exit j doc

75. A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation? "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.'' ''The client fell because the assistive personnel did not place non skid slippers on the client.'' ''An incident report has been complete and sent to risk management.''''The client does not appear to have any injuries resulting from the fall.''

"Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.''

118. A nurse is collecting data from a client who has a urinary tract infection and is taking ciprofloxacin. The client reports pain in her calf muscle. Which of the following statements should the nurse make? "That reaction means your dose is too high. Cut the pill in half." "Discontinue the medication. I will ask your provider for another antibiotic." "Continue to take the medication. Calf pain is a minor reaction that will resolve itself." "This is an allergic reaction. Take the medication with an antihistamine."

"Discontinue the medication. I will ask your provider for another antibiotic."

146. A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching? "I can take an antacid at the same time as this medication." "I will need to remain upright for one hour after taking this medication." "I have to take this medication on an empty stomach." "I should expect to have diarrhea while taking this medication."

"I have to take this medication on an empty stomach."

135. A nurse is reinforcing teaching with a group of adolescent male clients about testicular examinations. Which of the following statements by a client indicates an understanding of the teaching? "I should expect one testicle to be larger than the other.'' "I should apply gentle pressure with my thumb and forefinger when examining my testes" ''I should bear down when cupping my testes while I'm checking for abnormalities.'' ''I should perform a self-examination of my testicles weekly.''

"I should apply gentle pressure with my thumb and forefinger when examining my testes"

134. A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops. Which of the following statements indicates an understanding of the teaching? "I should check my heart rate while taking this medication.'' "I should take a zinc supplement while taking this medication.'' ''This medication will dilate my eyes.'' ''This medication will darken the color of my eyes.''

"I should check my heart rate while taking this medication.''

120. A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? "I should keep my baby rear-facing in the car seat until she is 2 years old." "I should position the car seat's retainer clip at the level of the baby's belly button." "I should place my baby in the car seat at a 90-degree angle." "I should enable the airbag when my baby is in the front seat of the car."

"I should keep my baby rear-facing in the car seat until she is 2 years old."

10. A nurse is reinforcing teaching about home infection prevention with a client who is HIV positive. Which of the following statements by the client indicates an understanding of the teaching? "I will use animal skin condoms when having sex""I will place used sharp items in an empty cereal box for disposal""I will put soiled dressings in a tied plastic bag before placing them in the trash""I will disinfect contaminated hard surfaces with mixture of one part peroxide to 10 parts water"

"I will put soiled dressings in a tied plastic bag before placing them in the trash"

100. A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1 week. Which of the following client statements indicates an understanding of the teaching? "I'll have my friend drive me home after the procedure.'' ''I will follow a full-liquid diet the day before the procedure.'' ''I can expect rectal bleeding for a week after the procedure.''' 'This procedure will take place while I'm under general anesthesia.''

"I'll have my friend drive me home after the procedure.''

20. A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states, "I am so tired all the time, but Mom needs me." Which of the following responses should the nurse make? "Let me give you some information about respite care for your mother I think you should find another family member who could help your mother you should think about place in your mother in a long-term care facility you owe it to your mother to take care of her now that she needs you

"Let me give you some information about respite care for your mother

40. A nurse is reinforcing teaching with a client about advanced directive. Which of the following information should the nurse include? "Your health care surrogate will make a decision on your behalf if you are unable." ''You will need an attorney to appoint a health care surrogate.''''You should appoint a family member as your health care surrogate.'' ''Once you have completed a living will, it cannot be changed.''

"Your health care surrogate will make a decision on your behalf if you are unable."

34. A nurse in a psychiatric unit is admitting a client who has self-inflicted cuts on their forearms. Which of the following is a priority response by the nurse? ''Who can we call to support you.''''Tell me why you hurt yourself.''''Do you have thoughts of suicide?''''What coping methods help you when you feel bad?''

'''Do you have thoughts of suicide?''

35. A nurse is reinforcing teaching about preventing dental caries with the parent of a 12-month-old toddler. Which of the following instructions should the nurse provide? ''Position the bristles of your child's toothbrush against the teeth at a 90-degree angle.'' ''Floss between your child's teeth before brushing.''''Clean the teeth with a small, soft-bristled toothbrush.''''Use a 5-inch strip of toothpaste on the toothbrush.''

''Clean the teeth with a small, soft-bristled toothbrush.'''

88. A nurse is reinforcing dietary teaching with a client who is 12 weeks of gestation. Which of the following statements should the nurse make? ''Limit your caffeine intake to 700 milligrams per day.'' ''Consume 600 micrograms of folic acid per day.'' ''Increase your dietary intake by 500 calories per day.'' ' 'Eat 40 milligrams of protein-rich foods per day.''

''Consume 600 micrograms of folic acid per day.''

74. A nurse is reinforcing teaching who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching? "Expect insulin glargine to be cloudy.'' ''Anticipate that the insulin glargine will peak in 3 hours.'' ''Draw up the insulin lispro and insulin glargine in separate syringes.'' ''Take an extra dose of insulin lispro prior to aerobic exercise.''

