Final

After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded? A. The urine in the drainage bag appears red to pink. B. The client reports bladder spasms and the urge to void. C. The normal saline irrigation is infusing at the rate of 50 gtt/minute. D. About 1,000 mL of irrigant have been instilled, and 1,200 mL of drainage have been returned.

B. The client reports bladder spasms and the urge to void.

After a surgical procedure, the health care provider orders a clear-liquid diet for a client. The nurse advises the unlicensed assistive personnel (UAP) to check the client's food tray for which of the following allowable items? Select all that apply. A. orange juice, farina, and coffee B. apple juice, chicken broth, and gelatin C. pineapple juice, a bran muffin, and milk D. orange juice, custard, and tea E. ginger ale, jello, and a fruitless popsicle

B. apple juice, chicken broth, and gelatin E. ginger ale, jello, and a fruitless popsicle

The nurse is caring for a 73-year-old client with a history of arthritis who was admitted after suffering a stroke. The stroke has made communication difficult for the client. Which pain assessment tool should the nurse use for this client? A. number scale from one to ten B. face rating scale C. body diagram D. questionnaire

B. face rating scale

The nurse is caring for a client who has been diagnosed with narcolepsy. Which actions may assist the client in managing this condition? Select all that apply. A. drink a small glass of red wine prior to retiring for the evening B. limit caffeine intake C. avoid smoking D. participate in vigorous exercise within 60 to 90 minutes of bedtime E. follow a regular schedule for sleep and rest

B. limit caffeine intake C. avoid smoking E. follow a regular schedule for sleep and rest

The nurse delegated bed bathing of a client with a heart disease to the unlicensed assistive personnel (UAP). The nurse would intervene if which action is being done by the UAP? A. removing dentures and placing in cup of water B. using the flat side of the fingers to give a back massage C. exposing only the area of the client being bathed D. using an inflatable bed cradle to shampoo the hair

B. using the flat side of the fingers to give a back massage

The nurse observes the unlicensed assistive personnel (UAP) delivering a food tray to the client prescribed a clear liquid diet. The nurse would intervene when which food product is seen on the food tray? A. cranberry juice B. vanilla yogurt C. iced coffee D. chicken broth

B. vanilla yogurt

The nurse is preparing to perform wound care for a client. What action should the nurse prioritize before changing the dressing? A. put on gloves B. wash hands thoroughly C. slowly remove the soiled dressing D. observe the dressing for the amount, type, and odor of drainage

B. wash hands thoroughly

The nursing instructor asks the nursing student why shouldn't the nurse palpate both carotid arteries at the same time. Which response by the student is correct? A. "The pulse can't be checked accurately if the arteries are palpated at the same time." B. "Checking both carotid arteries at the same time may cause transient hypertension." C. "Checking both carotid arteries at the same time may impair cerebral circulation." D. "Checking both carotid arteries at the same time may cause severe tachycardia."

C. "Checking both carotid arteries at the same time may impair cerebral circulation."

A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse if he'll ever be able to walk again. Which response by the nurse is appropriate? A. "If you keep a positive attitude, you can do anything." B. "What makes you think you won't be able to walk again?" C. "What has your physician told you about your ability to walk again?" D. "Most likely you won't be able to, but we never know for sure."

C. "What has your physician told you about your ability to walk again?"

When inspecting a client's skin, the nurse finds a vesicle on the client's arm. How will the nurse document his findings about this client's vesicle? A. Flat, nonpalpable, and colored B. Solid, elevated, and circumscribed C. Circumscribed, elevated, and filled with serous fluid D. Elevated, pus-filled, and circumscribed

C. Circumscribed, elevated, and filled with serous fluid

The nurse reinforces instructions about how to feed a client with a self-care deficit for the client's family members. Which instruction should the nurse stress to the family? A. Keep the client on a soft foods or a full liquid diet. B. Ask the health care provider to prescribe parenteral nutrition (PN) for the client. C. Determine which foods the client tolerates best and offer those foods. D. Have the health care provider prescribe a gastrostomy tube for feeding the client.

