the health care provider as soon as possible D) Check for any increase in the amount of thoracic drainage

The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied A) When it is 1/3 to 1/2 full B) Prior to meals C) After each fecal elimination D) At the same time each day

The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care? A) Cough and deep breathe every 2 hours B) Place the client in contact isolation C) Provide a diet high in protein D) Institute seizure precautions

The nurse is caring for a client with renal calculi. Which health care provider order would be a priority? A) Morphine sulfate as client controlled analgesia B) Push oral fluids and keep vein open C) Continuous warm compresses to the flank area D) Intravenous antibiotics

The nurse is caring for a client with the sexually transmitted infection (STI) chlamydia. The client reports having sex with someone who had many partners. Which response should the nurse provide? A. Inform that follow-up may end after the treatment is finished B. Reassure that complications will not occur if the infection is treated C. Notify that persons with STIs are reported to local health departments D. Explain how the infection is transmitted and the health risks involved

The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist the client with nutrition needs, the nurse should A) Offer small meals of high calorie soft food B) Assist the client to sit in a chair for meals C) Provide additional servings of fruits and raw vegetables D) Encourage the client to eat fish, liver and chicken

The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain the child is maintained in correct body alignment. B) Be sure the traction weights touch the end of the bed. C) Adjust the head and foot of the bed for the child's comfort D) Release the traction for 15-20 minutes every 6 hours PRN.

The nurse is caring for client with flail chest secondary to 3 right rib fractures after sustaining a fall from a ladder . The client is anxious, but stable with an oxygen saturation of ( SpO2 ) 93 %. Which action should the nurse take A. Splint affected side B. Insert nasal airway C. Coach through taking deep breaths D. Apply a non-rebreather mask

The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment? A) Activity intolerance caused by fatigue related to chronic tissue hypoxia B) Impaired mobility related to chronic obstructive pulmonary disease C) Self care deficit caused by fatigue related to dyspnea D) Ineffective airway clearance related to increased bronchial secretions

The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis? A) Repeatedly checking that the door is locked B) Verbalized suspicions about thefts C) Preference for consistent care givers D) Repetitive, involuntary movements

The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding? A) Retractions in the intercostal tissues of the thorax B) Chest pain aggravated by respiratory movement C) Cyanosis and mottling of the skin D) Rapid, shallow respirations

The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2

The nurse is performing physical assessments on adolescents. When would the nurse anticipate that females experience growth spurts? A) About 2 years earlier than males B) About the same time as males C) Just prior to the onset of puberty D) That increase height by 4 inches each year

The nurse is reassigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice? A) An 18 month-old who ate an undetermined amount of crystal drain cleaner B) A 14 month-old who chewed 2 leaves of a philodendron plant C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium) D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid

The nurse is teaching a client newly diagnosed with asthma how to use the metered dose inhaler (MDI). The client asks when they will know the canister is empty. The best response is A) Drop the canister in water to observe floating B) Estimate how many doses are usually in the canister C) Count the number of doses as the inhaler is used D) Shake the canister to detect any fluid movement

The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an understanding of the diet by stating A) "I will increase sodium and fluids and restrict potassium." B) "I will increase potassium and sodium and restrict fluids." C) "I will increase sodium, potassium and fluids." D) "I will increase fluids and restrict sodium and potassium."

The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age? A) Formula or breast milk B) Dilute nonfat dry milk C) Warmed fruit juice D) Fluoridated tap water

The nurse is wearing personal protective equipment (PPE) while caring for a client. When exiting the room, which PPE should be removed first? A. Gloves B. Mask C. Eyewear D. Gown

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignment is best for the charge nurse to give this nurse? A. Assist cardiac nurses with their assignments B. Monitor the central telemetry C. Perform the admission of a new client D. Transfer a client to another unit

The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet A) High in carbohydrates and proteins B) Low in carbohydrates and proteins C) High in carbohydrates, low in proteins D) Low in carbohydrates, high in proteins

The parents of a 4 year-old hospitalized child tell the nurse, "We are leaving now and will be back at 6 PM." A few hours later the child asks the nurse when the parents will come again. What is the best response by the nurse? A) "They will be back right after supper." B) "In about 2 hours, you will see them." C) "After you play awhile, they will be here." D) "When the clock hands are on 6 and 12."

The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. What is the nurse's best response to the parents? A) "Your child must use a care seat until he weighs at least 40 pounds." B) The child must be 5 years of age to use a regular seat belt. C) "Your child must reach a height of 50 inches to sit in a seat belt." D) "The child can use a regular seat belt when he can sit still."

When an autistic client begins to eat with her hands, the nurse can best handle the problem by? A) Placing the spoon in the client's hand and stating, "Use the spoon to eat your food." B) Commenting "I believe you know better than to eat with your hand." C) Jokingly stating, "Well I guess fingers sometimes work better than spoons." D) Removing the food and stating "You can't have anymore food until you use the spoon."

When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because A) Normal patterns of behavior may be labeled as deviant, immoral, or insane B) The meaning of the client's behavior can be derived from conventional wisdom C) Personal values will guide the interaction between persons from 2 cultures D) The nurse should rely on her knowledge of different developmental mental stages

Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills? A) Offer the client frequent opportunities to interact with 1 person B) Provide the client with frequent opportunities to interact with other clients C) Assist the client to analyze the meaning of the withdrawn behavior D) Discuss with the client the focus that other clients have similar problems

Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care? A) Measure head circumference B) Place in airborne isolation C) Provide passive range of motion D) Provide an over-the-crib protective top

Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects? A) Red reflex test B) Visual acuity C) Pupil response to light D) Cover test

Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)? A) Direct sunlight B) Foods containing tyramine C) Foods fermented with yeast D) Canned citrus fruit drinks

Which of these clients, who all have the findings of a board-like abdomen, would the nurse suggest that the health care provider examine first? A) An elderly client who stated that "My awful pain in my right side suddenly stopped about 3 hours ago." B) A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy C) A middle-aged client admitted with diverticulitis and has taken only clear liquids for the past week D) A teenager with a history of falling off a bicycle and did not hit the handle bars

Which of these is an example of a variation in the newborn resulting from the presence of maternal hormones? A) Engorgement of the breasts B) Mongolian spots C) Edema of the scrotum D) Lanugo

Which of these questions is priority when assessing a client with hypertension? A) "What over-the-counter medications do you take?" B) "Describe your usual exercise and activity patterns." C) "Tell me about your usual diet." D) "Describe your family's cardiovascular history."

Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? A. "When I get out of bed quickly, I feel a little dizzy" B. "The dressing over my incision feels like it is too tight" C. "I'm most comfortable when the head of the bed is raised." D. "This IV infusion makes me urinate more often than usual"

Which statement describes the use of a decision grid for decision making? A) It is both a visual and a quantitative method of decision making B) It is the fastest way for group decision making C) It allows the data to be graphed for easy interpretation D) It is the only truly objective way to make a decision in a group

Which statements by the client would indicate to the nurse an understanding of the issues with end stage renal disease? A) I have to go at intervals for epoetin (Procrit) injections at the health department. B) I know I have a high risk of clot formation since my blood is thick from too many red cells. C) I expect to have periods of little water with voiding and then sometimes to have a lot of water. D) My bones will be stronger with this disease since I will have higher calcium than normal

Which type of accidental poisoning would the nurse expect to occur in children under age 6? A) Oral ingestion B) Topical contact C) Inhalation D) Eye splashes

While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement? A. Obtain sputum samples B. Document degree of edema C. Initiate hourly urine output measurement D. Administer intravenous diuretics

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider the nurse should review which of the client's laboratory values? A. Culture for sensitive organisms B. Serum blood glucose (BG) level C. Creatinine level D. Serum albumin

While interviewing a client, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to A) Ask the client what she is feeling B) Assess the client for auditory hallucinations C) Recognize the behavior as a side effect of medication D) Re-focus the discussion on a less anxiety provoking topic

While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions? A) Maintain good oral hygiene and dental care B) Omit medication if the child is seizure free C) Administer acetaminophen to promote sleep D) Serve a diet that is high in iron

Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs

In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? a. Cornea are jaundiced. b. Oral mucosa is cyanotic c. Face is flushed and diaphoretic. d. Eyelids are matted and crusted.

b. Oral mucosa is cyanotic

a female child is brought to the ED after awakening with....arrival to the hospital, her respirations are labored, and she is drooling. what should the nurse implement? A. Prepare for emergency tracheostomy B. Assess the child for dehydration C. Examine the oropharyngeal area for foreign body D. COllect midstream urine specimens for culture

a young woman with Multiple sclerosis just received several immunizations in....college dormitory. 2 days later, she reports to the nurse that she is experiencing.....problems. what teaching should the nurse provide? A. Immunizations can trigger a relapse of the disease, so get B. These early signs of an infection may require medical tx C. These are common side effects of the vaccines and will re D. Plans to move into the dormitory need to be postponed for

an older male client who was successfully treated for Herpes zoster.....reports that he is now experiencing pain on his trunk where the lesions.....what action should the nurse take? A. Review the medication record to determine when the last... B. reassure the client. that. the infection is resolved and .. C. Teach the client about the importance of completing th... D. Contact healthcare. provider about the need to resu...

n preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube? A) Cardizem SR tablet (diltiazem) B) Lanoxin liquid C) Os-cal tablet (calcium carbonate) D) Tylenol liquid (acetaminophen

the charge nurse in an extended care facility is organizing unit activities for.....delegated to the practical nurse? A. Measure the client's body weight each morning B. Establish blood pressure parameters for client monitoring C. Evaluate a staff member providing wound care D. Evaluate client teaching through return demonstration

the lab findings for a client with chronic kidney disease (CKD) include elevated.... and serum creatinine levels. the client reports feeling fatigued and is unable to conce.... assessments. based on these findings, which action should the nurse implement? A. Provide high-protein snacks B. Administer PRN Oxygen C. Schedule frequent rest periods D. Monitor glucose levels q4 hours

the nurse identifies an electrolyte imbalance, crackles on auscultation.....with progressive heart disease. which intervention should the nurse implement? A. Measure the ankle circumference B. Record usual eating patterns C. Evaluate for muscle cramping D. Docuemnt abdominal girth

the nurse includes assessment for fat embolism syndrome in the....femur. which findings should the nurse include that are often the earlier signs? A. confusion, restlessness B. Petechial rash C. tachycardia, fever D. Pulmonary crackles

the nurse is assessing a 4 yo child with eczema. the child's skin is dry and scaly, and the mother reports..... of causing bleeding. which guideline is indicated for the care of this child? A. Keep the nails trimmed short B. Apply baby lotion too. the skin twice daily C. Bathe the. child. daily with bath oil D. ALlow the child to wear only 100% cotton clothing

what is the priority nursing action when initiating morphine therapy via an analgesia (PCA) pump? A. Initiate the dosage lockout mechanism on the PCA B. Assess the client's ability to use a numeric pain scale C. Assess the abdomen for bowel sounds D. Instruct the client to use the medication before the ....

which does snack selection indicate to the nurse that a school-age boy with gastritis ... dietary restrictions? A. sugar cookies B. PIzza C. Chocolate milkshake D. Tacos

which instruction should the nurse provide a pregnant client who is complaining of heartburn? A. Eat small meals throughout the day to avoid a full stomach B. Take an antacid at bedtime and whenever symptoms worsen C. Maintaining a sitting position for two hours after eating D. Limit fluids between meals to avoid overdistention of

A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit. C) Cervical dilation of 4 D) BP 138/88

A) FHT 168 beats/min

Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? A) "You look upset. Would you like to talk about it?" B) "I'd like to know more about your family. Tell me about them." C) "I understand that you lost your partner. I don't think I could go on if that happened to me." D) "You look very sad. How long have you been this way?"

A) "You look upset. Would you like to talk about it?"

A client who has a belief based in Hinduism is nearing death. The nurse should plan for which action? A) After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client's wrist B) The elders may be with the client during the process of the client dying and no last rites are given C) The family must be with the client during the process of dying and be the only ones to wash the body after death D) The body is ritually cleansed and burial is to be as soon as possible after the death occurs

A) After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client's wrist

A) Apply suction for no more than 10 seconds

A mother calls the hospital hot line and is connected to the triage nurse. The mother proclaims: "I found my child with odd stuff coming from the mouth and an unmarked bottle nearby." Which of these comments would be the best for the nurse to ask the mother to determine if the child has swallowed a corrosive substance? A) Ask the child if the mouth is burning or throat pain is present B) Take the child's pulse at the wrist and see if the child is has trouble breathing lying flat. C) What color is the child's lips and nails and has the child voided today? D) Has the child had vomiting or diarrhea or stomach cramps yet?

A) Ask the child if the mouth is burning or throat pain is present

An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be A) Assess the severity and location of the pain B) Obtain an order for an analgesic C) Reassure him that this is not unusual for his age D) Encourage him to increase his activity

A) Assess the severity and location of the pain

The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for a gastrostomy tube placement, the priority is to A) Auscultate the abdomen while instilling 10 cc of air into the tube B) Place the end of the tube in water to check for air bubbles C) Retract the tube several inches to check for resistance D) Measure the length of tubing from nose to epigastrium

A) Auscultate the abdomen while instilling 10 cc of air into the tube

The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? A) Avoid chocolate and cheese B) Take frequent naps C) Take the medication with milk D) Avoid walking without assistance

A) Avoid chocolate and cheese

A) Can predispose to dysrhythmias

A) Exercise doing weight bearing activities

Which approach is the best way to prevent infections when providing care to clients in the home setting? A) Hand washing before and after examination of clients B) Wearing non powdered latex free gloves to examine the client C) Using a barrier between the client's furniture and the nurse's bag D) Wearing a mask with a shield during any eye/mouth/nose examination

A) Hand washing before and after examination of clients

The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication? A) Non-steroidal anti-inflammatory drugs B) Cough medicines with guaifenesin C) Histamine blockers D) Laxatives containing magnesium salts

A) Non-steroidal anti-inflammatory drugs

A) Normal patterns of behavior may be labeled as deviant, immoral, or insane

A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? A) Notify the health care provider B) Readjust the traction C) Administer the ordered prn medication D) Reassess the foot in fifteen minutes

A) Notify the health care provider

A client with diarrhea should avoid which of the following? A) Orange juice B) Tuna C) Eggs D) Macaroni

A) Orange juice

A) Orthostatic hypotension is a common side effect

A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? A) Protamine B) Amicar C) Imferon D) Diltiazem

A) Protamine

A) S3 ventricular gallop

A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right wil the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees

A) Side-lying on the left with the head elevated 10 degrees

A) Stay with client and observe for airway obstruction

The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Report any client complaint of pain or discomfort B. Evaluate the client for sleep disturbances C. Assess the client for weakness and fatigue D. Weigh the client and report any weight gain E. Note and report the client's food and liquid intake during meals and snacks.

A, D, E

A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B) This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. D)The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.

A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.

During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? A) Wash hands thoroughly before and after client contact B) Wear gloves when in contact with body secretions C) Double glove when in contact with feces or vomitus D) Wear gloves when disposing of contaminated linens

A) Wash hands thoroughly before and after client contact

A) administer the medication in 2 separate injections

61-An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? (Select all that apply) A) Teach client to use incentive spirometer q2 while awake B) Remove urinary catheter as soon as possible and encourage voiding C)Maintain sequential compression devices while in bed D) Administer low molecular weight heparin as prescribed E) Assess pain level and medicate PRN as prescribed

A, B

A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the healthcare provider has prescribed all these medications. Which information should the nurse included when responding to this client? (Select all that apply.) A) One of the medications is used to anesthetize the corneal surface B) Pupillary dilation is necessary to access the eye chamber for lens removal C) The iris must be paralyzed during surgery to prevent it from reacting to light D) A medication is used to induce sleep during the procedure E) These medications assist in obstructing client ́s vision during the surgery

A, B, C

The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three days ago. The client plans to live with a family member Which actions should the nurse implement? (Select all that apply). A. Teach care of ostomy to care provider B. Assess the client for self ability C. Provide pain medication instructions D. Request a home safety inspection E. Call home care agency to set up oxygen

A, B, C

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective sign of depression? (Select all that apply) A) Interacts with a flat affect B) Avoids eye contact C) Reduce rate of intravenous fluid infusion D) Report feeling sad E) Expresses suicidal thoughts

A, B, C

Two days prior to discharge from the rehabilitation facility, the nurse is teaching a client who is recovering from Guillain-Barre syndrome about home. Which actions should the nurse include when providing discharge teaching to the client and spouse? (Select all that apply) A. Review safe transfer strategies B. Develop a nutritional plan C. Help identify community support D. Initiate a rigorous exercise routine E. Provide cooking instruction

A, B, C

A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (Rank the first action and the top with the remainder in descending order.) A. Observe breathing patterns B. Assess blood pressure C. Measure body temperature D. Palpate for pedal edema

A, B, C, D

An older adult male reporting abdominal pain is admitted to the hospital from a long-term care facility. It has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150mL of dark brown emesis. In what order should the nurse implement these interventions? (Highest to lowest priority) A. Send emesis sample to the lab B. Elevate the head of the bed C. Complete focused assessment D. Offer PRN pain medication

A, B, C, D

the nurse provides sliding scale insulin administration instructions to an.....diabetes. the client demonstrates an understanding of the intructions... procedure in which order? (select all) A. obtain blood glucose level B. verify insulin prescription. C. draw insulin into insulin syringe D. cleanse the selected site

A, B, C, D

an adult woman who was recently diagnosed with type II DM. the client is 5 foot 2 inches....in planning nutrition teaching for this client, what should the nurse recommend? (select all) A. Decrease processed carbohydrates in the diet B. Eliminate alcohol intake except for special. occasions C. Restrict protein to 10 % of total calories in the diet D. Increase dietary fiber such as whole grains E. Reduce daily fat intake to 10% of total calories

A,B, D

An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. Which actions should the nurse take? (Select all that apply) A. Encourage increased intake of high protein foods B. Instruct the daughter to check her mother;s temperature C. Review the client's current food and mediation allergies D. Ask if the mother is experiencing any pain with urination E. Determine if the mother has recently experienced a fall.

A, B, D

While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? (Select all that apply). A) Provide supplemental oxygen B) Auscultate bilateral lung fields C) Administer a nebulizer treatment D) Reinforce occlusive CT dressing E) Give PRN dose of pain medication

A, B, D

A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which interventions should the nurse implement? (Select all that apply) A) Give the client 4 ounces of orange juice B) Obtain blood pressure and pulse rate C) Provide the client with 1⁄2 cup diet carbonated soda D) Administer a PRN dose of regular insulin E) Check the client's current finger stick blood glucose

A, B, E

A client who is hospitalized and recently is now confused and lethargic. Which actions should the nurse implement? (Select all that apply) A) Measure capillary glucose level B) Monitor cardiac telemetry pattern C) Reduce rate if intravenous fluid infussion D) Withhold next dose of corticosteroid E) Initiate fall risk precautions

A, B, E

the nurse is teaching a primigravida about preeclampsia. which findings...should be reports to the HCP? (select all) A. Blurred vision B. Headache C. Lack of appetite D. Urinary frequency E. Chills and fever F. Swollen. hands

A, B, F

141. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply). A) Practice relaxation exercises B) Limit fluids to avoid bladder distention C) Space activities to allow for rest periods D) Avoid persons with infections E) Take warm baths before starting exercise

A, C, D

A client with Type I diabetes mellitus and a large draining ulcer of the right foot is admitted with a suspected Staphylococcus aureus infection. Which interventions should the nurse implement? (Select all that apply) A. Monitor the client's white blood cell count B. Explain the purpose of a low bacteria diet C. Send wound drainage for culture and sensitivity D. Institute contact precautions for staff and visitors E. Use standard precautions and wear a mask

A, C, D

when conducting diet teaching for a client who was diagnosed with HTN, which foods should the nurse encourage the client to eat? (select all) A. Fruits without sauce B. Canned soup C. Fresh or frozen vegetables without sauce D. Cottage cheese E. pickled olives

A, C, D

a client with a history of schizophrenia is admitted with Diabetic ketoacidosis (DKA)... should the nurse implement this during the admission process for this client? (select all) A. Obtain psychiatric and medical admission records B. Hold prescription. medications until glucose is regulated C. Interview the client about the reason for admission to the hospital D. Prepare the client for involuntary commitment admission E. Review the list of home medications and dosages

A, C, E.

An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) A) Administer a daily dose of lisinopril as scheduled. B) Assess the client for postural hypotension. C) Notify the healthcare provider immediately D) Provide a PRN dose of acetaminophen for headache E) Withhold the next scheduled daily dose of warfarin

A, D

An older adult client admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.) A) Measure neurological vital signs every 4 hours B) Place a bedside commode next to the bed C) Suction oral cavity every 4 hours D) Encourage family to participate in the client's care E) Play classical music room while client is awake

A, D, E

An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CAV). Which interventions should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.) A) Measure neurological vital signs every 4 hours B) Place a bed side commode next to bed C) Suction oral cavity every 4 hours. D) Encourage family participate in the client's care E) Play classical music in room while client is awake

A, D, E

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action should the nurse assign to the PN? (Select all that apply) A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). B. Start the second blood transfusion for a client twelve hours following a below the knee amputation C. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperatively D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy E. Obtain postoperative vital signs for a client one day following unilateral arthroplasty.