''Draw up the insulin lispro and insulin glargine in separate syringes.''

123. A nurse is reinforcing teaching with the guardians of a 6-year-old child who has cystic fibrosis. Which of the following information should the nurse include in the teaching? ''Provide homeschooling for your child.'' ''Do not include your child when making decision about treatment.'' ''Have your child wear a medical identification wristband.''' 'Ensure that your child does not receive the influenza vaccine annually.''

''Have your child wear a medical identification wristband.'''

70. A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching? "I can prevent nausea if I take the medication on an empty stomach.''''I will report black stools to my doctor.''''I can prevent constipation if I drink more milk while taking this medication.'' ''I will mix the medication with a full glass of water.''

''I will mix the medication with a full glass of water.''

49. A nurse is reinforcing teaching with a client who has a cystocele. Which of the following statements by the client indicates an understanding of the teaching? ''I should use a perineal spray to reduce odor from urinary leakage.''''I will decrease my fluid intake to reduce incontinence."''I will practice perineal exercises to decrease urinary leakage.''''I will experience less urinary incontinence if I use artificial sweeteners.''

''I will practice perineal exercises to decrease urinary leakage.''

130. A nurse is caring for a client who is visibly upset and tearful about a recent terminal diagnosis. Which of the following responses should the nurse make? "I'm going to contact your family so they can be with you.'' "When you feel better, we'll talk about your treatment options.'' ''I will stay with you for a while.'' ''I'm sorry you have to deal with this.''

''I will stay with you for a while.''

103. A nurse is reinforcing teaching with a client about advance directives and a health care proxy. Which of the following client statements indicates an understanding of the teaching? "Once my health care proxy is in place, I relinquish my right to make my own decisions.''' 'I do not need to name a release as my designee in my health care proxy.''' ' My health care proxy designee is not able to sign a consent form on my behalf.'' ''If I have a health care proxy, then I do not need to have a living will.''

''If I have a health care proxy, then I do not need to have a living will.''

58. A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping. Which of the following instructions should the nurse include in the plan of care? "Use a transcutaneous electrical nerve stimulator.'' ''Obtain a prescription for pramipexole.'' rd.'' ''Lie on your left side with your top leg forward.'' ''Soak in a bathtub of hot water each night.''

''Lie on your left side with your top leg forward.''

139. A nurse is reinforcing teaching with a client who has an ankle injury and requires crutches. Which of the following instructions should the nurse provide? ''Support your body weight by leaning on the crutches.''' 'Wash the tips of your crutches daily.''' 'Keep your elbows flexed at a 35o angle when using the crutches.'' ''Maintain your head and neck erect when walking with crutches.''

''Maintain your head and neck erect when walking with crutches.''

28. A nurse is reinforcing teaching with a female client about contraception. Which of the following statements by the client indicates an understanding of the teaching? ''My partner will use condoms with spermicides.'' ''I will be able to remove my contraceptive sponge immediately after intercourse.'' "My partner and I will both use condom during intercourse.''''My partner and I will use petroleum jelly with latex condoms.''

''My partner will use condoms with spermicides.''

112. A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective? "Our child has lost some weight since his last appointment.'' ''Our child has increased his daily caloric intake.''' 'Our child has a better grasp of reality.''' 'Our child is able to complete his homework on time.''

''Our child is able to complete his homework on time.''

101. A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include? "Drink at least 240 milliliters of water during each meal.'' ''Perform pulmonary hygiene 1 hour before meals.'' ''Lie down for 30 minutes after eating.'' ''Self-administer oxygen through your nasal cannula at 6 milliliter per minute during meals.''

''Perform pulmonary hygiene 1 hour before meals.''

32. A nurse is reinforcing teaching with a new parent about bathing her newborn. Which of the following statements should the nurse include? ''Use an alkaline soap to bathe the baby.''''Ensure the bath water is at least 96 degrees Fahrenheit.''''Apply talcum powder daily after bathing in order to prevent diaper rash.'' ''Perform sponge baths until the baby's umbilical falls off.''

''Perform sponge baths until the baby's umbilical falls off.''

65. A nurse is making a follow-up call to a client who has a new prescription for an ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make? "Restrict your daily fluid intake.'' ''Sit back down for a few minutes when this occurs.'' ''Take a daily potassium supplement.'' ''Discontinue this medication if this occurs again.''

''Sit back down for a few minutes when this occurs.''

106. A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of the medication. Which of the following responses should the nurse make? ''This medication will increase the immunity of your newborn.''' 'This medication will decrease the possibility of your newborn developing jaundice.'' ''This medication will decrease the risk of hemorrhage in your newborn.''' 'This medication will increase the absorption of nutrients in the intestines.''

''This medication will decrease the risk of hemorrhage in your newborn.'''