C. Determine which foods the client tolerates best and offer those foods.

A client with a new colostomy asks the nurse how to avoid detachment from the ostomy bag. What is the best response by the nurse? A. Limit fluid intake. B. Eat more fruits and vegetables. C. Empty the bag when it's about half full. D. Tape the end of the bag to the surrounding skin.

C. Empty the bag when it's about half full.

Which intervention might safely prevent constipation in a client who has end-stage ovarian cancer and requires high doses of opioids to control pain? A. Instructing the client to avoid consuming alcohol B. Telling the client to avoid taking over-the-counter medications C. Explaining the importance of increasing the intake of fiber and fluids D. Informing the client that taking laxatives routinely might help

C. Explaining the importance of increasing the intake of fiber and fluids

The nurse mentor is observing a newly hired nurse while she performs a head-to-toe assessment. The mentor knows the newly hired nurse is effective in evaluating a client's posterior tibial pulse when she palpates which area? A. Medially in the antecubital space B. Midway between the superior iliac spine and symphysis pubis C. On the inner aspect of the ankle, below the medial malleolus D. Along the top of the foot, over the instep

C. On the inner aspect of the ankle, below the medial malleolus

The nurse is reinforcing education for parents whose child is experiencing an episode of "midnight croup," or acute spasmodic laryngitis. What should the nurse be sure to include when reinforcing education? A. Give warm liquids. B. Raise the heat on the thermostat. C. Provide humidified air with cool mist. D. Take the child into the bathroom with a cold, running shower.

C. Provide humidified air with cool mist.

A client has severe pruritus from hepatitis B. Which nursing intervention would best enhance the client's comfort? A. Bathe the client in hot water to increase vasodilatation. B. Bathe the client in cold water to decrease itching sensation. C. Provide sponge baths for the client using tepid water. D. Instruct the client to avoid lotions and creams.

C. Provide sponge baths for the client using tepid water.

What nursing intervention should be provided for a client who is experiencing a seizure? A. Place client in prone position. B. Restrain the client's arms only. C. Turn the client to one side. D. Insert a bite block in the mouth.

C. Turn the client to one side.

The nurse is caring for a client receiving bolus gastrointestinal tube feeding. The nurse checks for residual before instilling the next bolus feeding and aspirates 120 mL. Which are the most appropriate actions by the nurse? A. Reposition the client and administer the feeding. B. Wait 15 minutes and then administer the feeding. C. Withhold the feeding and notify the health care provider. D. Reinstill the residual and withhold the feeding.

C. Withhold the feeding and notify the health care provider.

The nurse on the pediatric unit is caring for a child with asthma. When assisting the health care team to develop a plan of care, which problem should the team be sure to address? A. imbalanced nutrition B. excess fluid volume C. activity intolerance D. constipation

C. activity intolerance

The nurse is collecting data from a postoperative client. The nurse documents which subjective data? Select all that apply. A. vital signs B. laboratory test results C. client's description of pain D. electrocardiographic (ECG) waveforms E. client's nausea

C. client's description of pain E. client's nausea

A nurse is collecting data on a client with a history of constipation. Which data, obtained by the nurse, would indicate a risk factor for constipation? A. a 66-year-old white male B. daily fluid intake of 72 ounces (2.1 L) C. diet high in cheese, lean meats, and pasta D. engages in walking 20 minutes every other day

C. diet high in cheese, lean meats, and pasta

A nurse determines that an adolescent with a fractured left femur understands the instructions to perform only touch-down weight bearing when making what statement? A. "I will place full weight on my left leg." B. "I will place about 30% to 50% of my weight on my left leg." C. "I will keep my left leg off the floor." D. "I will allow my left leg to touch the floor without placing weight on it."