A, D, E

A client with cirrhosis of the liver is admitted with complications related to end-stage liver disease. Which intervention should the nurse implement? (Select all that apply) A. Report serum albumin and globulin levels B. Provide diet low in phosphorus C. Note signs of swelling in edema D. Monitor abdominal girthE Increase oral fluid intake to 1500 mL daily

A,C,D

Following mitral valve replacement surgery a client develops PVC's. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc's of D5W. The infusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/ minute? A) 60 microdrops/minute B) 20 microdrops/minute C) 30 microdrops/minute D) 40 microdrops/minute

A. 60 microdrops/minute Rationale: 2 gm=2000 mgm2000 mgm/500 cc = 4 mgm/x cc 2000x = 2000 x= 2000/2000 = 1 cc of IV solution/minute CC x 60 microdrops = 60 microdrops/minute

he nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be A) Reduce fear and protect self-esteem B) Minimize anxiety and delay apprehension C) Avoid conflict and leave unpleasant situations D) Increase independence and communicate more often

A. Reduce fear and protect self-esteem

A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse? A) Ask the client if he has noticed any bleeding or dark stools B) Tell the client to call 911 and go to the emergency department immediately C) Schedule a repeat Hemoglobin and Hematocrit in 1 month D) Tell the client to schedule an appointment with a hematologist

A. Ask the client if he has noticed any bleeding or dark stools

A child with Tetralogy of Fallot visits the clinic several weeks before planned surgery. The nurse should give priority attention to A) Assessment of oxygenation B) Observation for developmental delays C) Prevention of infection D) Maintenance of adequate nutrition

A. Assessment of oxygenation

The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed? A) Extreme fatigue B) Increased appetite C) Intense itching D) Constipation

A. Extreme fatigue

A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client A) Has increased airway obstruction B) Has improved airway obstruction C) Needs to be suctioned D) Exhibits hyperventilation

A. Has increased airway obstruction

37. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate? A) Unequal leg length B) Limited adduction C) Diminished femoral pulses D) Symmetrical gluteal folds

A. Unequal leg length

A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs? A) Weight gain of 2 pounds or more in a 48 hour period B) Urinating 4 to 5 times each day C) A significant decrease in appetite D) Appearance of non-pitting ankle edema

A. Weight gain of 2 pounds or more in a 48 hour period

A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg the nurse calculates infusion rate for the heparin solution at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to how many mL/hour?

ANWER: 18 -1st we calculate the weight weight = 220 divided by 2.2 =100kg -then we calculate total dose in units dose=18 units/hr -we use the reference to. get the final anwer 25000 units----in 250mL 1800 units -----in X mL X=1800* 250/25000=18

Today's prothrombin time for a client receiving Coumadin is 20 (normal range listed by the lab is 10-14). What is the appropriate nursing action? A) Notify the health care provider immediately B) Recognize that this is a therapeutic level C) Observe the client for hematoma development D) Assess for bleeding at gums or IV sites

A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering A) Pulmonary embolectomy B) Vena caval interruption C) Increasing the coumadin therapy to an INR of 3-4 D) Thrombolytic therapy

A client is being discharged home today, and will be taking K-dur 20mEq per day by mouth. The nurse should reinforce that potassium levels will be decreased by A) foods seasoned with salt substitute B) frequent daily snacks of black licorice C) prescribed potassium-sparing diuretics D) occasional use of a non steroidal anti-inflammatory drug (NSAID)

. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis and communicated? A) "My partner's breathing rate is usually below 12." B) "I find the mood swings and the change from a calm person to being angry all the time hard to deal with." C) "It seems our sex life is non-existant over the past 6 months." D) "In the morning and evening I hear complaints that reading is next to impossible from blurred print."

A 2 year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement? A) Place the child on clear liquids and gelatin for 24 hours B) Continue with the regular diet and include oral rehydration fluids C) Give bananas, apples, rice and toast as tolerated D) Place NPO for 24 hours, then rehydrate with milk and water

A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client's greatest risk factors for osteoporosis? A) Menopause at age 50 B) Has taken high doses of steroids for arthritis for many years C) Maintains an inactive lifestyle for the past 10 years D) Drinks 2 glasses of red wine each day for the past 30 years

A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to A) Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes B) Ask the client what foods are acceptable or bad C) Encourage her to eat for healing and strength D) Schedule the dietitian to meet with the client as soon as possible

A child is sent to the school nurse by a teacher who has a written note that Fifth's disease is suspected. Which characteristic would the nurse expect to find? A) Macule that rapidly progresses to papule and then vesicles B) Erythema on the face, primarily on cheeks giving a "slapped face" appearance C) Discrete rose pink macules will appear first on the trunk and fade when pressure is applied D) Kopeck spots appear first followed by a rash that appears first on the face and spreads downward

A client complains of some discomfort after a below the knee amputation. Which action by the nurse is appropriate to do initially? A) Conduct guided imagery or distraction B) Ensure that the stump is elevated for the initial day C) Wrap the stump snugly in an elastic bandage D) Administer opioid narcotics as ordered

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? A. Esinopril B. Allopurinol C. Furosemide D. Aspirin, low dose

A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority? A) Maintaining proper body alignment B) Frequent neurovascular assessments of the affected leg C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to assist the client with movement in bed

A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care? A) Altered nutrition: less than body requirements B) Potential complication hemorrhage C) Ineffective individual coping D) Fluid volume excess

A client has just returned from the Post-Anesthesia Care Unit (PACU) to the surgical unit after a cholecystectomy. When initial vital signs are taken the nurse notes a temperature of 94.8 degrees Fahrenheit. Which first nursing action is appropriate? A) Continue to monitor the vital signs as indicated B) Apply a warm blanket and check the temperature in 10 minutesC ) Ask the PACU nurse more details of what happened in PACU D) Call the health care provider and obtain further orders for warming

A client is admitted to a psychiatric unit with delusions. What findings can the nurse expect? A) Flight of ideas and hyperactivity B) Suspiciousness and resistance to therapy C) Anorexia and hopelessness D) Panic and multiple physical complaints

A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? A) Dyspnea B) Heart murmur C) Macular rash D) Hemorrhage

A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect in assessing this client? A) Hyperextension of the neck with passive shoulder flexion B) Flexion of the hip and knees with passive flexion of the neck C) Flexion of the legs with rebound tenderness D) Hyper flexion of the neck with rebound flexion of the legs

A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client complains of pain at the right groin insertion site. What action should the nurse implement A. Check femoral site for hematuria formation B. Stimulate the client to take deep breaths C. Evaluate the integrity of the IV insertion site D. Assess distal lower extremity capillary refill

A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicate a potential hazard for this test? A) Reflex incontinence B) Allergic to shellfish C) Claustrophobia D) Hypertension

A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take? A) Report the behavior to the charge nurse B) Talk with the client to find out about the preferred herbal preparation C) Contact the client's health care provider D) Explain the importance of the medication to the client

A client who experienced a cerebrovascular accident ( CVA ) is aphasic and has left sided paralysis . Which nurse should be responsible for coordinating the progression of this client's care A. Nurse case manager B. Adult nurse practitioner C. Neurology unit supervisor D. Risk management nurse

A client who is admitted to the intensive care unit with the syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? A. Patch one eye B. Evaluate swallow C. Reorient often D. Range of ocean

A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? A) Comatose, breathing unlabored B) Glascow Coma Scale 8, respirations regular C) Appears to be sleeping, vital signs stable D) Glascow Coma Scale 13, no ventilator required

A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client admission plan of care? A. Assess for symptoms of AIDS dementia B. Monitor for secondary infections C. Identify local support HIV support groups D. Observe for adverse drug reactions

A client with angina has been instructed about the use of sublingual nitroglycerin. Which of the following statements made to the nurse indicates a need for further teaching? A) "I will rest briefly right after taking 1 tablet." B) "I can take 2-3 tablets at once if I have severe pain." C) "I'll call the doctor if pain continues after 3 tablets 5 minutes apart." D) "I understand that the medication should be kept in the dark bottle."

A client with cervical cancer is hospitalized for the insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? A. Apply double gloves to retrieve the implant for disposal B. Place the implant in a lead container using long-handled forceps C. Reinsert the implant into the vagina D. Call the radiology department

A client with chronic kidney disease has an arteriovenous ( AV ) fistula in the left forearm . Which observation by the nurse indicates that the fistula is patent? A. Assessment of a bruit on the left forearm B. Auscultation of a thrill on the left forearm C. The left radial pulse is 2+ bounding D. Distended, tortuous veins in the left hand

A client with diabetes has a blood sugar is 306 this morning. After the nurse reports this lab result and the client's symptoms of excessive hunger and thirst, what would the nurse expect the health care provider to order? A) Orange juiceB ) Regular insulin C) NPH Insulin D) Repeat blood sugar level

A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client A) Eat foods high in sodium increases sputum liquefaction B) Use oxygen during meals improves gas exchange C) Perform exercise after respiratory therapy enhances appetite D) Cleanse the mouth of dried secretions reduces risk of infection

A male client approaches the nurse with an angry expression on his face and raises his voice, saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!" the nurse recognizes that the client is using which defense mechanism? A. Splitting B. Projection C. Rationalization D. Denial

A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Restlessness and increased mucus production C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor

A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial temperature is 35 degrees Celsius (95 degrees Fahrenheit) axillary. The nurse recognizes that cold stress may lead to what complication? A) Lowered BMR B) Reduced PaO2 C) Lethargy D) Metabolic alkalosis

A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolate. Which action is a nursing priority? A) Protect the eyes of the neonate from the heat lamp B) Monitor the neonate's temperature C) Warm all medications and liquids before giving D) Avoid touching the neonate with cold hands

A newly admitted elderly client is severely dehydrated. When planningcare for this client, which task is appropriate to assign to an unlicensed assistivepersonnel (UAP)? A) Converse with the client to determine if the mucous membranes are impaired B) Report hourly outputs of less than 30 ml/hr C) Monitor client's ability for movement in the bed D) Check skin turgor every 4 hours

A nurse administers the influenza vaccine to a client in a clinic. Within15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to. A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered

A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning? A) 9 month-old who stays with a sitter 5 days a week B) 20 month-old who has just learned to climb stairs C) 10 year-old who occasionally stays at home unattended D) 15 year-old who likes to repair bicycles

A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the A) Yang, the positive force that represents light, warmth, and fullness B) Yin, the negative force that represents darkness, cold, and emptiness C) Use of improper hot foods, herbs and plants D) A failure to keep life in balance with nature and others

A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? A) Why don't we now have the client turn back to the left side. B) That was done correctly. Did you have any problems with the insertion? C) Let's check to see if the suppository is in far enough. D) Did you feel any stool in the intestinal tract?

A nurse receives report on a client who is four hours port-total abdominal hysterectomy. The previous nurse reports that it was necessary to change the client's perineal pad hourly, and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first? A. Evaluate the skin turgor B. Assess weakness dizziness C. Change the perineal pad D. Measure the urinary output

A nurse working on an Endocrine Unit should see which client first ? A. An older client with addison's disease whose current blood sugar level is 62 mg/dL (3.44 mmol) B. A client taking corticosteroids who has become disoriented in the last two hours C. An adolescent male with type 1 diabetes who is arguing about his insulin dose D. An adult with a blood sugar of 384 mg/dL (21.31 mmol/L) and a urine output of 35 mL in the last hour

A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus? A) Discuss with the mother sharing parenting responsibilities B) Set time aside to get the mother to express her feelings and concerns C) Arrange for the parents to attend infant care classes D) Talk with the father and help him accept the wife's decision

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take? A. Develop a water safety teaching plan for the family B. Ask the older brother how he felt during the incident C. Tell the older brother that he seems depressed D. Commend the older brother for his heroic actions

An RN from the women's health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse? A) A newly diagnosed client with type 2 diabetes mellitus who is learning foot care B) A client from a motor vehicle accident with an external fixation device on the leg C) A client admitted for a barium swallow after a transient ischemic attack D) A newly admitted client with a diagnosis of pancreatic cancer

An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse? A. Gather information regarding how long it will take for the children to arrive B. Explain that the client will start to lose consciousness and the body systems will slow down .C. Reassure the spouse that the healthcare provider will notify when to call the children. D. Offer to discuss the client's health status with each of the adult children.

An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask? A) "Have you had a recent heart attack?" B) "Do you become short of breath during your normal dailyactivities?" C) "How many pillows do you use at night to sleep comfortably?" D) "Do you smoke?"

An eighteen month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of A) Septicemia B) Dehydration C) Hypokalemia D) Hypercalcemia

An older adult client with systemic inflammatory syndrome (SIRS) has a temperature of 101.8 F ( 38.8 C ), heart rate of 110 beats/minute, respiratory rate of 24 breaths/minute. Which additional finding is most important to report to the healthcare provider? A. Capillary glucose reading of 11- mg/dL (6.1 mmol/L SI) B. Serum creatinine of 2.0 mg/dL (176.8 mmol/L SI) C. Blood pressure of 130/99 mm Hg D. Hemoglobin of 12 g/dL (120 g/L SI)

An older adult who is in his early 70s is admitted to the emergency department because of a COPD exacerbation. The client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the client's living well. Which action should the nurse take? A. Facilitate a family meeting with the palliative care team B. Notify the healthcare provider of the clients wishes C. Place a certified copy of the living well in the client's room D. Alert the nursing staff of the clients do not resuscitate status

An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart failure (HF) arrives in the emergency department (ED) in the respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expect in the clients acute HF? A. Increased cardiac contractility B. Reduced preload C. Relaxed vascular tone D. Decreased afterload

An unlicensed assistive personnel (UAP) is assigned to ambulate a client with influenza who has a droplet precautions implemented. The UAP requests a change in assignment, stating the reason of having not been fitted yet for a N95 respirator mask. Which action should the nurse take? A. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client B. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client C. Before changing assignments, determine which staff members have fitted particulate filter masks D. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care.

At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity? A) "I give my insulin to myself in my thighs." B) "Sometimes when I put my shoes on I don't know where my toes are." C) "Here are my up and down glucose readings that I wrote on my calendar." D) "If I bathe more than once a week my skin feels too dry."

At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates A) Feelings of increasing anxiety related to paranoia B) Social isolation related to altered thought processes C) Sensory perceptual alteration related to withdrawal from environment D) Impaired verbal communication related to impaired judgment

Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? A) Sedative hypnotics are effective analgesics B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares C) Caffeine beverages can increase the effect of sedative hypnotics D) Avoidance of excessive exercise and high temperature is recommended

During the evaluation phase for a client, the nurse should focus on A) All finding of physical and psychosocial stressors of the client and in the family B) The client's status, progress toward goal achievement, and ongoing re-evaluation C) Setting short and long-term goals to insure continuity of care from hospital to home D) Select interventions that are measurable and achievable within selected timeframes

During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence? A) What degree of supervision for basic care do you think you need? B) Let's review your skills check-list for type and level of skill. C) Are you comfortable working independently? D) What client care tasks or assignments do you prefer?

Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about A) Mental development delays B) Evil eye or envy of others C) Fright from spiritual beings D) Balance in body systems

Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner's injuries by A) Seeking medical help for the victim's injuries B) Minimizing the episode and underestimating the victim's injuries C) Contacting a close friend and asking for help D) Being very remorseful and assisting the victim with medical care

In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and A) Increased retention of albumin in the vascular system B) Decreased colloidal osmotic pressure in the capillaries C) Fluid shift from interstitial spaces into the vascular space D) Reduced tubular reabsorption of sodium and water

One reason that domestic violence remains extensively undetected is A) Few battered victims seek medical care B) There is typically a series of minor, vague complaints C) Expenses due to police and court costs are prohibitive D) Very little knowledge is currently known about batterers and battering relationships

Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice? A) When a family member offers information about their loved one B) When the client threatens self-harm and harm to others C) When the health care provider decides the family has a right to know the client's diagnosis D) When a visitor insists that the visitor has been given permission by the client

The charge nurse on a cardiac step-down unit makes assignments for the team consisting of an RN, a PN, and an unlicensed assistive person. Which client should be assigned to the PN? A) A 49 year-old with new onset atrial fibrillation with a rapid ventricular response B) A 58 year-old hypertensive with possible angina. C) A 35 year-old scheduled for cardiac catheterization. D) A 65 year-old for discharge after angioplasty and stent placement.

The client with amyotrophic lateral sclerosis is scheduled for 160 ml of enteral feeding as a bolus every 4 hours. Before flushing with water the nurse aspirates the feeding tube contents and gets back 180 ml of feeding. What is the next appropriate nursing action? A) Administer the feeding as ordered B) Hold the next feeding C) Flush with sterile water D) Discard the undigested feeding

The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? A) "Do not worry. Epilepsy can be treated with medications." B) "The seizure may or may not mean your child has epilepsy." C) "Since this was the first convulsion, it may not happen again." D) "Long term treatment will prevent future seizures."

The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children? A) Growth problems will occur if the fracture involves the periosteum B) Epiphyseal fractures often interrupt a child's normal growth pattern C) Children usually heal very quickly, so growth problems are rare D) Adequate blood supply to the bone prevents growth delay after fractures

The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? A) Ask the client and family if they are satisfied with the care given B) Determine if the home health aide's care is consistent with the plan of care C) Investigate if the home health aide is prompt and stays an appropriate length of time for care D) Check the documentation of the aide for appropriateness and comprehensiveness

The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to A) Maintain adequate hydration B) Assist client to turn, deep breathe, and cough C) Ambulate client within 12 hours D) Splint incision

The mother of a 15 month-old child asks the nurse to explain her child's lab results and how they show her child has iron deficiency anemia. The nurse's best response is A) "Although the results are here, your doctor will explain them later." B) "Your child has less red blood cells that carry oxygen." C) "The blood cells that carry nutrients to the cells are too large." D) "There are not enough blood cells in your child's circulation."

The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months B) Whole milk is difficult for a young infant to digest C) Fluoridated tap water should be used to dilute milk D) Supplemental apple juice can be used between feedings

The mother of a toddler who is being treated for pesticide poisoning asks: "Why is activated charcoal used? What does it do?" What is the nurse's best response? A) "Activated charcoal decreases the systemic absorption of the poison from thestomach." B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child." C) "This substance helps to get the poison out of the body by the gastrointestinal system." D) "The action may bind or inactivate the toxins or irritants that are ingested by childrenor adults."

The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? A) "The injury is expected to heal quickly because of thin periosteum." B) "In some instancesthe resultis a retarded bone growth." C) "Bone growth is stimulated in the affected leg." D) "This type of injury shows more rapid union than that of younger children."

The nurse admitting a 5 month-old who vomited 9 times in the past 6hours should observe for signs of which overall imbalance? A) Metabolic acidosis B) Metabolic alkalosis C) Some increase in the serum hemoglobin D) A little decrease in the serum potassium

The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide to the unlicensed assistive personnel (UAP) who is working with the nurse? A. Notify the nurse when the transfusion has finished B. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately D. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion

The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP? A) Report signs of redness overlying a joint B) Monitor the client's response to ambulatory activity C) Encouragement for the independence in self-care D) Assist the client to transfer from a bed to a chair

The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which finding is most likely to occur? A) Chest pain B) Peripheral edema C) Nail clubbing D) Lethargy

The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, what must the nurse understand about adolescents with hemophilia? A) Must have structured activities B) Often take part in active sports C) Explain limitations to peer groups D) Avoid risks after bleeding episodes

The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? A) Our child had chickenpox 6 months ago. B) Strep throat went through all the children at the day care last month. C) Both ears were infected over 3 months age. D) Last week both feet had a fungal skin infection

The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? A) "We will call the health care provider if the child develops acne." B) "Our child should brush and floss carefully after every meal." C) "We will skip the next dose if vomiting or fever occur." D) "When our child is seizure-free for 6 months, we can stop the medication."

The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately? A) Prolonged inspiration with each breath B) Expiratory wheezes that are suddenly absent in 1 lobe C) Expectoration of large amounts of purulent mucous D) Appearance of the use of abdominal muscles for breathingThe nurse isteaching a newly diagnosed asthma client on how touse a peak flow meter. The nurse explains that this should be used to A) Determine oxygen saturation B) Measure forced expiratory volume C) Monitor atmosphere for presence of allergens D) Provide metered doses for inhaled bronchodilator

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery . Which action should the implement immediately A. Change the dressing using a compression bandage B. Test the fluid on the dressing for glucose C. Document the findings in the electronic medical record D. Mark the drainage area with a pen and continue to monitor

The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. What is the physiological basis for this instruction? A) Retards pepsin production B) Stimulates hydrochloric acid production C) Slows stomach emptying time D) Decreases production of hydrochloric acid

The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? A) Decreased cardiac output B) Tissue hypoxia C) Cerebral edema D) Reduced oxygen saturation

The nurse is assessing a client who has taken haldol (Haloperidol) for several months. Which of the following is a side effect of this medication and must be reported immediately to the health care provider? A) Muscle flaccidity B) Dystonic reaction C) Mood swings D) Dry, harsh cough

The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first? A) Take the client's vital signs B) Place the client in a sitting position with legs dangling C) Contact the health care provider D) Administer the PRN anti anxiety agent

The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition? A) Skin irritation B) Drug tolerance C) Severe headaches D) Postural hypotension

The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization? A) Younger siblings adapt very well B) Visitation is helpful for both C) The siblings may enjoy privacy D) Those cared for at home cope better

The nurse is caring for a child receiving albuterol (Proventil) for asthma. The parents ask the nurse why their child is receiving this medication. Which explanation is correct? A) decrease the swelling in the airways." B) relax the smooth muscles in the airways." C) reduce the secretions blocking the airways." D) stimulate the respiratory center in the brain that control respirations."