61. A nurse is reinforcing teaching with a client's family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching? ''We will frequently check the top of his ears for sores.'' ''We can use petroleum jelly to keep his nares moist.''''We can turn the oxygen up to 10 when he has trouble breathing.'' ''We will need to remove the nasal cannula when he is eating.''

''We will frequently check the top of his ears for sores.''

96. A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make? "You should use patterned-paced breathing when changing positions.'' ''You should change positions as little as possible.'' ''You can apply counterpressure to your back with each position change.' ''You can splint the incision with a pillow when changing positions.''

''You can splint the incision with a pillow when changing positions.''

50. A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching? ''You can skip a dose of this medication if you are nauseated.'' ''You might experience swollen gums while taking this medication.'' ''You should expect to have blood work every 6 months while taking this medication.'' ''You can safely take this medication if you become pregnant.''

''You might experience swollen gums while taking this medication.''

86. A nurse is reinforcing teaching with the parents of a child who has a new diagnosis of Wilms' tumor. Which of the following information should the nurse include in the teaching? ''Your child will not require further treatment after removal of the tumor.'' ''You should give your child captopril 200 mg PO daily.'' ''You should not palpate your child's abdomen prior to surgery.'' ''Your child should have surgery in 7 to 10 days to remove the tumor.''

''You should not palpate your child's abdomen prior to surgery.''

79. A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address? "My child still wets the bed at least two times per weeks.''''I have a difficult time getting my child to eat green vegetables.''''My child continually asks me the same questions.''''I have noticed that my child is withdrawn since we switched day care providers.''

'I have noticed that my child is withdrawn since we switched day care providers.''

104. A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching? "It takes 2 months of scheduled use before this medication is effective.'' "I will give this medication to my child every 2 hours if he is wheezing.'' ''I can stop giving my child this medication if he is taking a steroid.''' 'I will give this medication to my child once daily in the evening.''

'I will give this medication to my child once daily in the evening.''

27. A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include? ''Cover the electrical outlets with wet towels.''''Open the fireplace dampers in the day room.''''Move clients to a room above ground with few windows.'' ''Turn on fans in the facility to circulate air.''

'Move clients to a room above ground with few windows.''

22. A nurse is caring for a client who was recently diagnosed with depression. The client's partner asks when he will get better. Which of the following is an appropriate response by the nurse? ''We've seen steady improvement in other clients who are depressed.'' '' The important thing is that he gets better, not how long it takes.''''Tell me what you know about depression.''''No one really knows the answer to that question.''

'Tell me what you know about depression.''

52. A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse include? "You should avoid exercising for the next 6 weeks.''''You should avoid lying on your right side.'''You should avoid crossing your legs for 3 months.''''You should avoid putting a pillow between your legs when in bed.''

'You should avoid lying on your right side.'''

119. A nurse is assisting in the care of a client who is in active labor and is to undergo amniotomy. Which of the following actions should the nurse take? (Mark in order) Document the procedure in the electronic medical record. Check the fluid for color, odor, and consistency Position the client with a rolled towel under her hips Obtain a baseline reading of the FHR and contraction pattern Pass the sterile hook to the provider

1. Obtain a baseline reading of the FHR and contraction pattern 2. Position the client with a rolled towel under her hips 3. Pass the sterile hook to the provider 4. Check the fluid for color, odor, and consistency 5. Document the procedure in the electronic medical record.

83. A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse? Blood pressure 110/70 mm Hg Fluctuation in the water seal chamber with respiration 400 mL of drainage in the collection chamber within 4 hr Respiration rate 16/min

400 mL of drainage in the collection chamber within 4 hr

97. A nurse is giving a change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply) 1 ''The client in room 203 will undergo surgery at 0900 tomorrow.'' 2 ''The client in room 205 has had several visitors today.'' 3 ''The client in room 205 is scheduled for a dressing change at 1800.'' 4 ''The client in room 204 received some pain medicine earlier today.'' 5 "The client in room 204 has a new prescription for IV gentamicin.''

5 "The client in room 204 has a new prescription for IV gentamicin.'' 1 ''The client in room 203 will undergo surgery at 0900 tomorrow.'' 3 ''The client in room 205 is scheduled for a dressing change at 1800.''

25. A nurse is reviewing client confidentiality with a group of newly licensed nurses. Which of the following situations should the nurse include as an example of a breach in confidentiality? A facility risk manager includes information from a client's medical record in a written report.A nurse discusses a client's postoperative complications during a shift report recognize that the client nodding indicates an understanding of the information.A social worker reads a client's chart as a follow-up to a requested consultation.A nurse tells the chaplain that a client has a new diagnosis of cancer.

A nurse tells the chaplain that a client has a new diagnosis of cancer.

68. A nurse is caring for a client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously. Which of the following adverse effects of the medication should the nurse report to the provider? Bradycardia Epistaxis Weight gain Anorexia

Epistaxis

44. A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The nurse should expect which of the following instructions from the provider? Obtain an aPTT level. Change the medication to heparin IV. Reduce the dosage of the medication Administer protamine sulfate.

Administer protamine sulfate.