The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first? A. Review medical records to obtain pain tolerance expectations B. Attempt to obtain a self-report of pain level from the client C. Provide the first medication prescribed for pain management D. Wait until the client is awake before providing pain management

The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience A) High fever B) Nausea C) Face and neck edema D) Night sweats

The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care? A) Increase fluid intake to prevent dehydration B) Place client on a pressure reducing support surface C) Use skin care products designed for use with incontinence D) Increase caloric intake to aid healing

The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that A) The client should remain on bed rest in a semi-Fowler's position B) The client should alternate ambulation with bed rest with legs elevated C) The client may ambulate and sit in chair as tolerated D) The client may ambulate as tolerated and remain in semi-Fowler position in bed

The nurse is caring for a client with heart failure . Which method is used in computing the cardiac index to measure how the client's heart is functioning? A. Mean arterial pressure minus right atrial pressure B. Cardiac output divided by body surface area C. Stroke volume divided by end diastolic volume D. Stroke volume multiplied by heart rate

The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown? A) Massage legs frequently B) Frequent turning C) Moisten skin with lotions D) Apply moist heat to reddened areas

The nurse is completing the admission assessment of a 3-year-old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)? A. Tachycardia and tachypnea B. Sluggish and unequal papillary response C. Increased head circumference and bulging fontanels D. Blood pressure fluctuations and syncope

The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend A. Apply a gait belt around the client's waist once a standing position has been assumed B. Place the client's locked wheelchair on the client's strong side next to the bed C. Pull the client into position by reaching from the opposite side of the bed D. Hold the client at arms length while transferring to better distribute the body weight

The nurse is evaluating the chest drainage system of a with a chest tube inserted to treat a left hemothorax Which finding requires intervention by the nurse? A. Rise and fall of water level with respiration B. Continuous bubbling in the water-seal chamber C. Total fluid level in the water-seal chamber unchanged D. An average collection of 50 mL/hr drainage

The nurse is evaluating the teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendations? A. Grilled steak, baked potato with sour cream, green beans, coffee, and raisin cream pie B. Baked pork chop, applesauce, corn on the cob, 1% milk, and key lime pie C. Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon meringue pie D. Beef stir fry, fried rice, egg drop soup, diet soda, and pumpkin pie

The nurse is inserting a Foley catheter into the bladder of a female adult client. The nurse slips the catheter into an opening for four-5 inches and no urine is obtained. The most probable reason for this isthat A) there is no urine present in the bladder B) the catheter is in the vagina C) the catheter is not inserted in far enough D) the bladder is over distended

The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best? A) Fish sticks, french-fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) Peanut butter and jelly sandwich, apple slices, milk

The nurse is planning care for an 18 month-old child. Which action should be included in the child's care? A) Hold and cuddle the child frequently B) Encourage the child to feed himself finger food C) Allow the child to walk independently on the nursing unit D) Engage the child in games with other children

The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would be best to prepare the child? A) Introduce the child to all staff the day before surgery B) Explain the surgery 1 week prior to the procedure C) Arrange a tour of the operating and recovery rooms D) Encourage the child to bring a favorite toy to the hospital

The nurse is preparing a client for discharge following in-patient treatment for pulmonary tuberculosis. Which of these instructions should be given to the client? A) Continue medication until findings are relieved B) Continue medication use as prescribed C) Avoid contact with children, pregnant women or immune depressed persons D) Take medication with Amphogel if epigastric distress occurs

The nurse is providing discharge teaching to the parents of a 13 month old child who underwent repair for an atrial septal defect. The healthcare provider prescribes aspirin and an antibiotic for the first 6 months postoperatively to prevent infective endocarditis (IE). What information is most important for the nurse to discuss with the parents about the child's recovery and prevention of IE? A. Refer the mother to the healthcare provider to discuss infective endocarditis B. Brush the child's teeth every day and ensure the child receives regular dental followup C. Give the child acetaminophen for pain or fever and visit the surgeon for followup D. Monitor the child for regular bowel movements and urine output that exceeds intake

B) Jugular vein distention

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress . In addition to information about prescribed medication and administration , which instruction should the nurse include in the teaching? A. Find outlets for more social interaction B. Practice using muscle relaxation techniques C. Center attention on positive upbeat music D. Think about reasons the episodes occur

The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis? A) Respiratory rate B) Peak air flow volumes C) Pulse oximetry D) Skin color

The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? A) Complete the entire course of the medication for an effective cure B) Begin treatment with acyclovir at the onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birthdefects D) Continue to take prophylactic doses for at least 5 years after the diagnosis

The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? A) Void a little, clean the meatus, then collect specimen B) clean the meatus, begin voiding, then catch urine stream C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urine

The nurse is teaching a client with asthma about the correct use of the Azmacort (triamcinolone) inhaler. Which of the following statements, if made by the client, would indicate that the teaching was effective? A) "The inhaler can be used whenever I feel short of breath." B) "I should rinse my mouth after using the inhaler." C) "If I forget a dose, I can double up on the next dose." D) I should not use a spacer with my Azmacort.

The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women? A) Low tar cigarettes are less harmful during pregnancy B) There is a relationship between smoking and low birth weight C) The placenta serves as a barrier to nicotine D) Moderate smoking is effective in weight control

The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication? A) Nebulized treatments for home care B) Adding a spacer device to the MDI canister C) Asking a family member to assist the client with the MDI D) Request a visiting nurse to follow the client at home

The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized? A) Call the Poison Control Center once the situation is identified B) Empty the child's mouth in any case of possible poisoning C) Have the child move minimally if a toxic substance was inhaled D) Do not induce vomiting if the poison is a hydrocarbon

The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medicationthe nurse should say A) "Please state your name?" Upon entering the room the nurse should ask: B) " What is your name? What allergies do you have?" then check the client's name band and allergy band As the room is entered say C) "What is your name?" then check the client's name band Verify the client's allergies on the admission sheet and order. D) "Verify the client's name on the name plate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?"

The nurse observes a practical nurse PN pouring warm water over the perennial area of a female client with frequent urinary incontinence while the client is positioned on a bedpan. What action should the nurse take? A. Recommend a complete bath to cleanse the perennial area more fully. B. Evaluate the effectiveness of this measure to stimulate client voiding. C. Instruct the PN that this technique promotes infection in elderly females. D. Suggest contacting the health care provider for a prescription for catheter insertion.

The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a priority? A) Limit fluids B) Client controlled analgesia C) Cold compresses to elbow D) Passive range of motion exercise

The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse's best response about the purpose of the Denver? A) It measures a child's intelligence. B) It assesses a child's development. C) It evaluates psychological responses. D) It helps to determine problems.

The nurse sees a substance abusing client occasionally in the outpatient clinic. In evaluating the client's progress, the nurse recognizes that the most revealing resistant behavior is A) Recurring crises B) Continuing drug use C) Rationalizing comments D) Missing appointments

The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? A) Seizures B) Withdrawal C) Craving D) Marked tolerance

Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activitiesshould the nurse assign to the UAP? A) Assist with plans for any clients discharged B) Provide basic hygiene care to all clients on the unit C) Assess a client after an acute myocardial infarction D) Gather the vital signs of all clients on the unit

Upon completing the admission documents, the nurse learns that the87 year-old client does not have an advance directive. What action should the nurse take? A) Record the information on the chart B) Give information about advance directives C) Assume that this client wishes a full code D) Refer this issue to the unit secretary

Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most likely explain these findings? A) Ingestion of tetracycline B) Excessive fluoride intake C) Oral iron therapy D) Poor dental hygiene

Well caring for a toddler receiving oxygen via facemask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A. Use a topical lidocaine analgesic for cracked lips B. Use a water-soluble lubricant on the affected oral and nasal mucosa C. Ask the mother what she usually uses on the child's lips and nose D. Apply petroleum jelly to the child's nose

What is the best way for the nurse to accomplish a health history on a 14 year-old client? A) Have the mother present to verify information B) Allow an opportunity for the teen to express feelings C) Use the same type of language as the adolescent D) Focus the discussion of risk factors in the peer group

What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements

What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero? A) The disease will incubate longer and progress more slowly in this infant B) The infant is very susceptible to infections C) Growth and development patterns will proceed at a normal rate D) Careful monitoring of renal function is indicated

When a client is having a general tonic clonic seizure, the nurse should A) Hold the client's arms at their side B) Place the client on their side C) Insert a padded tongue blade in client's mouth D) Elevate the head of the bed

When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula A) Every four to six hours B) Continuously C) In a bolus D) Every hour

When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the nurse would suggest for the parents to give sips of which substance? A) Tea B) Water C) Milk D) Soda

When providing client care the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important? A. Past experience with similar problems B. Relevance to the situation C. Related personal values D. Frequency that the problem occurs

When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection? A) Gonorrhea B) Chlamydia C) Herpes D) HIV

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy? A. Report any allergies to shellfish or iodine B. Report any painful urination, blood in urine, or fever C. Lay prone for 24 hours after the procedure D. Avoid strenuous activity and sports for at least two weeks

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)? A. Leukocytes, neutrophils, and thyroxine B. Serum potassium, calcium, and phosphorus C. Blood pressure, heart rate, and temperature D. Erythrocytes, hemoglobin, and hematocrit

Which of the following situations is most likely to produce sepsis in the neonate? A) Maternal diabetes B) Prolonged rupture of membranes C) Cesarean delivery D) Precipitous vaginal birth

Which of the following times is a depressed client at highest risk for attempting suicide? A) Immediately after admission, during one-to-one observation B) 7 to 14 days after initiation of antidepressant medication and psychotherapy C) Following an angry outburst with family D) When the client is removed from the security room

Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? A) An infant with intermittent bulging anterior fontanel between crying episodes B) A toddler with severe deep abrasions over 98% of the body C) A preschooler with 1 lower leg fracture and the other leg with an upperleg fracture D) A school-age child with singed eyebrows and hair on the arms

Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from aninduced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicleson an erythematous base that appear on the skin

Which of these clients would be appropriate to assign to a PN? A) A trauma victim with multiple lacerations and requires complex dressings. B) An elderly client with cystitis and an indwelling urethral catheter. C) A confused client whose family complains about the nursing care 2 days after surgery. D) A client admitted for possible transient ischemic attack with unstable neuro signs.

Which self-care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus? A. Self-injection technique B. Blood glucose monitoring C. Diabetic diet meal planning D. A realistic exercise plan

Which statement describes strategies that help build personal power in an organization? A) Longevity in an organization, social ties to people in power, and a history as someone who does not back down in conflict ends with success B) Goals are met with the use of networking, mentoring, and coalition building C) High visibility and formal power are maintained with a confrontational style D) Credibility to one's position is enhanced when professional dress and demeanor are employed

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider the nurse should review which of the client's laboratory values? A. Serum albumin B. Culture of sensitive organisms C. Serum blood glucose (BG) level D. Creatine level

While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior? A) Strange bed and surroundings B) Separation from parents C) Presence of other toddlers D) Unfamiliar toys and games

While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what otherbehavior? A) Sexual promiscuity B) Poor body image C) Dropping out of school D) Drug experimentation

a client is receiving IV heparin and oral warfarin after a Pulmonary embolism .. client's activated partial prothromboplastin time (aPTT) value is two times the normal... PT level is the same as the control and the INR.... prescription should the nurse implement? A. withhold the heparin and continue the same dose of warfarin. B. Increase the warfarin dose C. Decrease the heparin dose D. Increase the heparin dose and decrease the warfarin dose

a client who had bariatric surgery 2 months ago is admitted because of......liquids. the client is pain-free. which intervention should the nurse include? A. Determine if the client is over-hydrating and maintain to feel satiated. B. Maintain the client on an NPO status C. Encourage. positive self-accolades for dietary adherence D. Administer. daily vitamin supplemnets

a client with Atrial fibrillation receives a new prescription for dabigatran etexilate... for the nurse to emphasize when teaching the client about this medication? A. Monitor your blood pressure regularly B. Report unusual bruising or bleeding C. Elevate your feet if swelling occurs D. Check your pulse rate every day

a client with metabolic syndrome plans to begin an exercise program. what instructions should the nurse provide to the client? A. wear long sleeves and a hat when exercising outdoors in direct sunlight B. Monitor blood pressure and heart rate as exercise activities is increased C. Weight-bearing exercises are most effective in improving bone ... D. Use hand-held weights to strengthen. muscles and build muscle

a male client suffering from depression has been taking an antidepressant medication.... nurse that he is smiling more and feeling better. which response is best? A. " Feeling hopeful is a good sign that your depression is improving B. " Antidepressants usually begin to improve your mood after 2 to 3 days". C. " Antidepressants can cause mild mood swings within several days... D. " Antidepressants can stabilize your mood within several days"

a male client with right-sided weakness calls for assistance with ambulating.. which should the nurse implement? A. bring a bedside commode to the client B. Stand on the client's right side as he walks C. Walk directly behind the client to prevent a fall D. Give the client a cane to hold in his right hand

a multiparous client who delivered her infant 3 hours ago asks the nurse....because it helped reduce perineal pain after her last delivery. what action should the nurse take? A. apply an ice pack to the perineum for the first 24. hours B. Review the use of sitz bath equipment with the client C. Teach. The client how to practice kegel exercises D. Use an analgesic spray to the perineal area to reduce ..

after the risks and benefits of having a cardiac catheterization are reviewed.....adult with unstable angina is scheduled for the procedure. when the nurse....signature, the client asks how the wires will keep a heart beating during the.......action should the nurse take? A. Postpone the procedure until the client understands the .. B. Notify the healthcare provider of the client's lack of understanding C. Explain the procedure again in detail and clarify any misunderstandings D. Call the client's next of kin and have them .....

an older client is admitted to the psychiatric unit for assessment of a recent....that in the evening this client often becomes restless, confused, and agitated... what is most important for the nurse to implement? A. ask family members to remain with the client in the evening B. Ensure that the client is assigned to a room close to the nursing station C. Postpone administration of nighttime medications ... D. Administer a pescribed PRN benzodiazepam at the onset ...

during a clinic visit, a client with a kidney transplant asks, what will happen..... which response is best for the nurse to provide? A. A. different combination of immunosuppressant medication ... B. Dialysis would need to be resumed if chronic rejection because,,, C. DIalysis may be necessary until the chronic rejection can ,,,, D. The immunosuppressant. medication will be. increased until,,,,,

following a house fire, an adult male has been admitted to t he emergency department with partial and full thickness burns burned on the dorsal surfaces of both arms and hands and his anterior legs. using the Rule of NInes to assess thee surface area should the nurse document ? A. 50% B. 27% C. 9% D. 36%

nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are complaining. As a changeagent, the nurse manager should first A) Support the planning committee and post the new schedule B) Explore how the planning committee evaluated barriers to the plan C) Design a different approach to deliver care with fewer staff D) Retain the previous staffing pattern for another 6 months

A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is A) "I must document and report any information." B) "I can't make such a promise." C) "That depends on what you tell me." D) "I must report everything to the treatment team."

B) "I can't make such a promise."

B) "Our child should brush and floss carefully after every meal."

The mother of a toddler who is being treated for pesticide poisoning asks: "Why is activated charcoal used? What does it do?" What is the nurse's best response? A) "Activated charcoal decreases the systemic absorption of the poison from the stomach." B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child." C) "This substance helps to get the poison out of the body by the gastrointestinal system." D) "The action may bind or inactivate the toxins or irritants that are ingested by children or adults."

B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child."

B) "The tube will remove excess air from your chest."

The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say A) "Please state your name?" Upon entering the room the nurse should ask: B) "What is your name? What allergies do you have?" then check the client's name band and allergy band As the room is entered say C) "What is your name?" then check the client's name band Verify the client's allergies on the admission sheet and order. D) "Verify the client's name on the name plate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?"

B) "What is your name? What allergies do you have?" then check the client's name band and allergy band As the room is entered say

An elderly client who lives in a retirement community is admitted with these behaviors as reported by the daughter: absence in the daily senior group activity, missing the weekly card games, a change in calling the daughter from daily to once a week, and the client's tomato garden is overgrown with weeds. The nurse should assign this client to a room with which one of these clients? A) An adolescent who was admitted the day before with acute situational depression B) A middle aged person who has been on the unit for 72 hours with a dysthymia C) An elderly person who was admitted 3 hours ago with cycothymia D) A young adult who was admitted 24 hours ago for detoxification

B) A middle aged person who has been on the unit for 72 hours with a dysthymia

A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP? A) A 76-year-old client with severe depression B) A middle-aged client with an obsessive compulsive disorder C) A adolescent with dehydration and anorexia D) A young adult who is a heroin addict in withdrawal with hallucinations

B) A middle-aged client with an obsessive compulsive disorder

A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these? A) Double vision and visual halos B) Extremity tingling and numbness C) Confusion and lightheadedness D) Sensitivity of sunlight

B) Extremity tingling and numbness

The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? A) Nausea and vomiting B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) C) Diffuse macular rash D) Muscle tenderness

B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)

A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first? A) Check the protein level in urine B) Have the client turn to the left side C) Take the temperature D) Monitor the urine output

B) Have the client turn to the left side

Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct? A) "It is to observe reactive service and product problem solving." B) Improvement of the processes in a proactive, preventive mode is paramount. C) A chart audits to finds common errors in practice and outcomes associated with goals. D) A flow chart to organize daily tasks is critical to the initial stages.

B) Improvement of the processes in a proactive, preventive mode is paramount.

A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first? A) Ask client if there are any old injuries also present B) Interview the client without the persons who came with the client C) Gain client's trust by not being hurried during the intake process D) Photograph the specific injuries in question

B) Interview the client without the persons who came with the client

A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client? A) It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) B) It is critical to report promptly to your health care provider any findings of peptic ulcers c) Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors D) With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine

B) It is critical to report promptly to your health care provider any findings of peptic ulcers

Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight

B) Obtain a health and dietary history

B) Oozing liquid stool

B) Pale mucosa of the eyelids and lips

A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? A) Sodium B) Potassium C) Phosphate D) Albumin

B) Potassium

B) Pupils fixed and dilated

B) Slow the rate of infusion

B) Sore throat, fever

B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares

A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client A) "Be sure and eat a fat-free diet until the test." B) "Do not eat or drink anything but water for 12 hours before the blood test." C) "Have the blood drawn within 2 hours of eating breakfast." D) "Stay at the laboratory so 2 blood samples can be drawn an hour apart."

B. "Do not eat or drink anything but water for 12 hours before the blood test"

A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (A1C) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart every 6h are prescribed. What actions should the nurse include in this client's plan of care? (Select all that apply.) A. Do not contaminate the insulin aspart so that it is available for IV use B. Review with the client proper foot care and prevention of injury C. Teach subcutaneous injection technique, site rotation, and insulin management D. Coordinate carbohydrate controlled meals at consistent times and intervals E. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose F. Fingerstick glucose assessments every 6h with meal

B, C, D, F

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) A) Take an additional dose for signs of hyperglycemia B) Recognize signs and symptoms of hypoglycemia C) Report persist polyuria to the healthcare provider D) Use sliding scale insulin for finger stick glucose elevation E) Take Glucophage with the morning and evening meal.

B, C, E

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation should the nurse provide this client? (Select all that apply) A. Avoid range of motion exercise B. Use a residual limb shrinker C. Apply alcohol to the stump after bathing D. Inspect skin for redness E. Wash the stump with soap and water

B, D, E

You are teaching a client about the patient controlled analgesia (PCA) planned for post-operative care. Which indicates further teaching may be needed by the client? A) "I will be receiving continuous doses of medication." B) "I should call the nurse before I take additional doses." C) "I will call for assistance if my pain is not relieved." D) "The machine will prevent an overdose."

B. "I should call the nurse before I take additional doses"

When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility? A) Digestive problems B) Amenorrhea C) Electrolyte imbalance D) Blood disorders

B. Amenorrhea

A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse? A) Arrange to change client care assignments B) Explain that this behavior is expected C) Discuss the appropriate use of "time-out" D) Explain that the child needs extra attention

B. Explain that this behavior is expected

A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The provider's diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first? A) Cardiopulmonary resuscitation B) Insertion of a chest tube C) Oxygen therapy D) Assisted ventilation

B. Insertion of a chest tube

A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate? A) Determine that adequate mist is supplied B) Inspect the nares and ears for skin breakdown C) Lubricate the tips of the cannula before insertion D) Maintain sterile technique when handling cannula

B. Inspect the nares and ears for skin breakdown

The nurse is caring for a client with status epileptics. The most important nursing assessment of this client is A) Intravenous drip rate B) Level of consciousness C) Pulse and respiration D) Injuries to the extremities

B. Level of consciousness

While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client? A) Compulsive behavior B) Sense of impending doom C) Fear of flying D) Predictable episodes

B. Sense of impending doom

In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test? A) Increased edema and weight gain B) Unchanged urine specific gravity C) Rapid protein excretion D) Decreased blood potassium

B. Unchanged urine specific gravity

. Based on principles of teaching and learning, what is the best initial approach to preop teaching for a client scheduled for coronary artery bypass? A) Touring the coronary intensive unit B) Mailing a video tape to the home C) Assessing the client's learning style D) Administering a written pre-test

A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should A) Administer a placebo B) Encourage increased fluid intake C) Administer the prescribed analgesia D) Recommend relaxation exercises for pain control

A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation? A) Degeneration of the alveoli B) Chronic broncho constriction of the large airways C) Lung remodeling and permanent changes in lung function D) Frequent pneumonia

A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? A) "I have problems with diarrhea." B) "I have difficulty falling asleep." C) "I have diminished sexual function." D) "I often feel jittery."

A 52 year-old client is being transfused with one unit of packed cells. A half hour after the transfusion was initiated, the client complains of chills and headache. Which action should the nurseimplement first? A) Notify the health care provider B) Check the client's temperature C) Stop the transfusion D) Obtain a urine specimen

A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. What would the nurse's best response to this request? A) "That's a good choice, and I know it is your favorite. You can have it today." B) "I'm sorry, that is not a good choice, but you could have pasta." C) "I know that is your favorite, but let me help you pick another lunch." D) "You cannot have the peanut butter until you are feeling better."

A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: "My child seems to have problems in learning to count and recognizing basic colors." Based on this data, the nurse suspects that the child is most likely showing the effects of which problem? A) Congenital abnormalities B) Chronic toxoplasmosis C) Fetal alcohol syndrome D) Lead poisoning

A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water B) Crede' the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again

A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse? A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver D) Selecting the appropriate venous access device

A 78 year-old client with pneumonia has a productive cough but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration? A) Suction the client frequently while restrained B) Secure all 4 restraints to 1 side of bed C) Obtain a sitter for the client while restrained D) Request an order for a cough suppressant

A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be thechild's greatest fear? A) Change in body image B) An unfamiliar environment C) Perceived loss of control D) Guilt over being hospitalized

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h

A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is A) Call for emergency transport to the hospital B) Immobilize the limb and joints above and below the injury C) Assess the child and the extent of the injury D) Apply cold compresses to the injured area

A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that remedies A) Destroy organisms causing disease B) Maintain fluid balance C) Boost the immune system D) Increase bodily energy

A client experiences intense anxiety after the home was destroyed by a fire. The client escaped from the fire with only minor injuries. The nurse knows that the most important initial intervention would be to: A) Suggest the client rent an apartment with a sprinkler system B) Provide a brochure on methods to promote relaxation. C) Determine available community and personal resources D) Explore the feelings of grief associated with the loss

A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? A) The client lost 2 pounds in 24 hours B) The client's potassium level is 4 mEq/liter. C) The client's urine output was 1500 cc in 5 hours D) The client is to receive another dose of Lasix at 10 PM

A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? A) A report of 10 pounds weight loss in the last month B) A comment by the client "I just can't sit still." C) The appearance of eyeballs that appear to "pop" out of the client's eye sockets D) A report of the sudden onset of irritability in the past 2 weeks

A client in the emergency center demonstrates rapid speech, flight of ideas , and reports sleeping only three hours during the past 48 hours. Based on these findings, it is most important for the nurse to review the laboratory value for which medication? A. Lorazepam B. Fluoxetine C. Divalproex D. Olanzapine

A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states "I demand to be released now!" The appropriate action is for the nurse to? A) You cannot be released because you are still suicidal. B) You can be released only if you sign a no suicide contract. C) Let's discuss your decision to leave and then we can prepare you for discharge. D) You have a right to sign out as soon as we get an order from the healthcare provider's discharge order

A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The most appropriate action by the nurse to protect the self would be which of these? A) Negative room ventilation B) Face mask with shield C) Particulate respirator mask D) Airborne precautions

A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be Consistent with this problem? A) Chest pain B) Pallor C) Inspiratory crackles D) Heart murmur

A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in the plan of care? A. Risk for ineffective self-health management related to deficient knowledge B. Ineffective coping related to personal vulnerability C. Risk for injury related to vertigo D. Anxiety related to disruption of lifestyle

A client is embedded with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs every two hours. Which finding should the nurse report immediately to the healthcare provider? A. Anorexia and abdominal distention B. Abdominal pain and vomiting C. Confusion and tremors D. Yellowing and itching of skin

A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client's partner asked to stay a few hours beyond the visiting time, in the client's private room. What would be the best response by the nurse demonstrating emotional support for the client? A) "No, it would be best if you brought the client some reading material that she could read at night." B) "No, your presence may cause the client to become more anxious." C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety." D) "Yes, would you like to spend the night when the client's behavior indicates that she is frightened?"

A client tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The client states that it still is taking hours to fall asleep at night. Which action should the nurse implement? A. Advise the client that lifestyle changes often take several weeks to be effective B. Encourage the client to exercise every day to eliminate bedtime wakefulness C. Ask the client for a description of the exercise schedule that is being followed D. Determine the amount of weight the client has lost since increasing activity

A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for A) Anxiety, unconscious anger, and hostility B) Guilt, indecisiveness, poor self-concept C) Psychomotor retardation or agitation D) Meticulous attention to grooming and hygiene

A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with A) Recreational and social needs B) Feelings of anger C) Life's stressors D) Issues of guilt and disappointment

A client who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. In preparing the client for the procedure, which intervention has the highest priority? A. Allow client to gargle with warm salt water B. Administer a sedative to alleviate anxiety C. Instruct client to write down questions D. Deny client's request for a midnight snack

A client with a diagnosis of Methicillin resistant Staphylococcus aureus(MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? A) airborne precautions B) droplet precautions C) contact precautions D) compromised host precautions

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impeding death. After notifying the family of the client's status, what priority action will the nurse implement? A. The impending sign of death should be documented B. The client's status should be converted to the Chaplin C. The client's need for pain medication should be determined D. The nurse manager should be updated on the client's status

A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is A) "You need to take your medicine, this is how you get well." B) "If you refuse your medicine, we'll just have to give you a shot." C) "What is it about the medicine that you don't like?" D) "I can see that you are uncomfortable right now, I'll wait until tomorrow."

A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which one of the following findings by the nurse would require immediate intervention? A) Decreased blood pressure and respirations. B) Flushing and headache. C) Restlessness and palpitations. D) Increased heart rate and blood pressure.

A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action? A) Discharge the client from home health care related to noncompliance B) Notify the health care provider of the client's failure to follow prescribed diet C) Discuss diet with the client to learn the reasons for not following the diet D) Make a referral to Meals-on-Wheels

A client with considerable pain asks: "What is your opinion regarding acupuncture as a drug-free method for alleviating pain?" The nurse responds, "I'd forget about it as those weird non-Westerntreatments can be scary." The nurse's response is an example of A) Prejudice B) Discrimination C) Ethnocentrism D) Cultural insensitivity

A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) diaphoresis with decreased urinary output B) increased heart rate with increase respirations C) improved respiratory status and increased urinary output D) decreased chest pain and decreased blood pressure

A male client on the psychiatric unit is making sexual advances towards a female nurse. Which action should the nurse implement first? A. Document as specifically as possible the client's behavior in the nurse's note B. Discuss with a client why he is making sexual advances toward the nurse C. Tell the client in a matter-of-fact manner to stop the sexual advances D. Request an immediate team meeting to discuss the inappropriate behavior

A male client tells the nurse that he is concerned that he may have a stomach ulcer , because he is experiencing heartburn and a dull gnawing pain that is relieved when he eats. Which is the best response by the nurse? A. Instruct the client that these mild symptoms can generally be controlled with changes in his diet B. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms C. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer D. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food.

A mother calls the clinic, concerned that her 5 week-old infant is "sleeping more than her brother did." What is the best initial response? A) "Do you remember his sleep patterns?" B) "How old is your other child?" C) "Why do you think this a concern?" D) "Does the baby sleep after feeding?"

A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: "The manager makes all decisions and rarely asks for our input." The best description of the nurse manager's management style is A) Participative or democratic B) Ultraliberal or communicative C) Autocratic or authoritarian D) Laissez faire or permissive

A newborn has hyperbilirubinemia and is undergoing phototherapy with a blanket. Which safety measure is most important during this process? A) Regulate the neonate's temperature using a radiant heater B) Withhold feedings while under the phototherapy C) Provide water feedings at least every 2 hours D) Protect the eyes of neonate from the phototherapy lights

A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention? A) Capillary refill of fingers on right hand is 3 seconds B) Skin warm to touch and normally colored C) Client reports prickling sensation in the right hand D) Slight swelling of fingers of right hand

A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? A) "I understand that a glass of wine with dinner is healthy." B) "Beer is not really hard alcohol, so I guess I can drink some." C) "If I drink, my baby may be harmed before I know I am pregnant." D) "Drinking with meals reduces the effects of alcohol."

A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to A) Begin mouth to mouth resuscitation B) Give the child water to help in swallowing C) Perform 5 abdominal thrusts D) Call for the emergency response team

A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? A) Use ready-to-feed commercial infant formula B) Boil the tap water for 10 minutes prior to preparing the formula C) Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled "lead free" to mix the formula

A nurse who is evaluating a mentally retarded 2 year-old in a clinic should stress which goal when talking to the child's mother? A) Teaching the child self care skills B) Preparing for independent toileting C) Promoting the child's optimal development D) Helping the family decide on long term care

A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants? A) Contains less lactose B) Is higher in calories/ounce C) Provides antibodies D) Has less fatty acid

A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements? A) I will arrange for a conference with you and the UAP within the next week. B) I can assure you that I will look into the matter. C) I would like for you to approach the UAP about the problem the next time it occurs. D) I will add this concern to the agenda for the next unit meeting.

A victim of domestic violence states, "If I were better, I would not have been beat." Which feeling best describes what the victim may be experiencing? A) Fear B) Helplessness C) Self-blame D) Rejection

A woman diagnosed with bipolar disorder is to take lithium (Lithane) as part of the treatment. What should the nurse discuss with the client as part of the teaching plan? A) Risks of oral contraceptives B) Reduction in exercise program C) Avoidance of alcohol D) Cessation of smoking

A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide? A. Plans to move into the dormitory need to be postponed for at least a semester B. These are common side effects of the vaccines and will resolve in a few days C. Immunizations can trigger a relapse of the disease, so get plenty of extra rest D. These early signs of an infection may require medical treatment with antibiotics

After an older client receives treatment for drug toxicity the healthcare provider prescribes a 24-hour creatinine clearance test . Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3 mg/dL (22.9 micromol/ L). Which action should the nurse implement? A. Evaluate the client's serum BUN level B. Initiate the urine collection as prescribed C. Notify the healthcare provider of the results D. Assess the client for signs of hypokalemia

After several months of chronic fatigue, morning stiffness, and joint pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to taking prednisone? A. Take prednisone doses before meals on an empty stomach B. Wear sunglasses when exposed to bright sunlight C. If sequential doses are missed, notify the healthcare provider D. Schedule a monthly laboratory visit for a complete food count

After the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a ritual bath on the deceased prior to moving the body. The appropriate response bythe nurse is A) I will have to check on hospital regulations and policies. B) These procedures have to be carried out by our staff. C) Is there anything you need from me to perform the ritual bath? D) A ritual bath will have to wait until after post-mortem care

The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis? A) Observe for edema proximal to the site B) Irrigate with 5 mls of 0.9% Normal Saline C) Palpate for a thrill over the fistula D) Check color and warmth in the extremity

After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleaseshim. I'm not going in there again." The nurse should respond by saying A) "He has a lot of problems. You need to have patience with him." B) "I will talk with him and try to figure out what to do." C) "He is scared and taking it out on you. Let's talk to figure out what to do." D) "Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day."

An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be A) Response to stimuli B) Bladder control C) Respiratory function D) Muscle weakness

An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice? A) Bologna sandwich, pudding, milk B) Frankfurter, baked potato, milk C) Chicken strips, corn on the cob, milk D) Grilled cheese sandwich, apple, milk

An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the following allergies. Of these allergies which one should all health care personnel be aware of? A) Shellfish B) Molds C) Balloons D) Perfumed soap

An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis? A. Ate an extra peanut butter sandwich before gym class B. Incorrectly administered too much insulin C. Had a cold and ear infection for the past two days D. Skipped eating lunch

An appropriate goal for a client with anxiety would be to A) Ventilate anxious feelings to the nurse B) Establish contact with reality C) Learn self-help techniques D) Become desensitized to past trauma

An older client is brought to the emergency department (ED) with a sudden onset of confusion that occurred after experiencing a fall at home. The client's daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR (Situation, background, assessment, recommendation) communication? A. Currently prescribing medications B. Client's healthcare power of attorney C. Increasing confusion of the client D. Fall at home as reason for admission

An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions? A) "How long have you been a UAP?" B) "What type of care did you give in pediatrics?" C) "Do you have your competency checklist that we can review?" D) "How comfortable are you to care for adult clients?"

As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "The urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D) "We notice muscle weakness and some unsteadiness."

At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform? A) Say 2 words B) Pull up to stand C) Sit without support D) Drink from a cup

At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should A) Invite the client to join the exercise group B) Tell the client you will call someone to come for her C) Give the client simple information about what she will be doing D) Firmly direct the client to her assigned group activity

Before administering digoxin (Lanoxin) to a client, which of the following nursing assessments is a priority? A) Auscultate breath sounds B) Check for bowel sounds C) Monitor the heart rate D) Measure the blood pressure

Delirium tremens could best be described as A) Disorganized thinking, feelings of terror and non-purposeful behavior B) A generalized shaking of the body accompanied by repetitive thoughts C) An excited state accompanied by disorientation, hallucination and tachycardia D) Single or multiple jerks caused by rapid contracting muscles

During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother? A) My child has lost 3 pounds in the last month. B) Urinary output seemed to be less over the past 2 days. C) All the pants have become tight around the waist. D) The child prefers some salty foods more than others.

During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse? A) "Mongolian spots are a normal finding in dark-skinned children." B) "Port wine stains are often associated with other malformations." C) "Telangiectatic nevi are normal and will disappear as the baby grows." D) "The child is too young for consideration of surgical removal of these at this time."

First-time parents bring their 5 day-old infant to the pediatrician's office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings? A) The pediatrician must examine the baby B) Emergency equipment should be available C) This breathing pattern is normal D) A future referral may be indicated

Following change-of-shift report on an orthopedic unit, which clientshould the nurse see first? A) 16 year-old who had an open reduction of a fractured wrist 10 hoursago B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident C) 72 year-old recovering from surgery after a hip replacement 2 hoursago D) 75 year-old who is in skin traction prior to planned hip pinning surgery

In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/minute with a normal depth to 32 breaths/minute and deep, and the client has become lethargic. Which assessment data should the nurse obtain next? A. Temperature B. Breath sounds C. Blood glucose D. White blood cell count

In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? A) Increased 10% in height B) 2 deciduous teeth C) Tripled the birth weight D) Head > chest circumference

Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice

On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family Which information is most important for the nurse to obtain? A. Which family member has the client's suicide note B. What drugs the client used for the suicide attempt C. When the client last took drugs for bipolar disorder D. Whether the client ever attempted suicide in the past

On daily cleaning of a tracheostomy, the client coughs and displaces the tracheostomy tube. The nurse could have avoided this by A) placing an obturator at the client's bedside B) having another nurse assist with the procedure C) fastening clean tracheostomy ties before removing old ties D) Withdraw catheter in a circular motion

One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement? A. Encourage ambulation in the room B. Palpate. the femoral pulse C. Observe for unilateral swelling D. Apply a warm compress to the area

Post-procedure nursing interventions for electroconvulsive therapy include A) Applying hard restraints if seizure occurs B) Expecting client to sleep for 4 to 6 hours C) Remaining with client until oriented D) Expecting long-term memory los

Prior to surgery, written consent must be obtained. Which is the nurse's legal responsibility with regard to obtaining written consent? A. Explain the surgical procedure to the client and ask the client to sign the consent form B. Ask the client or a family member to sign the surgical consent form C. Determine that the surgical consent form has been signed and is included in the client's record D. Validate the client's understanding of the surgical procedure to be conducted

The father of a 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? A. Reassure the client that his child will be allowed to visit B. Provide the client written information about end-of-life care C. Obtain a detailed report from the nurse transferring the client D. Mark the chart with client's request for no heroic measures.

The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? A) "I think you or your partner needs to stay with the child while in the hospital." B) "Oh, that behavior will stop in a few days." C) "Keep in mind that for the age this is a normal response to being in the hospital." D) "You might want to "sneak out" of the room once the child falls asleep."

The nurse administered intravenous gamma globulin to an 18 month-old child with AIDS. The parent asks why this medication is being given. What is the nurse's best response? A) "It will slow down the replication of the virus." B) "This medication will improve your child's overall health status." C) "This medication is used to prevent bacterial infections." D) "It will increase the effectiveness of the other medications your child receives."

The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time? A) Risk for fluid volume deficit related to morphine overdose B) Decreased gastrointestinal mobility related to mucosal irritation C) Ineffective breathing patterns related to central nervous system depression D) Altered nutrition related to inability to control nausea and vomiting

The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action? A) Pack the nose and ears with sterile gauze B) Apply pressure to the injury site C) Apply bulky, loose dressing to nose and ears D) Apply an ice pack to the back of the neck

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program ? A. A listing of African-american women who live in the community B. Morbidity data for breast cancer in women of all races C. Participation of community leaders in planning the program D. Technical assistance to produce a video on breast self-examination

The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective? A. Only 30% of clients did not attend self-management education sessions B. More than 50% of at-risk clients were diagnosed early in their disease process C. Clients who developed disease complications promptly received rehabilitation D. Average client scores improved on specific risk factor knowledge tests

The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? A) Increased serum glucose B) Decreased albumin C) Decreased potassium D) Increased sodium retention

The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis? A) Several otitis media episodes in the last year B) Weight and height in 10th percentile since birth C) Takes frequent rest periods while playing D) Changing food preferences and dislikes

The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to A) Wrap the leg with elastic bandages B) Apply pressure at the bleeding site C) Reinforce the dressing and elevate the leg D) Remove the dressings and re-dress the incision

The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory? A) "Name the year." "What season is this?" (pause for answer after each question) B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number." C) "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"

The nurse is auscultating a client's lung sounds . Which description should the nurse use to document this sound ? (Please listen to the audio file to select the option that applied) A. Stridor B. Low pitch or coarse crackles C. High pitched or fine crackles D. High pitched wheeze

The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? A) Schedule the therapy thirty minutes after meals B) Teach the child not to cough during the treatment C) Confine the percussion to the rib cage area D) Place the child in a prone position for the therapy

The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first? A) Perform defibrillation B) Administer epinephrine as ordered C) Assess for presence of pulse D) Institute CPR

The nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD? A. Monitoring telemetry and cardiac rhythm B. Assisting client to cough and deep breath C. Administering narcotics for pain relief D. Increasing the client's fluid intake

The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Bradycardia

The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care? A) Monitor for hyperkalemia B) Place in protective isolation C) Precautions with position changes D) Administer diuretics as ordered

The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing

The nurse is caring for a client with COPD who becomes dyspneic. The nurse should A) Instruct the client to breathe into a paper bag B) Place the client in a high Fowler's position C) Assist the client with pursed lip breathing D) Administer oxygen at 6L/minute via nasal cannula

The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? A) Storing the packed red cells in the medicine refrigerator while starting IV B) Slow the rate of infusion if the client develops fever or chills C) Limit the infusion time of each of the unit to a maximum of 4 hours D) Assess vital signs every 15 minutes throughout the entire infusion

The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to A) Dehydration B) Diminished blood volume C) Decreased cardiac output D) Renal failure

The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group? A) Aerobic exercise classes B) Transportation for shopping trips C) Reminiscence groups D) Regularly scheduled social activities

The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? A. The client's skin on the lower legs will be intact at the next clinic visit B. The client will express acceptance of their newly diagnosed health status C. The client's blood pressure readings will be less than 160/90 mmHg D. The nurse will encourage the client to walk thirty minutes every day

The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior? A) Reprimand the child and give a 15 minute "time out" B) Maintain a permissive attitude for this behavior C) Use patience and a sense of humor to deal with this behavior D) Assert authority over the child through limit setting

The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcomes indicate the program is effective? A. At risk clients received an increase number of routine health screenings B. Clients reported having new confidence in making healthy food choices C. Clients who incurred disease complications promptly received rehabilitation D. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign

The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken A) Once each day B) 3 times daily after meals C) With each meal or snack D) Each time carbohydrates are eaten

The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated . After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding? A. An audible voice when client is trying to communicate B. High pressure alarm sounds when client is coughing C. Restrained and restless with a low volume alarm sounding D. Diminished breath sounds in the right posterior base

The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when A) An individual displays restlessness B) There are obvious signs of depression C) Conducting any health assessment D) The resident reports memory lapses

The nurse is performing a pre-kindergarten physical on a 5 year old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? A) Vastus intermedius B) Gluteus rainlinus C) Vastus lateralis D) DorsogluteaI

The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence

The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan? A. Increase activity and exercise gradually, as tolerated B. Limit intake of fatty foods for one month after surgery C. Avoid crowds for first two months after surgery D. Notify the healthcare provider is edema occurs

The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding? A. Elevate the legs to assess for color changes B. Provide a heating pad for PRN use C. Offer cold packs when the pain occurs E. Suggest dangling the legs when pain begins

The nurse is removing a fecal impaction on a 75 year-old client. It is most important that the nurse remember that A) the procedure be done prior to the bath B) family members should be taught the procedure C) cardiac dysrhythmias can result during the process D) increased dietary fiber can minimize such problems

The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse? A) Chewable aspirin is the preferred analgesic B) Topical cortisone ointment relieves itching C) Papules, vesicles, and crusts will be present at one time D) The illness is only contagious prior to lesion eruption

The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group? A) Bulimia B) Anorexia C) Obesity D) Malnutrition

The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client's behavior most likely indicates A) Neologisms B) Dissociation * C) Flight of ideas D) Word salad

The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A) Donating blood B) Using public bathrooms C) Unprotected sex D) Touching a person with AIDS

The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize A) The need for at least 5 servings of dairy products daily B) Restriction of fluid intake to less than 1 liter per day C) The importance of walking as much as possible D) Early recognition of findings associated with tetany

The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspect of this care is A) Sedation as needed to prevent exhaustion B) Antibiotic therapy for 10 to 14 days C) Humidified air and increased oral fluids D) Antihistamines to decrease allergic response

The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching? A) "I'm going to try feeding my baby some rice cereal." B) "When he wakes at night for a bottle, I feed him." C) "I dip his pacifier in honey so he'll take it." D) "I keep formula in the refrigerator for 24 hours."