48. A nurse is assisting with the admission of a client who has pulmonary tuberculosis. Which of the following types of isolation precautions should the nurse initiate? Droplet Protective environment Airborne Contact

Airborne

99. A nurse is obtaining a capillary blood specimen to measure a client's blood glucose. Which of the following actions should the nurse take? Massage the client's finger away from the puncture site. Apply sterile gloves. Hold the lancet at 45o angle. Allow the antiseptic to dry before puncturing.

Allow the antiseptic to dry before puncturing.

108. A nurse is collecting data from a client who has a sodium level of 156 mEq/L. Which of the following findings should the nurse expect? Hypothermia Altered mental status Dysrhythmias Nausea and vomiting

Altered mental status

132. A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect? Circulatory overload Acute hemolytic Febrile Anaphylactic

Anaphylactic

121. A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan to take? Administer furosemide. Apply a cardiac monitor. Give a dose of alendronate. Monitor for Chvostek's sign

Apply a cardiac monitor.

15. A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which interventions should the nurse include in the client's plan of care? Apply support stockings. Administer diuretics Limit fluid intake place on bed rest

Apply support stockings.

89. A nurse is caring for a client who has clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use? Tuck the glove cuffs under the gown sleeves. Tie the gown with the gloves on. Push the gown sleeves up to the elbows. Apply the gown before the gloves.

Apply the gown before the gloves.

92. A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.50 C (90.50 F). Which of the following data is the priority for the nurse monitor? Pain sensation Muscle strength Heart rhythm Urinary output

Heart rhythm

80. A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate? Assist in discharging stable clients to home. Delegate tasks to emergency health care specialists.Provide informational updates to members of the media.Determine the acuity and number of casualties arriving at the facility.

Assist in discharging stable clients to home.

113. A nurse is providing preoperative care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take? Contact the next of kin to assist the client at home. Assist with a referral to a home health care agency. Call the provider about admitting the client to the facility overnight. Give the client a list of home care assistants to contact.

Assist with a referral to a home health care agency.

7. A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz) of which of the following beverages contains the least amount of caffeine? Hot cocoa Brewed green tea instant coffee

Hot cocoa

122. A nurse is collecting data from a client about risk factors for cardiovascular disease. The nurse should identify which of the following findings is a modifiable risk factor? Family history of cardiovascular disease Sex Cholesterol 240 mg/dL Age 65

Cholesterol 240 mg/dL

41. A nurse is preparing to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take? A. Don sterile gloves prior to opening sterile dressing supplies. B. Set up the sterile field above waist level C. Place the cap of a sterile solution inside the sterile field.D. Consider 5.08 cm (2 in) of the sterile field's border to be contaminated.

B. Set up the sterile field above waist level

105. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new prescription for propranolol. The nurse should plan to monitor the client for which of the following adverse effects of the medication? Ringing in the ears Hypertension Bradycardia Headache

Bradycardia

40. A nurse is caring for a client who adheres to kosher dietary practices. Which of the following foods should the nurse plan to offer the client? Bacon and eggs Cheeseburger Chicken sandwich Shrimp and French fries

Chicken sandwich

69. A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. Which of the following actions should the nurse take? Exaggerate lip movement while speaking. Ask a few questions at a time Choose a room that is well lit Sit on the client's right side.

Choose a room that is well lit

142. A nurse is caring for an older adult client who wears hearing aids with detachable ear molds. Which of the following actions should the nurse take when caring for the hearing aids? Clean the hearing aid with a soft cloth Change the battery once per month Disinfect the hearing aid with isopropyl alcohol Replace the ear molds once per year.

Clean the hearing aid with a soft cloth

12. A nurse on a medical-surgical unit is planning care at the beginning of a shift. Which of the following tasks should the nurse assign the personnel? Provide clients directions on collecting urine specimen remove a client's nasogastric tube administer a veginal suppository to a client Collect a random stool specimen from a newly admitted client.

Collect a random stool specimen from a newly admitted client.

71. A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? Evaluate the need to suction the airway of a client who has a new tracheostomy. Feed a client who has difficulty swallowing liquids following a stroke.Inspect the incision of a client who is postoperative following a leg amputation. Complete post mortem care for a client who has died.

Complete post mortem care for a client who has died.

62. A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take? Hold gently direct pressure on the protruding organ. Place the client's knees in an extended position. Cover the wound with sterile, saline-soaked gauze. Raise the head of the bed to a 450 angle.

Cover the wound with sterile, saline-soaked gauze.

21. A nurse is reinforcing dietary teaching with a client who has cholecystitis. Which of the following food choices should indicate that the client understands the nurse's instructions? Ans: Cream of potato soup Dark chocolate Skim milk Peanut butter

Cream of potato soup

26. A nurse is collecting data from a client who is 5 hr postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider? Decreased urinary output. Hgb 14 g/dL Pink-tinged urine Absence of bladder spasms

Decreased urinary output.