The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's mother reports that the child "feels very warm" to touch. The first action by the nurse should be to A) Reassure the mother that this is normal B) Offer the child cold oral fluids C) Reassess the child's temperature D) Administer the prescribed acetaminophen

The nurse observes an unlicensed assistive personnel (UAP) applying in alcohol-based hand rub while leaving the client's room after taking vital signs. What action should the nurse take? A. Instruct the UAP to return to the client's room to perform handwashing B. Supervise the UAP and the next client's room to evaluate hand hygiene C. Remind the UAP to continue rubbing the hands together until they are dry D. Advise the UAP to wear gloves when obtaining vital signs for all clients

The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3-year-old son for wetting his pants. What initial action should the nurse take? A. Provide disposable training pants while calming the mother B. Refer the mother to a community parent education program C. Inform the mother that toilet training is slower for boys D. Suggest that the new mother consult a pediatric nephrologist

The nurse should initiate discharge planning for a client A) When the client or family demonstrate readiness to learn self care modalities B) When informed that a date for discharge has been determined C) Upon admission to the emergency room D) When the client's condition is stabilized on the assigned unit

The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first A) Assess the client's airway B) Call for help C) Establish that the client is unresponsive D) See if anyone saw the client fall

The nurse, assisting in applying a cast to a client with a broken arm, knows that A) The cast material should be dipped several times into the warm water B) The cast should be covered until it dries C) The wet cast should be handled with the palms of hands D) The casted extremity should be placed on a cloth-covered surface

The nursing care plan for a client with decreased adrenal function should include A) Encouraging activity B) Placing client in reverse isolation C) Limiting visitors D) Measures to prevent constipation

The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse? A) Teach the parents how to perform cardiopulmonary resuscitation B) Recommend that the parents give in when he holds his breath to prevent anoxia C) Advise the parents to ignore breath holding because breathing will begin as a reflex D) Instruct the parents on how to reason with the child about possible harmful effects

The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurses immediate attention? A. A 16 year-old client diagnosed with major depression who refuses to participate in group B. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack C. An 18 year-old client with antisocial behavior who is being yelled at by other clients D. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby

The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? A) "The treatment requires reapplication in 8 to 10 days." B) "Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits.

To which of the following nursing home residents could the nurse safely administer tricyclic antidepressants without questioning the health care provider's order? A) An 85 year-old male with narrow-angle glaucoma B) An African-American with benign prostatic hypertrophy C) A 65 year-old female with mild hypertension D) A Hispanic female with coronary artery disease

What finding signifies that children have attained the stage of concrete operations (Piaget)? A) Explores the environment with the use of sight and movement B) Thinks in mental images or word pictures C) Makes the moral judgement that "stealing is wrong" D) Reasons that homework is time-consuming yet necessary

When admitting a client to an acute care facility, an identificationbracelet is sent up with the admission form. In the event these do not match, the nurse'sbest action is to A) Change whichever item is incorrect to the correct information B) Use the bracelet and admission form until a replacement is supplied C) Notify the admissions office and wait to apply the bracelet D) Make a corrected identification bracelet for the client

When admitting a client with a diagnosis of transient ischemic attack (TIA). Which intervention is most important for the nurse to include in this client's plan of care? A. Assess bilateral breath sounds B. Review client's daily medications C. Initiate neurological monitoring every 2 hours D. Palpate suprapubic region for urinary retention

When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse? A) Record the number of stools per day B) Maintain strict intake and output records C) Sterile technique for dressing change at IV site D) Monitor for cardiac arrhythmias

When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority? A) Follow-up on lab values before the visit B) Observe client findings for the effectiveness of antibiotics C) Ask for a log of urinary output D) As for the log of the oral intake

When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue A) Angry outbursts at significant others B) Fear of being left alone C) Giving away valued personal items D) Experiencing the loss of a boyfriend

Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items? A) The client has complaints of not sleeping well for the past week. B) The family wants to discontinue the home meal service, meals on wheels. C) The urine in the urinary catheter bag is of a deeper amber, almost brown color. D) The partner says the client has slower days every other day.

Which client is at highest risk for developing a pressure ulcer? A) 23 year-old in traction for fractured femur B) 72 year-old with peripheral vascular disease, who is unable to walk without assistance C) 75 year-old with left sided paresthesia and is incontinent of urine and stool D) 30 year-old who is comatose following a ruptured aneurysm of urine and stool

Which contraindication should the nurse assess for prior to giving a child immunizations? A) Mild cold symptoms B) Chronic asthma C) Depressed immune system D) Allergy to eggs

Which intervention best demonstrates the nurse's sensitivity to a 16year old's appropriate need for autonomy? A) Alertness for feelings regarding body image B) Allows young siblings to visit C) Provides opportunity to discuss concerns without presence of parents D) Explores his feelings of resentment to identify causes

Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)? A) Neuromalignant syndrome B) Acute extrapyramidal syndrome C) Glaucoma, prostatic hypertrophy D) Parkinson's disease, atypical tremors

Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy? A) Benzodiazepines B) Chlorpromazine (Thorazine) C) Succinylcholine (Anectine) D) Thiopental sodium (Pentothal Sodium)

Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? A) Drowsiness, lethargy, and inactivity B) Dry mouth, nasal congestion, and blurred vision C) Rash, blood dyscrasias, severe depression D) Hyperglycemia, weight gain, and edema

Which of these clients would be most appropriate to assign to a PN? A) A trauma victim with quadriplegia and a client 1 day post-op radical neck dissection B) A client with newly diagnosed type 2 diabetes mellitus and a client with a history of AIDS admitted for pneumonia C) A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation D) A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failure

Which one of these tasks can be safely delegated to a PN? A) Assess the function of a newly created ileostomy B) Care for a client with a recent complicated double barrel colostomy C) Provide stoma care for a client with a well functioning ostomy D) Teach ostomy care to a client and their family members

Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis? A) Active and passive range of motion exercises twice a day B) Every 4 hours incentive spirometer C) Chest physiotherapy twice a day D) Repositioning every 2 hours around the clock

Which statement made by a client indicates to the nurse that he may have a thought disorder? A) "I'm so angry about this. Wait until my partner hears about this." B) "I'm a little confused. What time is it?" C) "I can't find my 'mesmer' shoes. Have you seen them?" D) "I'm fine. It's my daughter who hasthe problem."

While assessing a 1 month-old infant, which finding should the nurse report immediately? A) Abdominal respirations B) Irregular breathing rate C) Inspiratory grunt D) Increased heart rate with crying

While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? A) "I want to protect my child from any falls." B) "I will set limits on exploring the house." C) "I understand the need to use those new skills." D) "I intend to keep control over our child."

While teaching a client about their medications, the client asks how long it will take before the effects of lithium take place. What is the best response of the nurse? A) Immediately B) Several days C) 2 weeks D) 1 month

While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take? A. Inform the client that falls occur more often in the hospital than at home B. Record a minimal risk for falls, documenting the client's statement C. Continue to obtain client data needed to complete the fall risk survey D. Place the client on a high fall risk protocol because of advanced age.

a 3-year-old boy with a congenital heart defect is brought to the clinic by his mother.... an earache. during the assessment the mother asks why her child is at the.....and height for his age. which response is best for the nurse to provide? A. "does your child seem mentally slower than his peers also?" B. "haven't you been feeding him according to. recommended daily ... C. "His smaller size is probably due to the heart disease?" D. " you should not worry about the growth tables. They are only average....

a 62-year-old male client tells the nurse that he has a high-density lipoprotein...... which action should the nurse take? A. Encourage the client to reduce consumption of fatty foods B. Ask the client about hereditary cardiac risk factors C. Confirm that this value is helpful in reducing cardiac risk D. Explain that the client may need medication therapy

the nurse is assessing a client's breath sounds. which medication from the clients.....most positive effect on this respiratory finding? (please listen to the audio clip) The sound was WHEEZING which indicates? A. Chloroquine B. Enalapril C. ALbuterol D. Losartan

the nurse is assisting the HCP with a wound debridement.....confused. the client is draped and a sterile field is created. which nursing action should implement for client safety? A. assess for discomfort when the procedure is. completed B. Verify that the client has given informed consent C. Instruct the client to keep hands under the sterile field D. Pour the cleansing solution onto the sterile cloth field

the nurse is preparing to send a client to the cardiac cath lab for an angioplasty. which client report is.....the procedure? A. Drank a glass of water in the past 2 hours B. Verbalize a fear of being in a confined space. C. Experience facial swelling after eating crab D. Reports left chest wall pain prior to admission

the parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy.....child wants to continue attending swimming classes. how should the nurse respond? A. provide a list of alternative activities that are less likely to cause fatigue B. Explain that their child. is too young to understand C. Encourage the parents to allow the child to continue. with supervision D. Suggest that the child be encouraged to participate

while changing a client's post-op dressing, the nurse observes......amount of yellow and green drainage and a foul odor. given there is....... MRSA, which is the most important action? A. Start progressive mobilization B. Request a nutrition consult C. Request a wound culture and sensitivity D. Forcee oral fluids

while changing a client's postoperative dressing, the nurse observes purulent drainage at the site. which of the client's laboratory values? A. platelet count B. Serum sodium level C. Neutrophil count D. Hematocrit

while providing a health history, a female client tells the clinic nurse that she frequently.... herself. which question is most important for the nurse to ask? A. " do you often have feelings of sadness?" B. " Are you having problems concentrating?" C. "Have you thought about taking your life?" D. "what problems are you facing right now?"

After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying A) "He has a lot of problems. You need to have patience with him." B) "I will talk with him and try to figure out what to do." C) "He is scared and taking it out on you. Let's talk to figure out what to do." D) "Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day."

C) "He is scared and taking it out on you. Let's talk to figure out what to do."

A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly refuses pain medication because the client believes that suffering is part of life. The client states "everyone's life is in God's hands." The next action for the nurse to take is to A) Report the situation to the health care provider B) Discuss the situation with the client's family C) Ask the client if talking with a priest would be desired D) Document the situation on the notes

C) Ask the client if talking with a priest would be desired

C) Assist him to stand by the side of the bed to void

C) Children are not to share hats, scarves and combs.

C) Keep conversations short

C) Loss of pulse in the extremity

After an explosion at a factory one of the workers approaches the nurse and says "I am an unlicensed assistive personnel (UAP) at the local hospital." Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers? A) Get temperatures B) Take blood pressure C) Palpate pulses D) Check alertness

C) Palpate pulses

A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? A) Allow the client to melt ice chips in the mouth B) Provide mints to freshen the breath C) Perform frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs

C) Perform frequent oral care with a tooth sponge

C) Place in respiratory/secretion precautions

C) Reinforce the dressing and elevate the leg

C) Reposition every two hours

A nurse states: "I dislike caring for African-American clients because they are all so hostile." The nurse's statement is an example of A) Prejudice B) Discrimination C) Stereotyping D) Racism

C) Stereotyping

A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? A) Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes. B) In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness. C) The flow of life is believed to flow through major pathways or nerve clusters in your body. D) By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over.

C) The flow of life is believed to flow through major pathways or nerve clusters in your body.

A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors

C) Visitors should wash their hands before and after touching the client

The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client A) Has had a change in respiratory rate by an increase of 2 breaths B) Has had a change in heart rate by an increase of 10 beats C) Was minimally responsive to voice and touch D) Has had a blood pressure change by a drop in 8 mmHg systolic

C) Was minimally responsive to voice and touch

A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to A) have the client identify coping methods B) get the description of the location and intensity of the pain C) accept the client's report of pain D) determine the client's status of pain

C) accept the client's report of pain

C) improved respiratory status and increased urinary output

The nurse observes a client prepare a meal in the a rehabilitation prior to discharge Which behaviors indicate the understands how to balance safely Select that apply A. Brings a heavy can close to the body before lifting B. Leans forward to pull a pan from a high shelf C. Locks knees while preparing food on the counter D. Bends from the waist to pick trash off the floor E. Widens stance from the waist to pick trash off the floor

C, D

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? (Select all that apply) A. Location of the initial IV site B. Red blood cell count (RBC) C. Swollen lymph nodes in the groin D. White blood cell count (WBC) E. Core body temperature

C, D, E

a client is admitted with an exacerbation of heart failure secondary..... require immediate intervention to reduce the likelihood of harm to.... (select all) A. A bedside commode is positioned near the bed B. A saline lock is present in the right forearm C. A full pitcher of water is on the bedside table D. A low-sodium diet tray was brought to the room E. The client is lying in a supine position in bed

C, E

During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem? A) "I have constant blurred vision." B) "I can't see on my left side." C) "I have to turn my head to see my room." D) "I have specks floating in my eyes."

C. "I have to turn my head to see my room"

The nurse is assessing a 12 year-old who has Hemophilia A. Which finding would the nurse anticipate? A) An excess of red blood cells B) An excess of white blood cells C) A deficiency of clotting factor VIII D) A deficiency of clotting factors VIII and IX

C. A deficiency of clotting factor VIII

The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation? A) Ask family members to dress the client B) Encourage the client to dress more quickly C) Allow the client the time needed to dress D) Demonstrate methods on how to dress more quickly

C. Allow the client the time needed to dress

A client who is terminally ill has been receiving high doses of an opiod analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli,what orders would the nurse expect from the health care provider? A) Decrease the analgesic dosage by half B) Discontinue the analgesic C) Continue the same analgesic dosage D) Prescribe a less potent drug

C. Continue the same analgesic dosage

While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication? A) Positive Homan's sign B) Fever and chills C) Dyspnea and cough D) Sensory impairment

C. Dyspnea and cough

The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure? A) Place pillows under the knees B) Use elastic stockings continuously C) Encourage range of motion and ambulation D) Massage the legs twice daily

C. Encourage range of motion and ambulation

A young adult male has been diagnosed with testicular cancer. Which of these statements by this client would need to be explored by the nurse to clarify information? A) This surgical procedure involves removing one or both testicles through a cut in the groin. My lymph nodes in my lower belly also may be removed. B) I have a good chance to regain my fertility later. However if I am concerned, I can have my sperm frozen and preserved (cryopreserved) before chemotherapy. C) If I have cancer at stage 3 it means I have less involvement of the cancer. D) After the surgical removal of a testicle, I can have an artificial testicle (prosthesis) placed inside my scrotum. This artificial implant has the weight and feel of a normal testicle.

C. If I have cancer at stage 3 it means I have less involvement of the cancer.

In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in A) Hearing, speech, and sight B) Endurance, strength, and mobility C) Learning, creativity, and judgment D) Balance, flexibility, and coordination

C. Learning, creativity, and judgment

The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best? A) "What is your reason for wanting such a plan?" B) "Have you talked with your health care provider about this?" C) "Let us discuss your rights as a couple." D) "Write your ideal plan for the next class."

C. Let us discuss your rights as a couple

The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate postoperative period? A) Raise the head of the bed at least 30 degrees B) Encourage ambulation within 24 hours C) Maintain in a flat position, logrolling as needed D) Encourage leg contraction and relaxation after 48 hours

C. Maintain in a flat position, logrolling as needed

A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, redfluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage

A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect? A) Flushed skin B) Bradycardia C) Mental confusion D) Hypotension

C. Mental confusion

The nurse is caring for a 5 year-old child who has the left leg in skeletal traction. Which of the following activities would be an appropriate diversional activity? A) Kicking balloons with right leg B) Playing "Simon Says" C) Playing hand held games D) Throw bean bags

C. Playing hand held games

A priority goal of involuntary hospitalization of the severely mentally ill client is A) Re-orientation to reality B) Elimination of symptoms C) Protection from harm to self or others

C. Protection from harm to self or others

An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for trachea esophageal fistula. The mother asks:"When can the tube can be used for feeding?" The nurse's best response would be which of these comments? A) Feedings can begin in 5 to 7 days. B) The use of the feeding tube can begin immediately. C) The stomach contents and air must be drained first. D) The incision healing must be complete before feeding.

C. The stomach contents and air must be drained first.

A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to A) Gently rub the skin with a cotton swab to relieve itching B) Place the favorite books and push-pull toys in the crib C) To check every few hours for the next day or 2 for swelling in the baby's feet D) Turn the baby with the abduction stabilizer bar every 2 hours

C. To check every few hours for the next day or 2 for swelling in the baby's feet

A client has an orderfor 1000 ml of D5W over an 8 hour period. Thenurse discovers that 800 ml has been infused after 4 hours. What is the priority nursingaction? A) Ask the client if there are any breathing problems B) Have the client void as much as possible C) Check the vital signs D) Auscultate the lungs

A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to A) Promote the client's comfort B) Reduce the drying time C) Decrease irritation to the skin D) Improve venous return

The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? A) May drink as much milk as desired B) Can have milk mixed with other foods C) Will benefit from fat-free cow's milk D) Should be limited to 3-4 cups of milk daily

. A client with urge incontinence was treated with onabotulinumtoxinA injections and is now experiencing urinary retention. Which action should the nurse include in the client's plan of care? A. Provide a bedside commode for immediate use in the client's room B. Teach the client techniques for performing intermittent catheterization C. Explain the need to limit intake of oral fluids to reduce client discomfort D. Remind the client to practice pelvic floor (Kegel) exercises regularly

A 16 year-old boy is admitted for Ewing's sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the initial treatment most often includes A) Amputation just above the tumor B) Surgical excision of the mass C) Bone marrow graft in the affected leg D) Radiation and chemotherapy

A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which o staff members should the charge nurse assign the client? A) Unlicensed assistive personnel (UAP) B) Senior nursing student C) PN D) RN

A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem? A) Allergies B) Scabies C) Regression D) Pinworms

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? A. A retraining program will need to be initiated when the child returns home B. Diapering will be provided since hospitalization is stressful to preschoolers C. A potty chair should be brought from home so he can maintain his toileting skills D. Children usually resume their toileting behaviors when they leave the hospital

A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states "I refuse both radiation and chemotherapy because they are 'hot.'" The next action for the nurse to take is to A) Document the situation in the notes B) Report the situation to the health care provider C) Talk with the client's family about the situation D) Ask the client to talk about the concerns about the "hot"treatments

A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. Which finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? A.Regular contractions occurring every 10 minutes B. Biophysical profile results showing oligohydramnios. C.Sterile vaginal exam revealing 3 cm dilatation D.Fetal heart tones located in the upper right quadrant

A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse? A) Explain to the client that the dentures must come out as they may get lost or broken in the operating room B) Ask the client if there are second thoughts about having the procedure C) Notify the anesthesia department and the surgeon of the client's refusal D) Ask the client if the preference would be to remove the dentures in the operating room receiving area

A 7 year old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider? A. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips B. Serum pH of 7.45 C. Gastric output of 100mL in the last 8 hours D. Serum potassium of 3.0 mg/dL (3mmol/L)

A charge nurse working in a long term care facility is making out assignments. Which assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires intervention by the supervisor? A) Provide decubitus ulcer care and apply a dry dressing B) Bathe and feed a client on bed rest C) Oral suctioning of an unresponsive elderly client D) Teaching a family intermittent (bolus) feedings via G-tube before discharge

A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement? A. Obtain the client's 24-hour dietary recall B. Document mucosal membrane status C. Schedule a consult with a nutritionist D. Initiate prescribed intravenous fluids

A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important? A) I got back from Central America a few weeks ago. B) I had the best raw oysters last week. C) I have many different sex partners. D) I had a blood transfusion 15 years ago.

A client fell in the bathroom when left unattended by the unlicensed assistive personnel (UAP). Which information should the nurse include in the client's health record? A. The UAP left the client to assist another client B. The last time client was assisted to the bathroom C. The unit was understaffed when the client fell D. The client fell sustaining a fracture to the left hip.

A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important to emphasize to the client? A) Maintain a low sodium diet B) Take a diuretic with lithium C) Come in for evaluation of serum lithium levels every 1-3 months D) Have blood lithium levels drawn during the summer months

A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)? A) Teach the client how to cough up secretions B) Changes the tracheostomy trach ties C) Monitor if client has shortness of breath D) Perform routine tracheostomy dressing care

A client is admitted with a diagnosis of urolithiasis . Which finding is most important for the nurse to report to the healthcare provider? A. Volume of each voiding is more than 300 mL B. Serum potassium level is elevated C. Relief of flank pain that radiated into the groin D. Hematuria that is beginning to turn pink

A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound? A) Transparent dressing B) Dry sterile dressing with antibiotic ointment C) Wet to dry dressing D) Occlusive moist dressing

A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A) Reverse B) Airborne C) Standard precautions D) Contact

A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)? A) Ask the client the degree of relief and document the client's response B) Decrease the set rate on the pump by 2 ml/minute C) Check the IV site for drainage and loose tape D) Assist the client with ambulation and a gown change

A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication? A) Potassium B) Arterial blood gasses C) Blood urea nitrogen D) Thiocyanate

A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first? A. Start an intravenous infusion B. Administer oxygen via facemask C. Perform a vaginal exam D. Begin continuous fetal monitoring

A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what? A) Dystonia B) Akathesia C) Brady dyskinesia D) Tardive dyskinesia

A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take? A) Call the health care provider B) Access the site by cutting a window in the cast C) Record the findings in the nurse's notes only D) Outline the spot with a pencil and note the time and date on the cast

A client was admitted to the eating disorder unit with bulimia nervosa. The nurse assessing for a history of complications of this disorder expects A) Respiratory distress, dyspnea B) Bacterial gastrointestinal infections, over hydration C) Metabolic acidosis, constricted colon D) Dental erosion, parotid gland enlargement

A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client? A) Reading B) Checkers C) Cards D) Ping-pong

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider? A. A change in the sleep-wake cycle B. Mild sedation C. Dizziness reported after initial dose D. Somnambulism - (sleepwalking)

A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger? A. Loud hallway noise B. Frequent cough C. Fever D. Full bladder

A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response ofthe nurse should be which of these statements? A) I am sorry. Referral information can only be provided by the client's health care providers. B) "I can never give any information out by telephone. How do I know who you are?" C) Since this is a referral, I can give you the this information. D) I need to get the client's written consent before I release any information to you.

A client with a fractured femur has been in Russell's traction for 24 hours. Which nursing action is associated with this therapy? A) Check the skin on the sacrum for breakdown B) Inspect the pin site for signs of infection C) Auscultate the lungs for atelectasis D) Perform a neurovascular check for circulation

A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? A) Pulverize all medications to a powdery condition B) Squeeze the tube before using it to break up stagnant liquids C) Cleanse the skin around the tube daily with hydrogen peroxide D) Flush adequately with water before and after using the tube Skip

A client with multiple burn injuries is being treated in the burn trauma unit just hours after the injuries occurred . The healthcare provider instructs the nurse to avoid auto contamination when performing dressing changes . Which intervention is most important for the nurse to implement? A. Dress each wound separately B. Assign equipment to this one client C. Utilize reverse isolation protocol D. Use gown, mask, and gloves with dressing changes

A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts "You think you're so perfect and pure and good." An appropriate response for the nurse is A) "Is that why you've been starring at me?" B) "You seem to be in a really bad mood." C) "Perfect? I don't quite understand." D) "You are angry right now."

A client with postpartum depression , who is admitted to the behavioral health unit refuses to leave her room or eat meals In addition to maintaining physical safety, which short - term goal should the nurse include in the plan of care? A. Sleep at least 6 hours per night B. Consumes 3 meals and 1500 mL of fluid per day C. Engages in one client-to-client interaction daily D. Attends one group activity per day

A client, recovering from alcoholism, asks the nurse, "What can I do when I start recognizing relapse triggers within myself?" How might the nurse best respond? A) "When you have the impulse to stop in a bar, contact a sober friend and talk with him." B) "Go to an AA meeting when you feel the urge to drink." C) "It is important to exercise daily and get involved in activities that will cause you not to think about drug use." D) "Identify your relapse triggers as part of getting better."

A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? A. Explain to the family that they must accept their mothers B. Discuss the success of clinical trials and ask the client to C. Ask the client. her children present if she is fully under D. Explore the client's decision to refuse treatment and offer support.

A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct? A) Days 7-10 B) Days 10-13 C) Days 14-16 D) Days 17-19

A diabetic client asks the nurse why the health care provider ordered a glycolsylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test: A) Provides a more precise blood glucose value than self-monitoring B) Is performed to detect complications of diabetes C) Measures circulating levels of insulin D) Reflects an average blood sugar for several months

A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is A) A transparent film dressing B) Wet dressing with debridement granules C) Wet to dry with hydrogen peroxide D) Moist saline dressing

A male client who fell off a roof has right and left femur fractures and crushing injuries to both ankles. He is supine with bilateral skin traction applied to the lower extremities while awaiting surgery within the next 4 hours. When asked to evaluate his pain on a scale of 1 to 10, he screams that it is 20. For the last 4 hours, he has received morphine 2 mg IV hourly. His vital signs are heart rate 130 beats/minute, respirations 32 breaths/minute, blood pressure 180/90 mmHg. Which intervention is most important for the nurse to implement? A. Request the healthcare provider to consider a different analgesic B. Evaluate the traction for amount of tension applied to each extremity C. Determine if client is experiencing cumulative effects of the total dosage D. Assess the extremities for signs of compartment syndrome q2 hours

A male client with stomach cnacer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is recieing lacted ringers solution IV. One hour after admission to the unit the nurse notes 300 mL of blood in the suctin canister. the clients heart rate is 155 beat/minute and his blood presure.In addition to reporting the findings to the surgeon, which action should the nurse implement first? A. Measure and document the client's urinary output. B. Request the client's reserved unit of packed red blood cells. C. Prepare for the placement of central venous catheter. D. Increase the infusion rate of Lactated Ringer's solution.

A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss? A) The newborn needs additional assessments B) The mother should breast feed more often C) A change to formula is indicated D) The loss is within normal limits

A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces

A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis? A) Gestational age assessment suggested growth retardation B) Meconium was cleared from the airway at delivery C) Phototherapy was used to treat Rh incompatibility D) The infant received mechanical ventilation for 2 weeks

A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) drowsiness B) complaint of nausea C) pulse rate of 92 D) restlessness

A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states," This is not my baby, and I do not want it." The nurse's best response is A) "This is a common occurrence after birth, but you will come to accept the baby." B) "Many women have postpartum blues and need some time to love the baby." C) "What a beautiful baby! Her eyes are just like yours." D) "You seem upset; tell me what the pregnancy and birth were like for you."

A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate? A) A client admitted with multiple trauma with a history of a newly implanted pacemaker B) A new admission with left-sided weakness from a stroke and mild confusion C) A 53 year-old client diagnosed with cardiac arrest from a suspected myocardial infarction D) A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident

A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best? A) "A recovering person has to be very careful not to lose control, therefore, confine your drinking just at family gatherings." B) "At your next AA meeting discuss the possibility of limited drinking with your sponsor." C) "A recovering person needs to get in touch with their feelings. Do you want a drink?" D) "A recovering person cannot return to drinking without starting the addiction process over."

A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse? A) "The violence is temporarily caused by unusual circumstances, don't stop hoping for a change." B) "Perhaps, if you understood the need to abuse, you could stop the violence." C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?" D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."

A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms? A) Drink small amounts of liquids frequently B) Eat the evening meal just before retiring C) Take sodium bicarbonate after each meal D) Sleep with head propped on several pillows

A young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed . Which response is best for the nurse to provide ? A. Encourage the client to seek genetic counseling to determine his risk for mental illness B. Inform the client that his mother's schizophrenia has affected his psychological development C. Tell the client that mental illness has a familial predisposition s he should see a psychiatrist D. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed

After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? A. notify the healthcare provider of the need to reposition the B. Remove the catheter and apply direct pressure for 5 minutes C. Secure the catheter using an aseptic technique D. Initiate intravenous fluids as prescribed

After receiving report on an inpatient acute care unit, which client should the nurse assess first? A. The client with an obstruction of the large intestine who is experiencing abdominal distention B. The client who has surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds C.The client with a small bowel obstruction who has nasogastric tube that is draining greenish fluid D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity

After reviewing the Braden Scale findings of residents at a long - term facility , the charge nurse should tell the unlicensed assistive personnel (UAP) to prioritize skin care for which client? A. A poorly nourished client who requires liquid supplements B. An older adult who is unable to communicate elimination needs C. A woman with osteoporosis who is unable to bear weight D. A older man whose sheets are damp each time he is turned.

After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, "My husband told me to get treatment or he would divorce me. I don't believe I really need treatment but I don't want my husband to leave me." Which response by the nurse would assist the client? A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people can't get well." B) "In early recovery, it's quite common to have mixed feelings, but I didn't know you had been pressured to come." C) "In early recovery it's quite common to have mixed feelings, perhaps it would be best to seek treatment on an out client bases." D) "In early recovery, it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you."

An elderly client with tuberculosis has difficulty coughing up secretions for a sputum specimen. Which nursing action is appropriate? A) Spray the oropharynx with saline B) Ask the client to drink a warm liquid C) Force fluids for the next 8 hours D) Raise the head of the bed to at least 45 degrees

An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? A. Urine specific gravity is 1.040 B. Systolic blood pressure decreases by 10 points when standing C. The client denies being thirsty D. Skin tenting occurs when the client's forearm is pinched

An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurse's response should be based on what information? A. The client probably has an organic brain disease and will likely have alzheimer's disease within a few years B. The family needs a social worker to talk to them about how to handle their father when he becomes annoying C. The daughter is under stress and should be encouraged to think about happier times D. If the client was compulsive about food when he was younger, the aging process can magnify this

An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as a result of a cerebral vascular accident (CVA). Which action should the nurse include in the plan of care? A. Use hands and arm gestures to improve communication and comprehension B. Provide additional light in the room to promote sensory stimulation C. Place a clock and calendar in the room to improve orientation D. Teach the client to turn his head from side to side to visual scanning

As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? A) Ask the student: "What did you forget to do?" B) Stop. Tell me why aspiration is needed. C) Loudly state: "You forgot to aspirate." D) Walk up and whisper in the student's ear "Stop. Aspirate. Then inject."

As the nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate? A) High doses of aspirin will be continued for some time B) Complete recovery is expected within several days C) Active range of motion exercises should be done frequently D) The measles, mumps and rubella vaccine should be delayed

During the initial home visit a nurse is discussing the care of a newly diagnosed client with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time? A) Leave a book about relaxation techniques B) Write out a daily exercise routine for them to assist the client to do C) List actions to improve the client's daily nutritional intake D) Suggest communication strategies

During the use of an interpreter to teach a client about a procedure to do in the home the nurse should take which approach? A) Speak directly to the interpreter while presenting information and use pauses for questions B) Talk to the interpreter in advance and leave the client and interpreter alone C) Include a family member and direct communications to that person D) Face the client while presenting the information as the interpreter talks in the native language

In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding? A) Age 40 years B) Lactose intolerance C) Family history of breast cancer D) Uses cocaine on weekends

The RN delegates the task of taking vital signs of all the clients on the medical- surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client's blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client's left arm. Which of these statements is most accurate? A) The RN is accountable for this situation. B) The RN did not delegate appropriately. C) The UAP is covered by the RN's license. D) The UAP is responsible for following instructions.

The healthcare provider prescribes a sepsis protocol for a client with multiorgan failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the plan of care? A. Assess warmth of extremities B. Keep head of bed raised 45 degrees C. Monitor blood glucose level D. Maintain strict intake and output

The nurse asks a client with a history of alcoholism about the client's drinking behavior. The client states "I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense mechanism? A) Denial B) Projection C) Intellectualization D) Rationalization

The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago . The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage . What action should the nurse implement ? A. Monitor the client's current white blood cell count (WBC) B. Withhold next scheduled dose of low molecular weight heparin C. Confirm that the continuous passive motion device is intact D. Determine if the wound drainage device is functioning correctly

The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of evaluation would best measure learning? A) Performance on written tests B) Responses to verbal questions C) Completion of a mailed survey D) Reported behavioral changes

The nurse in the same day surgery unit assigns the unlicensed assistive personnel (UAP) to give a 1000 ml soap solution enema (SSE) to a client scheduled for an abdominal hysterectomy. Whichstatement by the nurse is most appropriate? A) "Administer enemas until the results are clear." B) "Give 3 enemas before surgery." C) "Let me know the results of the enema." D) "Slow the flow of the solution if cramping occurs."

The nurse instructs a client in use of a incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration? A. Auscultate the client's lungs for adventitious sounds B. Encourage the client to practice until successful C. Emphasize the need to inhale slowly into the spirometer D. Remind the client to cough after using the spirometer

The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C)Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings

The nurse is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse's immediate attention? A) Temperature of 37.5 degrees Celsius B) Urine output of 300 cc in 4 hours C) Poor skin turgor D) Blood glucose of 350 mg/dl

The nurse is assessing a client on admission to a community mental health center. The client discloses that she has been thinking about ending her life. The nurse's best response would be A) "Do you want to discuss this with your pastor?" B) "We will help you deal with those thoughts." C) "Is your life so terrible that you want to end it?" D) "Have you thought about how you would do it?"

The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)? A) April 8 B) January 15 C) February 11 D) December 2

The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? A) Covering the wound with a dry dressing B) Using hydrogen peroxide soaks C) Leaving the area open to dry D) Applying a hydrocolloid or foam dressing

The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the mother supports the presence of this problem? A) When I put my finger in the left hand the baby doesn't respond with agrasp. B) My baby doesn't seem to follow when I shake toys in front of the face. C) When it thundered loudly last night the baby didn't even jump. D) When I put the baby in a back lying position that's how I find the baby.

The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information? A) "I usually avoid driving at night since lights sometimes seem to make things blur." B) "I take half of the usual dose for my sinuses to maintain my blood pressure." C) "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem." D) "I take extra fiber and drink lots of water to avoid getting constipated."

The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance? A) Arterial septal defect B) Patent ductus arteriosus C) Aortic stenosis D) Ventricular septal defect

The nurse is caring for a 15 month-old child with a first episode of otitis media. Which of the following interventions should the nurse include in instructions to the child's parents? A) Explain that the child should complete the full 5 days of antibiotics B) Provide them with handout describing care of myringotomy tubes C) Describe the tympanocentesis to detect persistent infections D) Emphasize the importance of a return visit after completion of antibiotics

The nurse is caring for a 16 year-old client with femur fracture14 hours after surgery. Assessment findings include tachycardia, increased shortness of breath, a temperature of 100.2 degreesFahrenheit, complaints of feeling anxious, and oxygen saturation level of 88%. In immediately notifying the provider of these findings, the nurse recognizes the client is at risk for A) compartment syndrome B) atelectasis C) myocardial infarction D) fatty embolism

The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses

The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client? A) Protection for the granulation tissue B) Heal infection C) Decried eschar D) Keep the tissue intact

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? A. Determine if the client is experiencing any anxiety B. Auscultate the client's bilateral lung sounds and oxygen saturation C. Notify the healthcare provider about the client's distress D. Assess the delivery mechanism of the oxygen tank, tubing, and cannula

The nurse is caring for a client with uncontrolled hypertension. Which findings require priority nursing action? A) Lower extremity pitting edema B) Rales C) Jugular vein distension D) Weakness in left arm

The nurse is caring for a newborn who has just been diagnosed with hypospadias. After discussing the defect with the parents, the nurse should expect that A) Circumcision can be performed at any time B) Initial repair is delayed until ages 6-8 C) Post-operative appearance will be normal D) Surgery will be performed in stages

The nurse is caring for four clients, Client A has emphysema, and oxygen saturation is 94%. Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L). Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L), and Client D, scheduled for an appendectomy has a white blood cell (WBC) count of 14,000 mm3 (14 x 103/L). What intervention should the nurse implement? A. Move Client D into an isolation room 24 hours before surgery B. Increase Client A's oxygen to 4 L a minute per nasal cannula C. Ask the dietitian to add a banana to Client C's breakfast tray D. Verify that Client B has two units of packed cells available

The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? A) Leave the order for the oncoming staff to follow-up B) Contact the charge nurse for an interpretation C) Ask the pharmacy for assistance in the interpretation D) Call the provider for clarification

The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the health care provider? A) Lifts head from the prone position B) Rolls from abdomen to back C) Responds to parents' voices D) Falls forward when sitting

The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse? A) "Do you want to take this pretty red medicine?" B) "You will feel better if you take your medicine." C) "This is your medicine, and you must take it all right now." D) "Would you like to take your medicine from a spoon or a cup?"

The nurse is preparing a client for discharge who was hospitalized with an acute flare of systemic lupus erythematosus (SLE) symptoms. Which instruction is most important for the nurse to include? A. Use a walker when weakness occurs B. Take prescribed cortisone accurately C. Decreased daily intake of sodium in diet D. Avoid extreme environmental temperatures

The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test? A) Client should be NPO after midnight B) Client should receive a sedative medication prior to the test C) Discontinue anti-coagulant therapy prior to the test D) No special preparation is necessary

The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate? A) The parents' name and telephone number B) The currency of the immunization and allergy history of the child C) The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the ingested substance D) The affected child's age and weight

The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client? A) "Take at least 2 weeks off from work." B) "You will need another chest x-ray in 6 weeks." C) "Take your temperature every day." D) "Complete all of the antibiotic even if your findings decrease."

The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction? A) "I should position my baby completely facing me with my baby's mouth in front of my nipple." B) "The baby should latch onto the nipple and areola areas." C) "There may be times that I will need to manually express milk." D) I can switch to a bottle if I need to take a break from breast feeding

The nurse is speaking to a group of parents and school teachers of children about care for children with rheumatic fever. It is a priority to emphasize that A) Home schooling is preferred to classroom instruction B) Children may remain strep carriers for years C) Most play activities will be restricted indefinitely D) Clumsiness and behavior changes should be reported

The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these demonstrates the normal pathway? A) AV node, SA node, Bundle of His, Purkinje fibers B) Purkinje fibers, SA node, AV node, Bundle of His C) Bundle of His, Purkinje fibers, SA node , AV node D) SA node, AV node, Bundle of His, Purkinje fibers

The nurse is teaching administration of albuterol inhalation to an adult with asthma. Which of the following demonstrates proper teaching? A) "Use this medication at bedtime to promote rest." B) "Discontinue the inhalation if you are dizzy." C) "Inhale this medication after other asthma sprays." D) "Notify the health care provider if you need the drug more often."

The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4year-old child? A) "I strap the infant car seat on the front seat to face backwards." B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen." C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa." D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper."

The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to? A) Walk up to the health care provider and quietly state: "Stop this unacceptable behavior." B) Allow the staff nurse to handle this situation without interference C) Notify the of the other administrative persons of a breech of professional conduct D) Request an immediate private meeting with the health care provider and staff nurse

The nurse prepares to administer eye drops to a 6 year-old child. Which of these demonstrates the correct method for instillation of eye drops? A) Directly on the anterior surface of the eyeball B) In the corner where the lids meet C) Under the upper lid as it is pulled upward D) In the conjunctival sac as the lower lid is pulled down

The nurse prepares to give a one year-old child an intramuscular injection. Where is the best site for this injection? A) Deltoid muscle B) Ventrogluteal muscle C) Dorsogluteal muscle D) Vastus lateralis muscle

The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem? A) Chronic vessel plaque formation B) Pulmonary embolism C) Occlusions at the vessel bifurcations D) Coronary artery aneurysms

The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include A) Pointing out inconsistencies in speech patterns to correct thought disorders B) Accepting client and the client's behavior unconditionally C) Encouraging dependency in order to develop ego controls D) Consistent limit-setting enforced 24 hours per day

The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealingwith the parents' comments? A) Focus on the child's needs and recovery B) Explain the cause of the child's illness C) Acknowledge that early care would have been better D) Accept their feelings without judgment

The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention? A. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack B. A 16-year-old client with major depression who refuses to participate in group C. A 17-year-old client with bipolar disorder who is pacing around the lobby D. An 18-year-old client with antisocial behavior who is being yelled at by other client's.

To obtain data for the nursing assessment, the nurse should: A) Observe carefully the client's nonverbal behaviors B) Adhere to pre-planned interview goals and structure C) Allow clients to talk about whatever they want D) Elicit clients' description of their experiences, thoughts and behaviors

To prevent medication errors by an older client who is sometimes confused, which intervention by the home health nurse is likely to be most effective? A. Have an alert family member administer medications B. Encourage taking medications at the same times daily C. Instruct the client to wear glasses when reading labels D. Provide education both verbally and in written format

What is the most important consideration when teaching parents how to reduce risks in the home? A) Age and knowledge level of the parents B) Proximity to emergency services C) Number of children in the home D) Age of children in the home

What might the nurse suggest to a client with fibrocystic breasts in an attempt to help relieve her symptoms? A. "Eliminate caffeine from your diet." B. "Avoid vigorous physical exercise immediately after your menstrual period." C. "Eat a low-carbohydrate, high-protein diet." D. "Increase high-calcium foods in your diet."

When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding? A. The second stage of labor lasted 10 minutes B. She received butorphanol 2mg IVP during labor C. She is over 35 years of age D. She is a gravida, 6 para 5

When caring for a client with a traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past eight hours the client's GCS score has been 14. What does this GCS finding indicate about the client? A. Rehabilitative prognosis is an expected full recovery B. Risk for a reversible cerebral damage related to increased ICP C. Insertion of an ICP monitoring device is necessary D. Neurologically stable without indications of an increased ICP

When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in? A) Competitive board games with older children B) Playing with their own toys along side with other children C) Playing alone with hand held computer games D) Playing cooperatively with other preschoolers

When screening children for scoliosis, at what time of development would the nurse expect early signs to appear? A) Prenatally on ultrasound B) In early infancy C) When the child begins to bear weight D) During the preadolescent growth spurt

When suctioning a client's tracheostomy, the nurse should instill saline in order to A) Decrease the client's discomfort B) Reduce viscosity of secretions C) Prevent client aspiration D) Remove a mucus plug

When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child? A) Provide a verbal explanation just prior to the surgery B) Provide the child with a booklet to read about the surgery C) Introduce the child to another child who had heart surgery 3 days ago D) Explain the surgery using a model of the heart

When the nurse enters the room of a male client who was admitted for a fractured femur , his cardiac monitor displays a normal sinus rhythm ( NSR ) , but he has no spontaneous respirations and his carotid pulse is not palpable . Which intervention should the nurse implement A. Analyze the cardiac rhythm in another lead B. Obtain a 12-lead electrocardiogram C. Observe for swelling at the fracture site D. Begin chest compressions at 100/minute

Which approach is a priority for the nurse who works with clients from many different cultures? A) Speak at least 2 other languages of clients in the neighborhood B) Learn about the cultures of clients who are most often encountered C) Have a list of persons for referral when interaction with these clients occur D) Recognize personal attitudes about cultural differences and real or expected biases

Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall

Which of the following classifications of medications would be most often used for clients with schizophrenia? A) Anti-depressants B) Mood stabilizers C) Anxiolytics D) Neuroleptics

Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test? A) Client must be NPO before the examination B) Enema to be administered prior to the examination C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination D) No special orders are necessary for this examination

Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn't hurt when I went.

Which of these clients would the nurse monitor for the complication of C. difficile diarrhea? A) An adolescent taking medications for acne B) An elderly client living in a retirement center taking prednisone C) A young adult at home taking a prescribed amino glycoside D) A hospitalized middle aged client receiving clindamycin

an older client with chronic emphysema is admitted to the ED with weakness, palpitations, and vomiting. which information is most important...initial interview? A. History of smoking over the past 6 months B sleep. patterns during the previous few weeks C. Activity level. prior to the onset of symptoms D. Recent compliance with. prescribed medications

the nurse is caring for a client who has COPD and a recent fall. what nursing intervention requires the greatest caution when caring for a cl.. A. Monitoring telemetry and cardiac rhythm B. Assisting client to cough and deep breath C. Increasing the client's fluid intake D. Administering narcotics for pain relief

the nurse is feeding an older client who was admitted with aspiration....coughing while attempting to drink through a straw. which interventions should the nurse implement? A. Assess the client's oral cavity for ulcerations B. Monitor the client when using a straw for liquids C. Teach coughing and deep breathing exercises D. Request thick nectar liquids for the client

the nurse is working in an infectious disease unit. which client should be assigned to a room with negative airflow.. and requiring staff to observe airborne, as well as standard precautions? A. a female adolescent admitted with multiple genital herpes simplex II lesions. B. An older client with scabies who is admitted from an. extended care facility C. Twin siblings admitted with. scarlet fever which is complicated by pneumonia. D. A client with a positive Mantoux and sputum cultures results positive for AFB.

the nurse should be most concerned about the risk of injury/falls after administering what medication A. Pantoprazole B. Famotidine C. Clarithromycin D. Promethazine

After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate A) 3 oz. broiled fish, 1 baked potato, . cup canned beets, 1 orange, and milk B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence? A) "I am determined to leave my house in a week." B) "No one else in the family has been treated like this." C) "I have only been married for 2 months." D) "I have tried leaving, but have always gone back."