114. A nurse is collecting data from a 9-year-old child during a well-child visit. Which of the following findings should the nurse expect? Express conflict over independence and control Demonstrates self-centered thinking Displays emotional detachment from parents Grasps concept of cause-and-effect

Demonstrates self-centered thinking

87. A nurse delegates a task to an assistive personnel (AP) and the AP refuses to complete the assigned task. Which of the following actions should the nurse take? Assign the task to another AP. Perform the task on behalf of the AP. Report the AP to the risk manager. Discuss the AP's concerns about performing the task.

Discuss the AP's concerns about performing the task.

47. A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenever medication changes are prescribed by the client's provider. The nurse should identify that the client is using which of the following defense mechanisms? Spitting Conversion Sublimation Displacement

Displacement

8. A nurse is contributing to the plan of care for a client who has acute alcohol withdrawal and a blood alcohol level of 150 mg/dL. The nurse should identify which of the following medications is contraindicated for this client?

Disulfiram

145. A nurse on a medical surgical unit is assisting with the admission of a client who has advanced lung cancer. Which of the following actions regarding advance directives should the nurse take? Contact facilities risk manager to verify if the client has a living will. Document client's decision about end-of-life care in the medical record. Ensure that an attorney has received the client's advance directives.Tell the client that a family member should serve as a health care surrogate.

Document client's decision about end-of-life care in the medical record.

138. A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include? Hold the hands slightly higher than the elbows when using running water. Clean hands with alcohol-based hand gel for 15 seconds. Wash hands under running water for at least 10 seconds. Dry hands thoroughly from fingers to wrist.

Dry hands thoroughly from fingers to wrist.

147. A nurse is caring for a client who has been given methylergonovine intramuscularly for a postpartum hemorrhage. The nurse should monitor for which of the following adverse effects? Uterine Relaxation Elevated Blood Pressure Diarrhea Hematuria

Elevated Blood Pressure

38. A nurse and an assistive personnel (AP) are repositioning a client who is immobile up in bed using a draw sheet. The nurse should instruct the AP to take which of the following actions? Stand next to the client's shoulders. Flex his hips while pulling the client. Lower the client's bed to the lowest position. Place a small pillow under the client's head.

Flex his hips while pulling the client.

39. A nurse is collecting data from a client who has bipolar disorder. Which of the following findings should the nurse expect? Well-groomed appearance Ritualistic behavior Flight of ideas Command hallucinations

Flight of ideas

9. A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority? Frequent swallowing Coffee ground appearance of emesis dark brown blood between the teeth report of sore throat

Frequent swallowing

30. A nurse is collecting data from a client who has diabetes ketoacidosis. Which of the following findings should the nurse expect? Fruity breath odor Clammy skinElevated blood pressure Bounding pulse

Fruity breath odor

137. A nurse is applying antiembolic stockings for a client who is postoperative. Which of the following actions should the nurse take? Remove the stockings once every 24 hr. Elevate the client's legs for 5 min prior to applying the stockings. Roll the top of the stockings down so it fits snugly above the client's calf. Have the client point his toes before inserting his foot into the stockings.

Have the client point his toes before inserting his foot into the stockings.

125. A nurse is assisting the provider with a lumbar puncture for a client who has manifestations of meningitis. Into which of the following positions should the nurse assist the client? Trendelenburg with her body in Sims' position Prone with her arms at her side and her legs extended Head flexed to the chest and her knees pulled up to the abdomen Arms raised above her head with her legs elevated on pillows

Head flexed to the chest and her knees pulled up to the abdomen

90. A nurse is collecting data from a client who is taking an oral contraceptive. Which of the following findings is a contraindication for the use of oral contraceptives? Gastroesophageal reflux disease History of mononucleosis 1 year ago Irregular menstrual cycles Headaches with aura

Headaches with aura

131. A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse expect? Tachycardia Hyperthermia Hypertension Tachypnea

Hypertension

41. A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm? Hypertension Decreased body temperature Bradycardia Increased incisional drainage

Hypertension

57. A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of the medication? Hypertension Hyperglycemia Tinnitus Hematuria

Hypertension

127. A nurse is caring for a client who is 2 days postoperative following a total bilateral mastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority on which of the following actions? Identifying the client's perception of the changes in her physical appearance Providing the client with information on community resources that will strengthen her coping skills Encouraging the client to write about her feelings in a journal each day Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds

Identifying the client's perception of the changes in her physical appearance

23. A nurse is assisting with the plan of care for a child who has neutropenia. Which of the following interventions should the nurse include? Monitor the child's platelet count. Inspect the child's skin daily for abrasions. Administer the varicella vaccine. Place the child in a room with negative pressure airflow.

Inspect the child's skin daily for abrasions.

53. A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps) Deep Palpation Auscultation Inspection Light Palpation

Inspection Auscultation Light Palpation Deep Palpation

115. A nurse is reinforcing teaching about hand hygiene with a newly licensed nurse. Which of the following information should the nurse include in the teaching? Use hot water to wash hands. Apply friction to hands for 10 seconds. Dry hands starting from forearm to fingers. Interlace the fingers while rubbing hands together.

Interlace the fingers while rubbing hands together.

81. A nurse is reinforcing teaching about common discomforts during the first trimester with a client who is at 10 weeks of gestation. Which of the following examples should the nurse include? Swelling Burning during urination Diarrhea Leukorrhea

Leukorrhea

94. A nurse is reinforcing teaching with a newly licensed nurse about transcribing medication prescriptions. Which of the following prescriptions should the newly licensed nurse identify is an accurate transcription? Heparin 500 U subcutaneous every 8hr MgSO4 10 g PO daily Doxazosin .5 mg PO at bedtime Lorazepam 0.5 mg PO PRN at bedtime

Lorazepam 0.5 mg PO PRN at bedtime

51. A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect? Loss of taste Increased appetite Bladder infection Loose stools

Loss of taste

14. A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan? Measure the client's abdominal girth daily. Keep a client's daily protein intake below 0.8 grams / kg position the clients of pain with legs elevated restrict the clients sodium intake to 3 grams per day

Measure the client's abdominal girth daily.

84. A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Lower the side rails of the bed when the seizure begins. Restrain the client's arms and legs to prevent injury. Measure the duration of the seizure Insert an oral airway into the client's mouth.

Measure the duration of the seizure

73. A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement first? Create a schedule with an assistive personnel to do hourly rounding for the client. Apply rubber-soled slippers before ambulation. Determine the client's ability to use the call light. Move the bedside table with the client's personal items close to the bed.

Move the bedside table with the client's personal items close to the bed.

149. A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment? Slurred speech Onset of hearing loss Constipation Hyperthermia

Onset of hearing loss

33. A nurse is caring for a client who is postoperative following a total knee arthroplasty. The client reports a pain level of 6 on a scale from 0 to 10. Which of the following medications should the nurse administer? Acetaminophen Ibuprofen Oxycodone Celecoxib

Oxycodone

82. A nurse is caring for a client who is postoperative following a total knee arthroplasty. The client reports a pain level of 6 on a scale from 0 to 10. Which of the following medications should the nurse administer? Celecoxib Oxycodone Acetaminophen Ibuprofen

Oxycodone

109. A nurse is collecting data from a client who has acute cholecystitis. Which of the following findings should the nurse expect? Increased abdominal discomfort prior to meals Pain radiating to the jaw Pain in the right upper abdomen Discomfort with urination

Pain in the right upper abdomen

13. A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which commendations should the nurse make? Perform pelvic rocking exercises several times per day. Sit in the hot tub for 30 minutes every evening Raise chairs to keep knees lower than hips use arms to pick up heavy items

Perform pelvic rocking exercises several times per day.

126. A nurse in a provider's office is collecting data from a client who was just diagnosed with tuberculosis. Which of the following actions should the nurse take first? Communicate with personnel about the need for prophylaxis. Place a mask on the client. Notify the local health department. Contact those who live with the client.

Place a mask on the client.

60. A nurse is caring for a client who is unable to perform ADLs and wears dentures. Which of the following actions should the nurse take when providing denture care? Remove the lower dentures before the upper dentures. Use a circular motion to cleanse the biting surface of the dentures. Place a towel in the sink when cleaning the dentures. Store the dentures in a dry denture cup on the bedside table after cleaning.

Place a towel in the sink when cleaning the dentures.

136. A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphagia. Which of the following instructions should the nurse include in the teaching? Use a needleless syringe to instill feedings. Give the client a straw to use for drinking. Place oral suction equipment next to the client's bedside. Provide thin liquids to help the client swallow.

Place oral suction equipment next to the client's bedside.

133. A nurse is preparing a sterile field to perform a dressing change of a client's leg wound. Which of the following actions should the nurse take? Hold the irrigation solution bottle 5 cm (2 in) above the sterile container Place the irrigation solution bottle cap on the sterile field. Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field. Open the outer wrapper of the sterile package toward her body

Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field.

124. A nurse is assisting with developing a plan of care for a client who is immobile. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers? Place a donut-shaped cushion under the client. Place the client in a 30deg lateral position. Turn the client every 3 hr Check the client's skin every 4 hr

Place the client in a 30degree lateral position.

93. A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures? Irrigation of a wound with antibiotic solution Placement of a central venous catheter Administration of an iron injection using z-track technique Insertion of a nasogastric tube

Placement of a central venous catheter

63. A nurse is reviewing the medical record of a client who is at 37 weeks of gestation and has HELLP syndrome. Which of the following laboratory findings should the nurse expect? BUN 20 mg/dL Hemoglobin 12 g/dL Sensation of tingling Pale-colored toes WBC count 18,000/mm3 Platelet count 77,000/mm3

Platelet count 77,000/mm3

7. A nurse is reviewing the medical record of a client who has COPD. Which of the following findings indicates a need to request referral for the client? Potassium 3.5 mEq/L Sodium 138 mEq/L Prealbumin 13 mg/dL Total calcium 10 mg/dL

Prealbumin 13 mg/dL

107. A nurse is contributing to the plan of care who has bipolar disorder and is experiencing acute mania. Which of the following interventions should the nurse include in the plan of care? Encourage the client to participate in group activities. Provide the client with high-calorie finger foods. Check the client's vital signs every 4 hr.Allow the client to establish his own schedule.