D) "I have tried leaving, but have always gone back."

A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is A) "I apologize for the delay. I was involved in an emergency." B) "Let's talk. Why are you upset about this?" C) "I am surprised that you are upset. The request could have waited a few more minutes." D) "I see this is frustrating for you. I have a few minutes so let's talk."

D) "I see this is frustrating for you. I have a few minutes so let's talk."

D) "I went to the health care provider last week for a cold and I have gotten worse."

which conditions are most likely to respond to treatment with antihistamines ?(select all) A. Bronchitis B. Myocarditis C. Otitis media D. Contact dermatitis E. ALlergic rhinitis

D, E

D) Bed in lowest position, wheels locked, place bed against wall

A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A) Reverse B) Airborne C) Standard precautions D) Contact

D) Contact

A 2 day-old child with spina bifida and meningomyocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents? A) Depression B) Anger C) Frustration D) Disbelief

D) Disbelief

D) Flush adequately with water before and after using the tube

D) Have gloves on while handling bedpans with feces

D) I went to the bathroom and my urine looked very red and it didn't hurt when I went.

Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy? A) Eat a light diet for the rest of the day B) Rest for the next 24 hours since the preparation and the test is tiring. C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

D) No bowel movement for 3 days

A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? A) To observe the type and amount of nasogastric tube drainage B) Monitor the client for nausea or other complications C) Irrigate the nasogastric tube with the ordered irrigate D) Perform nostril and mouth care

D) Perform nostril and mouth care

A 10 year-old child has a history of epilepsy with tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure would be to A) Move any chairs or desks at least 3 feet away from the child B) Note the sequence of movements with the time lapse of the event C) Provide privacy as much as possible to minimize fighting the other children D) Place the hands or a folded blanket under the head of the child

D) Place the hands or a folded blanket under the head of the child

A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do? A) The refusal of any treatment for self and the neonate until she talks to a reader B) The placement of a rosary necklace around the neonate's neck and not to remove it unless absolutely necessary C) Arrange for a church elder to be at the emergency department when the ambulance arrives so a "laying on hands" can be done D) Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen."

D) Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen."

The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses

D) Pupil responses

Which of these findings would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? The client A) Has revitalized a relationship with her family to help cope with the death of a daughter B) Had recognized regressive behavior as a defense mechanism C) Expresses a desire to be cared for and pampered D) Recognizes feelings with appropriate expression of feelings

D) Recognizes feelings with appropriate expression of feelings

D) Serum potassium 6 mEq/L

The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? A) Assign an RN to provide total care of the client B) Assign a nursing assistant to help the client with self-care activities C) Delegate complete care to an unlicensed assistive personnel D) Supervise a nursing assistant for skin care

D) Supervise a nursing assistant for skin care

D) prevent the drug from tissue irritation

A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) drowsiness B) complaint of nausea C) pulse rate of 92 D) restlessness

D) restlessness

A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is A) difference in the intake and output B) changes in the mucous membranes C) skin turgor D) weekly weight

D) weekly weight

Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing A) "This action of my lips helps to keep my airway open." B) "I can expel more when I pucker up my lips to breathe out." C) "My mouth doesn't get as dry when I breathe with pursed lips." D) "By prolonging breathing out with pursed lips the little areas in my lungs don't collapse."

D. "By prolonging breathing out with pursed lips the little areas in my lungs don't collapse"

Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective? A) "I may experience seizures if I stop the medication apruptly." B) " I may experience an increase in my heart rate for a few weeks." C) " I can expect to feel nervousness the first few weeks." D) " I can have a heart attack if I stop this medication suddenly."

D. "I can have a heart attack if I stop this medication suddenly"

The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up? A) A 13 month-old unable to walk B) A 20 month-old only using 2 and 3 word sentences C) A 24 month-old who cries during examination D) A 30 month-old only drinking from a sip cup

D. A 30 month-old only drinking from a sip cup

The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to A) Begin cardiopulmonary resuscitation B) Prepare for immediate defibrillation C) Notify the "Code" team and health care provider D) Assess airway breathing and circulation

D. Assess airway breathing and circulation

The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has A) Achieved developmental milestones at an erratic rate B) Delay in musculoskeletal development C) Displayed difficulty with speech development D) Delay in achievement of most developmental milestones

D. Delay in achievement of most developmental milestones

Which of the following measures would be appropriate for the nurse to teach the parent of a nine month- old infant about diaper dermatitis? A) Use only cloth diapers that are rinsed in bleach B) Do not use occlusive ointments on the rash C) Use commercial baby wipes with each diaper change D) Discontinue a new food that was added to the infant's diet just prior to the rash

D. Discontinue a new food that was added to the infant''s diet just prior to the rash

At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially A) Allow the staff to change assignments B) Clarify reasons for current assignments C) Help staff see the complexity of issues D) Facilitate creative thinking on staffing

D. Facilitate creative thinking on staffing

57. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is A) Progressive failure to adapt B) Feelings of anger or hostility C) Reunion wish or fantasy D) Feelings of alienation or isolation

D. Feelings of alienation or isolation

The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. Which of these should be emphasized to the client to avoid? A) Large indoor gatherings B) Exposure to sunlight C) Active physical exercise D) Foods rich in vitamin K

D. Foods rich in vitamin K

On admission to the hospital a client with an acute asthma episode has intermittent nonproductive coughing and a pulse oximeter reading of 88%. The client states, "I feel like this is going to be a bad time this admission. I wish I would not have gone into that bar with all those people who smoke last night." Which nursing diagnoses would be most important for this client? A) Anxiety related to hospitalization B) Ineffective airway clearance related to potential thick secretions C) Altered health maintenance related to preventative behaviors associated with asthma D) Impaired gas exchange related to broncho constriction and mucosal edema

D. Impaired gas exchange related to broncho constriction and mucosal edema

While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality? A) Flexion of lower extremities B) Negative Ortlani response C) Lengthened leg of affected side D) Irregular hip symmetry

D. Irregular hip symmetry

Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: "We just don't know how he caught the disease!" The nurse's response is based on an understanding that A) AGN is a streptococcal infection that involves the kidney tubules B) The disease is easily transmissible in schools and camps C) The illness is usually associated with chronic respiratory infections D) It is not "caught" but is a response to a previous B-hemolytic strep infection

D. It is not "caught" but is a response to a previous B-hemolytic strep infection

A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse? A) Call a chaplain B) Deny the feelings C) Cite recovery statistics D) Listen to the client

D. Listen to the client

The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately? A) 3 episodes of vomiting in 1 hour B) Periodic crying and irritability C) Vigorous sucking on a pacifier D) No measurable voiding in 4 hours

D. No measurable voiding in 4 hours

Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes? A) Give written pre and post tests B) Ask questions during practice C) Allow another diabetic to assist D) Observe a return demonstration

D. Observe a return demonstration

The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate? A) Offer ice cream every 2 hours B) Place the child in a supine position C) Allow the child to drink through a straw D) Observe swallowing patterns

D. Observe swallowing patterns

A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is A) High risk for infection related to vomiting B) Altered family processes related to chronic illness C) Fluid volume deficit related to vomiting D) Risk for aspiration related to loss of consciousness

D. Risk for aspiration related to loss of consciousness

The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? A) Altered tissue perfusion B) Risk for fluid volume deficit C) High risk for hemorrhage D) Risk for infection

D. Risk for infection

1. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? A) Nutrition B) Elimination C) Activity D) Safety

D. Safety

The nurse is caring for an acutely ill 10 year-old client. Which of the following assessments would require the nurses immediate attention? A) Rapid bounding pulse B) Temperature of 38.5 degrees Celsius C) Profuse Diaphoresis D) Slow, irregular respirations

D. Slow, irregular respirations

The RN is planning care at a team meeting for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application? A) Infant will experience minimal pain B) Muscle spasms will be relieved C) Mobility will be managed as tolerated D) Tissue perfusion will be maintained

D. Tissue perfusion will be maintained

To auscultate for a carotid bruit, the nurse places the stethoscope at what location.

Photo note: Place the red dot on the base of the neck of the right side

A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position?

See Photo Answer: D

Which laboratory finding for an adult client is most critical for the nurse to report to the healthcare provider ? (Click on the correct location on the chart To change , click on a new location)

Serum glucose 62 mg/ dL (3.4 mmol/L)

A client with syndrome of inappropriate antidiuretic hormone secretion (SIDH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? a. Initiate seizure precautions. b. Assess neurological status every 8 hours. c. Limit oral water intake. d. Administer a hypertonic IV fluids as prescribed.

The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900, what nursing action is most important? a. Confirm that the client has been NPO since midnight. b. Review postoperative instructions with the client. c. Offer to assist the client to the restroom to void. d. Determine when the client last had pain medication.

The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client's plan of care? a. Ensure adequate IV and oral fluid intake. b. Provide ice packs to major joint areas. c. Space analgesics to prevent addiction to narcotics. d. Re-enforce the importance of nutritional balance.

Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? a. "When I get out of bed quickly, I feel a little dizzy." b. "The dressing over my incision feels like it is too tight." c. "I'm most comfortable when the head of the bed is raised." d. "This IV infusion makes me urinate more often than usual."

A male client being treated for testicular cancer with chemotherapy has a decreased alpha fetoprotein radioimmunoassay (AFP). Which nursing intervention should the nurse implement? a. Advise the client that the treatment is having a beneficial effect. b. Instruct the client to obtain prostate-specific antigen (PSA) testing. c. Inform the client that his chemotherapy dose will probably be increased d. Discuss options for hospice care with the client and family members.

a. Advise the client that the treatment is having a beneficial effect.

A client with a C-7 spinal cord injury is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor? a. An acutely distended bladder. b. Profuse forehead diaphoresis. c. Skeletal traction misalignment. d. A severe pounding headache.

a. An acutely distended bladder.

The nurse who is working on a post surgical intensive care unit receives report regarding the assigned clients for the upcoming shift. Which client should the nurse assess first? a. An adult who has a collapsed lung related to a fall from ladder 8 hours ago and now has 100 mL chest tube drainage. b. A young adult who had an abdominoperineal resection 3 days ago and is currently complaining of chills. c. An older adult who had a mastectomy 2 days ago and has 50 mL serosanguinous fluid in the Jackson-Pratt (JP) drain. d. A teenager who had a gunshot wound repair yesterday and has quarter-size dark drainage on the dressing.

a. An adult who has a collapsed lung related to a fall from ladder 8 hours ago and now has 100 mL chest tube drainage.

The nurse notes that a client's legs become dusky-red whenever the client is sitting with both feet dangling. Which follow-up assessment should the nurse complete? a. Ankle brachial index (ABI). b. Joint range of motion. c. Calf diameter. d. Skin elasticity.

a. Ankle brachial index (ABI).

The healthcare provider prescribes oral vancomycin for a female client who has Clostridium difficile in the stool. Which action should the nurse take before administering the first dose? a. Assess body temperature. b. Auscultate bowel sounds. c. Check serum creatinine. d. Measure oxygen saturation.

a. Assess body temperature.

After administering the ACE Inhibitor lisinopril, it is most important for the nurse to monitor which assessment finding? a. Blood pressure and risk for falls. b. Serum potassium and skin turgor. c. Heart rate and complaints of nausea. d. Eosinophil count and constipation.

a. Blood pressure and risk for falls.

A Journalist asks the nurse working in the Emergency Department about the condition of a local politician recently admitted to the medical center following a publicly reported building fire. Which aclion should the nurse take? a. Direct the journalist to the agency's Communication/Marketing department. b. Document the official identification of the journalist before providing any information. c. Obtain verbal consent from a family member before discussing the client's condition. d. Provide only general information regarding the client's over-all condition.

a. Direct the journalist to the agency's Communication/Marketing department.

A client who is admitted to the emergency room following a motorcycle accident is having difficulty breathing. While assessing the client's chest and lungs, the nurse notes that there are no breath sounds over the left flelds. Which actions should the nurse implement? (Select all that apply.) a. Elevate the head of the bed 45 degrees. b. Place client in Trendelenburg position. c. Withhold narcotic pain medication. d. Apply a high-flow oxygen by face mask. e. Obtain a chest tube insertion kit.

a. Elevate the head of the bed 45 degrees. d. Apply a high-flow oxygen by face mask. e. Obtain a chest tube insertion kit.

An adolescent female with an eating disorder is admitted to the in-patient psychlatric unit. Which intervention should the nurse implement? a. Encourage the client to weigh herself daily at bedtime. b. Allow the client to select an arts and crafts activity. c. Recommend exercise and recreation in the morning. d. Put the client in charge of choosing snacks for the unit.

a. Encourage the client to weigh herself daily at bedtime.

The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? a. Exercise in a swimming pool. b. Splint affected joints during activity. c. Perform passive range of motion exercises twice daily. d. Begin a training program lifting weights and running.

a. Exercise in a swimming pool.

When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? a. Explain that the client may be placed in five positions b. Instruct the client to breathe shallow and fast. c. Obtain arterial blood gases (ABGs) prior to procedure. d. Perform the drainage immediately after meals.

a. Explain that the client may be placed in five positions

A 60-year-old female client asks the nurse about hormone replacement therapy (HRT) as a means of preventing osteoporosis. Which factor in the client's history is a possible contraindication for use of HRT? a. Her mother and sister have a history of breast cancer. b. Her 60-year-old sister has Alzheimer's disease. c. She is taking medication for high blood pressure. d. She had problems with "hot flashes" several years ago.

a. Her mother and sister have a history of breast cancer.

The home health nurse observes an older client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. Which action should the nurse take? a. Hold the walker securely to prevent slipping when the client rises. b. Apply a gait belt to assist the client to rise out of the chair. c. Instruct the client to use the arms of the chair for support. d. Encourage client to use the weaker leg with the walker when rising.

a. Hold the walker securely to prevent slipping when the client rises.

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? a. Hypoalbuminemia that results in a decreased colloidal oncotic pressure. b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules. c. Decreased renin-angiotensin response related to an increase in renal blood flow. d. Decreased portacaval pressure with greater collateral circulation.

a. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.

When is the best time for the nurse to assess a client for residual urine? a. Immediately after the client voids. b. Just prior to the client voiding. c. After draining the urinary catheter bag. d. When the client's bladder is distended.

a. Immediately after the client voids.

After taking lactulose for several days, which therapeutic response should the nurse expect for a client with hepatic encephalopathy? a. Improved mental status. b. Reduction in number of liquid stools. c. Ability to ambulate independently. d. Increase in urine output.

a. Improved mental status.

Arterial blood gas (ABG) results Indicate that a client with respiratory faiture who is being mechanically ventilated has respiratory acidosis. The ventilator rate is set at 6 breaths/minute, pressure support at 10 cm H20, and oxygen concentration at 30%. Which action should the nurse implement to help correct the client's acidosis? a. Increase in the ventilator rate. b. Provide manual resuscitation. c. Decrease the pressure support. d. Increase oxygen concentration.

a. Increase in the ventilator rate.

A client recently diagnosed with Hodgkin's disease undergoes biopsy of cervical lymph nodes under local anesthesia. Which intervention is most important to include in this client's plan of care? a. Monitor for tracheal deviation and swelling at biopsy site. b. Assess for drainage on dressing covering cervical incision. c. Auscultate blood pressure every 15 minutes for one hour. d. Perform neurological assessment prior to discharge.

a. Monitor for tracheal deviation and swelling at biopsy site.

When teaching a client with Parkinson's disease, which rationale for the prescription of carbldopa-levodopa should the nurse include? a. Increases the amount of dopamine available for muscles to function correctly. b. Slows the scarring in the myelin sheath improving muscle tone and strength. c. Reduces the inflammatory process improving nerve transmission and function. d. Acts as an antiseizure medication reducing the tremors caused by the disease.

a. Increases the amount of dopamine available for muscles to function correctly.

A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a "do not resuscitate" (DR) prescription. Which action should the nurse take? a. Initiate an ethics committee review of the case b. Place a DR bracelet on the client's arm. c. Ensure resuscitation equipment is available. d. Ask the family to review options with the client.

a. Initiate an ethics committee review of the case

While admitting a client to the surgical unit who had a pneumonectomy 4 hours ago, the call system alarm is initiated by a client in another room. Which action should the nurse implement? a. Investigate the reason for the call bell alarm then complete the admission assessment. b. Tell the unit clerk to ask the client via the intercom what is needed. c.Ask a coworker to respond to the client whose call bell is alarming. d. Complete the postoperative admission assessment then investigate the call bell alarm.

a. Investigate the reason for the call bell alarm then complete the admission assessment.

The nurse Is reviewing the laboratory values for a client with acute pancreatitis who reports of the abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to evaluate the client's clinical recovery? a. Lipase. b. Creatinine. c. Bilirubin. d. Glucose.

a. Lipase.

The nurse is assessing a client who was recently extubated. The client has oral medications prescribed. Which clinical findings indicate the client may be able to safely take oral medications? (Select all that apply.) a. Manages oral secretions. b. Alert and oriented. c. Ability to pass flatus. d. Dentures are in place. e. Gag reflex present.

a. Manages oral secretions. b. Alert and oriented. e. Gag reflex present.

A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? a. Offer information about ultrasonography and genotyping to determine sex assignment. c. Explain that corrective surgical procedures consistent with sex assignment can be delayed. c. Discuss the need for cortisol and aldosterone replacement therapy after discharge. d. Support the parents in their decision to assign sex of their child according to their preference.

a. Offer information about ultrasonography and genotyping to determine sex assignment.

During a 24-hour chart revlew of a client in acute renal failure, the nurse notices that a prescription, written 12 hours ago for every 6 hours serum potasslum levels, was not transcribed by the previous shift. Which is the best immediate action for the nurse to take? a. Order the lab work as prescribed and follow procedures for completing an incident report. b. Telephone the nurse responsible for the error at home to report the omission of the transcription. c. Call the healthcare provider and ask if the prescription is still needed since 12 hours have elapsed since it was written. d. Notify the nursing supervisor of the previous shift's omission in not transcribing the prescription.

a. Order the lab work as prescribed and follow procedures for completing an incident report.

A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? a. Place the client in Trendelenburg. b. Administer oxygen via face mask. c. Notify the operating room team. d. Administer a fluid bolus of 500 mL.

a. Place the client in Trendelenburg.

An older woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? (Select all that apply.) a. Recommend installing grab bars by toilets, bathtub, and shower. b. Have the home health nurse assess the home for fall risks. c. Encourage exercise to improve balance and mobility. d. Wear an emergency response pendant at home. e. Request that a family member move in with her.

a. Recommend installing grab bars by toilets, bathtub, and shower. b. Have the home health nurse assess the home for fall risks. d. Wear an emergency response pendant at home.

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement? a. Reduce the stimuli in the area before continuing the teaching. b. Provide the client with step-by-step written instructions. c. Reassure the client that the skill is not difficult to learn. d. Demonstrate the skill, speaking slowly and using simple terms.

a. Reduce the stimuli in the area before continuing the teaching.

The nurse is communicating with a 12-year-old who is hearing impaired. Which action is best for the nurse to use when attempting to communicate with this child? a. Use a picture board to communicate needs. b. Attract the child's attention before speaking. c. Convey ideas by writing short sentences. d. Emphasize emotions with facial expressions.

a. Use a picture board to communicate needs.

After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary pacemaker. When the client expresses concern and fear of the pacemaker, how should the nurse respond? a. Use simple terms to describe how the pacemaker functions. b. Offer reassurance that the staff will monitor the pacemaker. c. Reinforce that the pacemaker is a temporary measure. d. Encourage discussion about the concerns and fears.

a. Use simple terms to describe how the pacemaker functions.

A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy test and ultrasound were negative, so an exploratory laparotomy was completed during the night. When coffee ground material is observed in the drainage from the nasogastric tube (NGT), which Intervention should the nurse implement? a. Verify correct placement of the nasogastric tube b. Perform gastroccult test on the nasogastric drainage. c. Listen for evidence of diminished bowel sounds. d. Irrigate the nasogastric tube with water until clear.

a. Verify correct placement of the nasogastric tube

The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe, colicky abdominal pain, nausea, vomiting, and abdominal distention. Which pathophysiologic mechanism supports the client's clinical presentation? a. An incompetent lower esophageal sphincter. b. A weakened diaphragm with high, abdominal pressure c. Intestinal scar tissue buildup from a chronic condition. d. A history of having Helicobacter pylori infection.

b. A weakened diaphragm with high, abdominal pressure

A middle-aged client is returned from the intensive care unit to the surgical unit following a right pneumonectomy for cancer of the lung. The client has a patient control analgesic (PCA) pump and 2 right chest tubes which are clamped for the surgeon to release serosanguineous drainage. Which assessment finding requires immediate intervention by the nurse? a. Pain at level of 5 on a scale of 1 to 10 with use of PCA. b. Absence of lungs sounds on the operative side. c. A high-pitched, course sound over the trachea. d. Requests to see his family at his bedside immediately.

b. Absence of lungs sounds on the operative side.

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client's history should the nurse further explore? a. Inadequate diversional activity. b. Alcohol use. c. Witness to an accident. d. Family history of dementia.

b. Alcohol use.

The nurse observes an elderly male client walking aimlessly in the hallway and staring straight ahead blankly. How should the nurse enter computer documentation of this finding? a. Demonstrates signs of early dementia. b. Appears confused and depressed. c. Ambulatory and disoriented to place. d. Wandering behavior with flat affect.

b. Appears confused and depressed.

A postoperative client has a large amount of serosanguineous drainage on the surgical dressing and the nurse notes that the operative report Indicates that the client has a Penrose drain near the incision. What intervention should the nurse implement when changing the client's dressing? a. Place sterile gauze dressings under the Penrose drain. b. Apply sterile gloves before removing the soil dressing. c. Cover the Penrose drain with a saline moistened gauze. d. Wear a face mask or shield during the dressing change.

b. Apply sterile gloves before removing the soil dressing.