Provide the client with high-calorie finger foods.

55. A nurse is planning care for four clients. Which of the following tasks should the nurse as the charge nurse to reassign to an RN? Administering a subcutaneous insulin injection Providing discharge teaching about home IV medication therapy Collecting a sputum culture Removing an NG tube

Providing discharge teaching about home IV medication therapy

67. A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment? Reduced fat in the stools Improved respiratory functionImproved absorption of vitamins B and C Decreased sodium excretion

Reduced fat in the stools

111. A nurse is assisting with the care of a client who is at 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take? Explain that nonreactivity might require immediate medication administration. Remind the client to press the button when she feels fetal movement. Tell the client the test should take about 10 min. Assist the client into a supine position.

Remind the client to press the button when she feels fetal movement.

110. A nurse is reinforcing teaching about home safety precautions with the parents of a 3-month-old infant. Which of the following instructions should the nurse include in the teaching? Remove bibs when the infant is going to sleep Make sure the crib mattress is soft. Start using a highchair for feedings. Place no more than one small pillow in the crib.

Remove bibs when the infant is going to sleep

78. A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states. ''I guess I will be locked in my room again for wetting the bed.'' Which of the following actions should the nurse take? Report the suspected abuse to the nurse manager. Contact the client's caregiver to discuss the client's commentReview the medical record to see if the client has reported abuse in the past. Restrict family members from visiting with the client.

Report the suspected abuse to the nurse manager.

42. A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP's performance of the task? Request the AP to provide a return demonstration of the task. Ask the family if the AP performed the task correctly. Tell the AP to list the steps of the task.Instruct the AP to report back once the task is complete.

Request the AP to provide a return demonstration of the task.

36. A nurse is caring for a client who speaks a different language than the nurse. The client's partner tells the nurse that the client would like to go home against medical advice (AMA). Which of the following actions should the nurse take? Request the services of an interpreter to determine the client's wishes. Have the client's partner sign an AMA form.Discharge the client and notify the health care provider.Ask the partner to reiterate the consequences of leaving AMA to the client.

Request the services of an interpreter to determine the client's wishes.

56. A nurse is discussing risk factors for child abuse with members of a parenting group. The nurse should identify which of the following findings as a characteristic of perpetrators of child abuse? Rigid expectations of behavior High self-esteem Laissez-faire leadership style Self-blame for financial problems

Rigid expectations of behavior

95. A nurse is transcribing a client's prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider? Route Dosage Medication Time

Route

66. A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take? Secure the tubing with adhesive tape to the lower abdomen. Instruct the client to hold the drainage bag at waist height when ambulating. Collect a sterile specimen from the urinary drainage bag. Coil the tubing on the bed above the collection bag.

Secure the tubing with adhesive tape to the lower abdomen.

59. A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply) Sensation of tingling Pale-colored toes Pain relieved by analgesia Decreased skin turgor Diminished capillary refill

Sensation of tingling Pale-colored toes Diminished capillary refill

102. A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report? Hyperreflexia Skin rash with fever Tinnitus with ear pain Diplopia

Skin rash with fever

148. A nurse is caring for a client who is receiving continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take? Stop the infusion Elevate the arm Apply a warm compress Document the infiltration

Stop the infusion

76. A nurse is caring for an adolescent who states, "I joined the track and field team, so I won't argue with my brothers anymore.'' The nurse should identify that the client is using which of the following defense mechanisms? Denial Regression Repression Sublimation

Sublimation

54. A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene? Applies suction during catheter removal Auscultates breath sounds Suctions for 30 seconds Oxygenates with 100% oxygen

Suctions for 30 seconds

24. A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take? Supplement spoken language with pictures Ask a family member of the client to interpret Speak to the client at an increased volume. Recognize that the client nodding indicates an understanding of the information

Supplement spoken language with pictures

77. A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take? Ask the facility chaplain to visit the client. Tell the client she should discuss this decision with her family. Discuss alternative treatment methods with the client. Support the client's decision to stop the treatment.

Support the client's decision to stop the treatment.

46. A nurse is reinforcing teaching about passive range-of-motion exercises with the family of a client who has had a stroke. Which of the following instructions should the nurse include in the teaching? Repeat each exercise movement 10 times.Position the bed at mid-thigh level.Move each joint past the point of resistance.Support the extremity above and below each joint during the exercises

Support the extremity above and below each joint during the exercises

64. A nurse is caring for a client who has Graves' disease. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm? Tachycardia Respiratory depression Hypotension Neck pain

Tachycardia

85. A nurse is caring for a client who has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations should the nurse make? Take the medication with an antacid. Take the medication and then lay down for 30 min. Take the medication with crackers. Take the medication with calcium fortified orange juice.

Take the medication with crackers.

18. A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a transfusion reaction? Straw colored urineApical pulse rate 58/min Temperature 38.8 C (101.8 F) Blood Pressure 158/92 mmHg

Temperature 38.8 C (101.8 F)

45. A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reactions can occur following the procedure? Neck pain Voice Alteration Tingling of the scalp Temporary memory loss

Temporary memory loss

144. A nurse is collecting data from a client whose partner died 1 year ago. Which of the following findings indicates that the client is experiencing complicated grief? The client develops chest pain each time he talks about his partner. The client reports he has no interest in dating.The client attends a grief support group twice each month. The client keeps a framed picture of his partner on the wall.

The client develops chest pain each time he talks about his partner.

16. A nurse is monitoring a client's arterial pulses. The nurse should check for a dorsalis pedis pulse in which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer) The foot

The foot

11. A nurse in a provider's office is collecting data from a client who has candidiasis. Which of the following findings should the nurse expect? Thick, white vaginal discharge Feeling of pelvic heaviness hard, painless Chanchre frothy, malodorous discharge

Thick, white vaginal discharge

143. A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include? Provide three large meals per day. Encourage socialization during meal times. Elevate the head of the client's bead to 30 degrees. Tilt the client's head forward during meals.

Tilt the client's head forward during meals.

31. A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests does the nurse anticipate from the client's family? To cremate the client's body To bury the client's body within 24 hr of their death islam To stay with the client's body for 8 hr following their deathTo prohibit medical personnel from touching the client's body

To cremate the client's body

16. A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include? Conduct change-of-shift- report near clients' rooms. Turn on overhead lights briefly when checking IV lines. Wear shoes with rubber soles.Open curtains between clients in semi private rooms.

Turn on overhead lights briefly when checking IV lines.

117. A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown? Clean the client's skin with soap and hot water. Use a moisture barrier on the client's skin. Limit the client's fluid intake. Massage the area around the client's coccyx.

Use a moisture barrier on the client's skin.

43. A nurse is administering a client's morning oral medications. Which of the following actions should the nurse take? Identify the client by using one identifier before giving the medication. Document medication administration prior to administering medication. Verify the medication three times with the medication administration record. Administer time-critical medication 60 min before or after the scheduled time.

Verify the medication three times with the medication administration record.

72. A nurse is reviewing the laboratory values of a client who has COPD. Which of the following findings should the nurse report to the provider? Hgb 20 g/dL Iron 150 mcg/dL WBC 13,000/mm3 Potassium 3.7 mEq/L

WBC 13,000/mm3

19. A nurse is collecting data from a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? (Click on the "exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Weight Temperature gross motor skills feeding habits

Weight

91. A nurse is caring for a 3-year-old child who has acute bacterial conjunctivitis of the right eye and has been prescribed bacitracin ophthalmic ointment. Which of the following actions should the nurse take? Wipe any excess medication from the inner canthus outward. Gently massage the eyelid to facilitate absorption of the medication.Place an occlusive dressing on the affected eye to prevent the spread of infection. Instruct guardian to apply erythromycin ophthalmic ointment every morning for 14 days.

Wipe any excess medication from the inner canthus outward.

37. A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching? Wrap the leg with an elastic bandage. Maintain bed rest for 48 hr. Keep legs in a dependent position. Implement a sodium restricted diet.

Wrap the leg with an elastic bandage.

2. A nurse is contributing to the plan of care for an older adult client. Which of the following physiological changes should the nurse recommend considering when administering medication? a. Decreased kidney function b. increased liver functionc. decreased pulmonary function d. increased metabolism

a

5. A nurse in a clinic is caring for a client who is 40 weeks gestation and experiences a sudden gush of vaginal fluid. Which of the following findings is evidence of an obstetric complication? a. preceded by bloody show b. Appears greenish brown in color meconium c. hasaphof7 d. Turns A nitrazine strip blue

a

1. A nurse reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching? a. you will feel pressure when I inflate the catheter balloon b. you cannot drink fluids for a 4 hours after the procedurec. you will need to urinate for the procedured. you will have a leg bag to collect the urine

c

3. A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? a. Turn the child onto their backb. Restrain the child upper extremityc. Place a pillow under the child's headd. Place a padded tongue blade in the child's mouth

c

4. A nurse is caring for a client who is receiving a continuous enteral tube feeding and develops diarrhea. Which of the following actions should the nurse take? a.Switch the client to a formula containing left protein. b. provide the client with low calorie formula.c. increase the rate of the clients feeding.d. Administer the client's formula at room temperature

d

6. A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's Disease. Which of the following information should the nurse include?

c. Provide a stimulating environment for the client

29. A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first? Report the incident to the charge nurse Speak to the staff members in private about client confidentiality Participate in an in-service about client confidentiality Tell the staff members to stop their discussion

tell the staff members to stop their discussion