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete? a. Observe for edema around the ankles. b. Auscultate the client's bowel sounds. c. Count the apical and radial pulses simultaneously. d. Measure the client's capillary glucose level.

b. Auscultate the client's bowel sounds.

A client is receiving a continuous infusion of normal saline at 125 ml/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 mL over the past 24 hours with a central venous pressure of 15 mmH. The nurse notes respiratory crackles and bounding central pulses. Vital signs: temperature 101.2 °F (38.4° C), heart rate 96 beats/minute, respirations 24 breaths/minute, and blood pressure of 160/90 mmH. Which intervention should the nurse implement first? a. Review last administration of IV pain medication. b. Decrease IV fluids, to keep vein open rate. c. Administer PRN dose of acetaminophen. d. Calculate total intake and output for last 24 hours.

b. Decrease IV fluids, to keep vein open rate.

The nurse notes that the influenza immunization rates are much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in these under-served immunization groups? a. Reports describing influenza rates during times of greatest prevalence. b. Designation of clinics conveniently located in target neighborhoods. c. Legislative proposals that mandate influenza vaccinations for all. d. Radio announcements about the availability of the influenza vaccine.

b. Designation of clinics conveniently located in target neighborhoods.

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take? a. Listen to the ethics committee discussions and then inform the client what actions should be taken. b. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client. c. Educate the client about current nursing literature findings related to the client's ethical dilemma. d. Challenge members of the healthcare team whose opinions differ from the wishes of the client.

b. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client.

A middle-aged male client, admitted to a critical care unit several weeks ago because of serious injuries sustained in a motor vehicle accident, is currently in stable condition. Based on this client's age and recent life-threatening crisis, which intervention is should the nurse Implement? a. Provide a routine schedule of activities to facilitate trust. b. Encourage the client to reflect on personal goals and priorities. c. Discuss the cause of the accident with the client and his family. d. Allow long periods of uninterrupted rest in order to reduce fatigue.

b. Encourage the client to reflect on personal goals and priorities.

Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from an indwelling urinary catheter? a. Ensure that the drainage bag is attached to the bed frame. b. Ensure continued sterility of the specimen container c. Securely fasten the clamp on the drainage bag. d. Label the container with the client's identifiers.

b. Ensure continued sterility of the specimen container

While intervlewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How shoul the nurse document this finding? a. Muscle flaccidity. b. Intention tremor. c. Transient ischemic attack. d. Sensory dysfunction.

b. Intention tremor.

Which diet should the nurse recommend for a client who is in acute renal failure? a. High protein, low carbohydrate, low sodium, low potassium. b. Low protein, high carbohydrate, low sodium, low potassium. c. Low protein, high carbohydrate, low sodium, high potassium. d. High protein, low carbohydrate, low sodium, high potassium.

b. Low protein, high carbohydrate, low sodium, low potassium.

Which long-term outcome is most important for the nurse include in the plan of care for an older adult client with chronic pyelonephritis? a. Maintains blood pressure within normal limits. b. Manages activities of daily living independently. c. Restricts fluid intake to 1 L/day. d. Measures oral temperature daily.

b. Manages activities of daily living independently.

The nurse is caring for a child newly diagnosed with attention deficit hyperactive disorder (ADHD). The child's mother asks about information of the treatment options.. Which Information is most helpful for the nurse to provide? a. Emphasize the addictive nature of popular medications. b. Offer effective time management strategies. c. Explore the combination of medication and behavioral therapies d. Discuss dietary changes such as increasing protein intake.

b. Offer effective time management strategies.

The mother of a 14-month-old tells the nurse that she feeds her child nothing but prepared toddler foods and feels they provide the best nutrition for her child, but is concerned about the cost. How should the nurse respond? a. Advise the mother that these foods will only be needed until the growth spurt of the toddler years is complete. b. Reassure the mother that beginning to replace prepared foods with table foods can provide the needed nutrients c. Affirm that these prepared foods are the best way to ensure that the toddler gets all the needed nutrients. d. Teach the mother how to develop a budget to allow her to continue to provide the needed prepared toddler foods.

b. Reassure the mother that beginning to replace prepared foods with table foods can provide the needed nutrients

After placing a 36-week-gesation newborn in an isolette and drying the infant with several blankets, what Should the nurse implement next? a. Administer the vitamin K injection. b. Remove the wet blankets and linens from the isolette. c. Place erythromycin opthalmic ointment in both eyes. d. Open the door to assess the infant's vital signs.

b. Remove the wet blankets and linens from the isolette.

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products, such as milk, to help coat and protect their ulcer. Which is the best follow-up action by the nurse? a. Remind the client that it is also important to switch to decaffeinated coffee and tea. b. Review with the client the need to avoid foods that are rich in milk and cream. c. Reinforce this teaching by asking the client to list dairy foods that he might select. d. Suggest that the client also plan to eat frequent small meals to reduce discomfort.

b. Review with the client the need to avoid foods that are rich in milk and cream.

A young client who is being taught to use an inhaler for symptoms of asthma tells the nurse the intention to use the inhaler but, plans to continue smoking cigarettes. In evaluating the client's response, what is the best initial action by the nurse? a. Review factors surrounding client's beliefs about smoking cessation. b. Revise the plan of care based on the client's plans to continue smoking. c. Inform the health care provider of this statement made by the client. d. Explain that denial of illness can interfere with the treatment regimen.

b. Revise the plan of care based on the client's plans to continue smoking.

After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse? a. Circumferential edema of right foot. b. Right foot pale with sluggish capillary refill. c. Complaint of throbbing right leg pain. d. Increased temperature to lower extremity.

b. Right foot pale with sluggish capillary refill.

After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without rellef. Her vital signs are heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70 mmH. The nurse obtains a 12- lead electrocardiogram (ECG). Which assessment finding is most critical? a. Irregular pulse rate. b. ST elevation in three leads. c. Complaint of radiating jaw pain. d. Bile colored emesis.

b. ST elevation in three leads.

The parent of an adolescent tells the clinic nurse, "My child has athlete's feet. I have been applying triple antibiotic ointment for two days, but there has been no improvement." Which instruction should the nurse provide? a. Antibiotics take two weeks to become effective against infections such as athlete's foot. b. Stop using the ointment and encourage complete drying of feet and wearing clean socks. c. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration. d. Continue using the ointment for a full week, even after the symptoms disappear.

b. Stop using the ointment and encourage complete drying of feet and wearing clean socks.

A 26-year-old client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? a. muscle cramping and dry, flushed skin. b. palpitations and shortness of breath. c. bradycardia and constipation. d. lethargy and lack of appetite.

b. palpitations and shortness of breath.

The charge nurse is making client assignments in the Intensive Care Department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12-week internship. Which client should the nurse assign to the new graduate nurse? a. A client with Adult Respiratory Distress Syndrome who is on a ventilator. b. A client in end-stage liver failure who is experiencing esophageal bleeding. c. A client with chest tubes secondary to a stab wound to the chest. d. A client with multisystem failure secondary to a motor vehicle collision.

c. A client with chest tubes secondary to a stab wound to the chest.

A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? a. Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes. b. In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness. c. The flow of life is believed to flow through major pathways or nerve clusters in your body. d. By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over.

An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? a. Determine the client's level of mobility and need for assistance. b. Instruct the UAP that all clients deserve equal care. c. Advice the client to maintain bedrest so that safety can be ensured. d. Assign another UAP to care for the client.

In caring for a client with Cushing's syndrome which serum laboratory value is most important for the nurse to monitor? A. Creatinine B. Lactate C. Glucose D. Hemoglobin

The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome shows a plan of care for this client? a. The client will express acceptance of his changing health status. b. The client's family will state signs and symptoms about the disease. c. The nurse will demonstrate the procedure for accurate eye care. d. The client's daily blood pressure will be less than 140/80 mmHg this month.

The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? a. It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes. b. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain c. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent d. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks

The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is effective? a. At-risk clients received an increased number of routine health screenings. b. Clients reported having new confidence in making healthy food choices. c. Clients who incurred disease complications promptly received rehabilitation. d. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention? a. A 16-year-old client diagnosed with major depression who refuses to participate in group. b. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. c. An 18-year-old client with antisocial behavior who is being yelled at by other clients d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby.

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement? A. Tell the client to stop the inappropriate behavior B. Complete an unusual occurrence report C. Leave the room and close the door quietly D. Ignore the behavior and hang the IV antibiotic

the nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed as seen in the. picture. what action should the nurse take first? A. Instruct the UAP to raise the bed level B. Provide. gloves for. the. UAP to apply C. Offer to help. reposition the client D. Place the side rails in an up position

The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment? a. "The fire is burning my skin away right now." b. "The voices are telling me to kill the next person I see." c. "The nurse at night is trying to poison me with pills." d. "The snakes on the wall are going to eat me."

c. "The nurse at night is trying to poison me with pills."

A client with stage I bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 1 to 10 scale. Which intervention should the nurse implement? a. Give maximum dosage when score reaches 10. b. Educate client on signs and symptoms of narcotic dependency. c. Administer opioid and non-opioid medication simultaneously. d. Alternate IV and IM analgesic medications.

c. Administer opioid and non-opioid medication simultaneously.

The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives a prescription for clonidine 0.2 mg PO taken twice daily. Which action should the nurse take? a. Monitor for signs of signs of bleeding or hemorrhage. b. Compare daily electrolyte levels prior to each morning dose. c. Advise to sit up slowly from a reclining position. d. Administer the medication on an empty stomach.

c. Advise to sit up slowly from a reclining position.

When preparing a client who is to undergo a resection of a leiomyosarcoma of the uterus, the nurse notices that apixaban is listed on the medication reconciliation list. Which assessment finding requires immediate nursing intervention? a. Abdominal redness and itching. b. Nausea and dry mouth. c. Bleeding gums. d. Finger joint pain.

c. Bleeding gums.

Which assessment finding places a client at risk for problems associated with impaired skin integrity? a. Smooth nail texture. b. Scattered macula on the face. c. Capillary refill 5 seconds. d. Absence of skin tenting.

c. Capillary refill 5 seconds.

Two days after admission for a fractured wrist from a fall while intoxicated, a male client with a history of mental illness and alcohol abuse becomes anxious, agitated, and diaphoretic. His vital signs are temperature 99.6 °F (37.6 °C), heart rate 112 beats/minute, respirations 26 breaths/minute, and blood pressure 190/108. He tells the nurse that bugs are crawling in his bed. Which prescription should the nurse administer? a. Buspirone. b. Codeine. c. Chlordiazepoxide. d. Risperidone.

c. Chlordiazepoxide.

A client with rheumatold arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make? a. Evidence of spread of the disease to the kidneys. b. Representative of a decline in the client's condition. c. Confirmation of the autoimmune disease process. d. Indication of the onset of joint degeneration.

c. Confirmation of the autoimmune disease process.

Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which intervention is most Important for the nurse to implement? a. Page the pediatrician STAT. b. Inform the parents of the infant's condition. c. Continue resuscitative efforts. d. Repeat the Agar assessment in 5 minutes.

c. Continue resuscitative efforts.

A client has a new prescription for the maximum recommended dosage of piperacillin/tazobactam for nosocomial pneumonia. The nurse should report which laboratory finding to the healthcare provider before administering the prescribed dose? a. Elevated white blood cell count. b. Presence of gram positive bacteria in the sputum. c. Decreased creatinine clearance d. Elevated cholesterol and lipoproteins.

c. Decreased creatinine clearance

During the admission assessment of a terminally ill client, the client expresses being an agnostic. Which is the best nursing action in response to this statement? a. Invite the client to a healing service for people of all religions. b. Provide information about the hours and location of the chapel. c. Document the statement in the client's spiritual assessment. d. Offer to contact a spiritual advisor of the client's choice.

c. Document the statement in the client's spiritual assessment.

In assessing a 70-year-old client with Alzheimer's disease, the nurse notes that the client has deep inflamed cracks at the corners of the mouth. Which intervention should the nurse include in this client's plan of care? a. Scrub the lesions with warm soapy water. b. Notify the healthcare provider of the need for oral antibiotics. c. Ensure that the client gets adequate B vitamins in foods or supplements. d. Encourage the client to drink orange juice for added vitamin C.

c. Ensure that the client gets adequate B vitamins in foods or supplements.

The nurse is performing intake interviews at a psychlatric clinic. A female client with a known history of drug abuse reports that she had a heart altack four years ago. Use of which substance places the client at highest risk for myocardial infarction? a. Marijuana. b. Benzodiazepine. c. Methamphetamine. d. Alcohol.

c. Methamphetamine.

A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. while planning care, the nurse is most concerned about preventing which complication related to these findings? a. Atelectasis. b. Exit site infection. c. Peritonitis. d. Outflow obstruction.

c. Peritonitis.

A client's tumor measures 2 cm before and after receiving a course of radiotherapy. What physiological mechanism renders this response to radiation therapy for cancers? a. Cellular anchorage that is necessary for cancer cell growth is removed. b. Cell growth is disrupted during the resting phase of the cell cycle. c. Production of ionizing energy damages DNA, hence stops replication. d. Reduction of contact inhibition results in cell death by phagocytosis.

c. Production of ionizing energy damages DNA, hence stops replication.

A client with hypothyroidism reports difficulty falling asleep because of feelings of depression. Which action should the nurse implement? a. Withhold next scheduled dose of levothyroxine. b. Request a PRN sedative-hypnotic to help with insomnia. c. Review most recent thyroid function test results. d. Encourage increased exercise and activity during the day.

c. Review most recent thyroid function test results.

The nurse uses the Glasgow coma scale (GCS) to assess a client who has had a stroke. When the nurse calls out the client's name, the client does not open eyes, does not respond to a painful stimulus, and does not make any spoken sound during the assessment. Which statement based on the GCS reflects correct documentation in the electronic medical record of the client's neurological status? a. GCS indicates no function. b. Comatose with no score using GCS. c. Score of 3 on the GCS. d. Unable to assess client using GCS.

c. Score of 3 on the GCS.

A successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist this client in diminishing his anxiety? a. Reinforce the reality of his financial situation. b. Direct him to drink a glass of red wine at bedtime. c. Teach him to limit sugar and caffeine intake. d. Encourage him to initiate daily rituals.

c. Teach him to limit sugar and caffeine intake.

An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview? a. History of smoking over the past 6 months. b. Sleep patterns during the previous few week. c. Activity level prior to onset of symptoms. d. Recent compliance with prescribed medications.

The nurse is educating a client in end-stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the client's daily diet? a. The intake of protein should be increased to stimulate the kidney's nephrons function. b. The intake of protein should be increased due to its loss through the filter membrane. c. The protein intake should be decreased to prevent nitrogenous waste buildup. d. The intake of protein should be decreased due to the progressively failing function of the kidney.

c. The protein intake should be decreased to prevent nitrogenous waste buildup.

A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to patient's safety, which short-term goal should the nurse include in the plan of care? a. Attends one group activity per day. b. Sleeps at least 6 hours per night. c. Engages in one client-to-client interaction daily. d. Consumes 3 meals and 1500 mL of fluid per day.

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. What action should the nurse take first? a. Determine if the newborn is in the nursery. b. Activate the lockdown procedure. c. Ask the mother if any visitors were expected to arrive. d. Match ID bands of all infants and mothers on the unit.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? a. Determine if the client is experiencing any anxiety. b. Auscultate the client's bilateral lung sounds and oxygen saturation. c. Notify the healthcare provider about the client's distress. d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.

The nurse is conducing a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? a. Gradual onset of continuous eye pain and blurred vision. b. Recent change in the ability to read and drive after dark. c. Gray-white circle around the iris of both eyes. d. Cloudy opacity of the crystalline lens.

Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure? a. *I feel sick to my stomach and am going to throw up." b. "I am having pain in my lower back when I move my legs." c. "My throat hurts badly when I swallow and when I talk." d. "I have a headache that gets worse when I sit up"

d. "I have a headache that gets worse when I sit up"

Which client is the most likely candidate for total parenteral nutrition (TPN)? a. A client diagnosed with type 1 diabetes in diabetic ketoacidosis. b. An obese client who is on a medically supervised starvation diet. c. An older client who is having a laparoscopic cholecystectomy. d. A client experiencing an acute exacerbation of Crohn's disease.

d. A client experiencing an acute exacerbation of Crohn's disease.

The nurse-manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse-manager that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. What is the priority action by the nurse-manager? a. Determine if the client has a PRN prescription for an antianxiety agent. b. Contact the healthcare provider to ensure that a prescription for restraints was written. c. Close the door to the room to avoid disturbing other clients in nearby rooms. d. Advise the staff nurse to remove the restraints from the client's wrists.

d. Advise the staff nurse to remove the restraints from the client's wrists.

A client with hematuria secondary to a urinary tract infection has a prescription for IV administration of the cephalosporin cefoperazone. Which action should the nurse implement? a. Hold the scheduled dose and consult with the healthcare provider. b. Monitor the client's PT/IN before administering the dose. c. Administer the prescribed dose of medication as scheduled. d. Assess the client's blood pressure before and after the dose.

d. Assess the client's blood pressure before and after the dose.

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients? a. Ensure supplemental oxygen and respiratory medications are available at all times. b. Use nasal or cough tissues followed by hand washing at all times. c. Get annual flu and Pneumococcal vaccine polyvalent (PPSV23) vaccines. d. Avoid large crowded areas during the colder months of the year

d. Avoid large crowded areas during the colder months of the year

A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first? a. Demonstrate the proper use of personal protective equipment. b. Offer to assist the UAP with the collection of the specimen. c. Provide the UAP with the infection control policy. d. Determine the UAP's knowledge about HIV transmission.

d. Determine the UAP's knowledge about HIV transmission.

A 17-year-old client gave birth 12 hours ago. She states that she doesn't know how to care for her baby. To promote parent-infant attachment behaviors, which intervention should the nurse implement? a. Explore the basis of fears with the client. b. Provide a video on newborn safety and care. c. Ask if she has help to care for the baby at home. d. Encourage rooming-in while in the hospital.

d. Encourage rooming-in while in the hospital.

A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul breathing and has a severe headache along with nausea. Her arterial blood gases (ABG) are: pH 7.50; PaCO, 30 mmH ; HCO, 24 mEq/L (24 mmol/L). Which assessment finding warrants Immediate intervention by the nurse? a. Muscle stiffness. b. Abdominal pain. c. Mental stupor. d. Fruity breath.

d. Fruity breath.

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRS)? a. Within the first trimester of pregnancy. b. During admission to labor and delivery. c. When the client has ankle edema. d. If the client has an elevated blood pressure.

d. If the client has an elevated blood pressure.

A 4-year-old girl returns to the pediatrician's office for a postoperative visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior should the nurse consider normal for this age child? a. Draws picture of self with facial features. b. "Talks" to an imaginary friend. c. Sits quietly in her mother's lap. d. Ignores other children in the play area.

d. Ignores other children in the play area.

While inserting an indwelling urinary catheter into a client, the nurse observes urine flow in the tubing. Which action should be taken next? a. Inflate the balloon with 5 ml of sterile water. b. Document the color and clarity of the urine. c. Ask the client to breathe deeply and slowly exhale. d. Insert the catheter an additional inch.

d. Insert the catheter an additional inch.

A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings. His appetite is poor and he often refuses oral intake of solids and liquids. For the past several days he has been unable to get out of bed. Which action should the hospice nurse implement? a. Ask family to remain nearby, but in another room. b. Encourage family to speak often with the client. c. Teach family how to assist the client to a wheelchair. d. Instruct family to offer client only soft, bland foods

d. Instruct family to offer client only soft, bland foods

An adult recently diagnosed with glaucoma, tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client? a. Wear prescription glasses. b. Eat a diet high in carotene. c. Avoid frequent eye pressure measurements. d. Maintain prescribed eyedrop regimen

d. Maintain prescribed eyedrop regimen

A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take? a. Obtain vital sign measurements. b. Measure capillary glucose level. c. Encourage ambulation in the room. d. Monitor for bloody diarrheal stools.

d. Monitor for bloody diarrheal stools.

The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram. What information should the client acknowledge understanding? a. Admit to others that he is a substance abuser. b. Completely abstain from heroin or cocaine use. c. Attend monthly meetings of alcoholics anonymous. d. Remain alcohol free for 12 hours prior to the first dose.

d. Remain alcohol free for 12 hours prior to the first dose.

An older client with a history of Type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. The client is lethargic, moderately confused, and cannot remember when taking the last dose of insulin or eating. Which action should the nurse implement first? a. Administer the client's usual dose of insulin. b. Obtain a serum potassium level. c. Assess pupillary response to light. d. Start an intravenous infusion of normal saline.

d. Start an intravenous infusion of normal saline.

During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personnel (UP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe a PRN dose of an oral over-the- counter laxative for a client who is constipated. What instruction should the nurse provide the unit clerk? a. Be sure to write down what is prescribed and then repeat it back to the healthcare provider. b. Remain with this client and monitor the vital signs while the nurse takes the call. c. Ask the healthcare provider to remain on "hold" until the nurse can confirm the prescription. d. Tell the healthcare provider the nurse will return the phone call as soon as possible.

d. Tell the healthcare provider the nurse will return the phone call as soon as possible.

The nurse is developing a plan of care for a client who reports intermittent claudication and who is newly diagnosed with type 2 diabetes. Which outcome should the nurse include in the plan of care for this client? a. The client will express acceptance of their newly diagnosed health status. b. The client's blood pressure readings will be less than 160/90 mmH. c. The client's skin on the lower legs will be intact at the next clinic visit. d. The nurse will show the client how to perform stress management techniques.

d. The nurse will show the client how to perform stress management techniques.

after removing a clients dressing that is saturated with sanguineous drainage, where should the nurse put the dressing?

red biohazard bag

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