D. "I will allow my left leg to touch the floor without placing weight on it."

An older adult client who has recently been diagnosed with hypothyroidism lives independently in an apartment in a community development designed for older adults. The client asks the nurse assigned to the complex for advice about managing this condition. What is the best response by the nurse? A. "Stop taking your self-prescribed daily aspirin." B. "Stop attending group activities." C. "Keep the temperature in your apartment cooler than usual." D. "Increase fiber and fluids in your diet."

D. "Increase fiber and fluids in your diet."

A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction? A. "Keep the stoma uncovered." B. "Keep the stoma dry." C. "Have a family member perform stoma care initially until you get used to the procedure." D. "Keep the stoma moist."

D. "Keep the stoma moist."

A client diagnosed with renal calculi is experiencing severe pain despite having received pain medication. A nurse pages a physician. Which intervention can the nurse perform while awaiting the physician's response? A. Assist the client to ambulate in the hallway. B. Explain that the client can't safely take any more pain medication. C. Provide the client with a heating pad. D. Perform nonpharmacologic pain interventions.

D. Perform nonpharmacologic pain interventions.

The nurse cares for a client who is post-op bowel resection and has a nasogastric (NG) tube to low intermittent suction. Which care intervention should the nurse administer? A. Flush the NG with saline once per shift. B. Offer ice chips to moisturize the mouth. C. Secure the suction tubing to the bed rail. D. Provide meticulous mouth care as needed.

D. Provide meticulous mouth care as needed.

A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. Which finding indicates that the client is responding appropriately to TENS therapy? A. Muscle tension in the area of TENS application is not palpable. B. The nurse observes decreased joint stiffness and improved mobility. C. There is a reduction in tissue swelling in the affected area on inspection. D. The client reports an improvement in discomfort over the painful area.

D. The client reports an improvement in discomfort over the painful area.

A client has been admitted to the hospital with heart failure. On entering the room, the nurse notices that the client is having difficulty breathing. Which position would be most appropriate to help the client's breathing? A. flat in bed with feet elevated B. semi-Fowler position C. side-lying position D. high Fowler position

D. high Fowler position

The nurse is caring for an 11-year-old child with cerebral palsy who has a pressure ulcer on the sacrum. When reinforcing education for the parent about dietary intake, which foods should the nurse plan to emphasize? A. legumes and cheese B. whole grain products C. fruits and vegetables D. lean meats and low-fat milk

D. lean meats and low-fat milk

A graduate nurse, working in a long-term facility, is caring for a client who has hearing loss. When observing the graduate, the nurse mentor would intervene if which action is taken by the graduate? A. speaks clearly and at a normal pace B. eliminates background noise as much as possible C. before speaking, gets the client's attention D. moves around and multitasks when speaking

D. moves around and multitasks when speaking

The nurse observes a client, who has left-sided paralysis from a stroke, dress independently. Which action by the client indicates proper technique for dressing the upper-extremities? A. buttons the shirt first before placing it on over the head B. puts the shirt over the head before pulling it onto the affected arm C. requests help because this activity is impossible to do independently D. places the affected arm in the shirt before the unaffected arm

D. places the affected arm in the shirt before the unaffected arm

The nurse is caring for a child with bronchopulmonary dysplasia that is preparing for discharge. Which parental care outcome should be anticipated? A. reports increased levels of stress B. only makes safe decisions with professional assistance C. participates in routine, but not complex, caretaking activities D. verbalizes the causes, risks, therapy options, and nursing care

D. verbalizes the causes, risks, therapy options, and nursing care

When reviewing an adult client's chart, which finding related to the bladder should the nurse identify as normal? A. A soft, smooth bladder B. A hard, rough bladder C. A nonpalpable bladder D. A palpable bladder located 3" to 5" (7.5 to 12.7 cm) above the symphysis pubis

C. A nonpalpable bladder

An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse observes the client during feeding and is concerned most with which potential development? A. Hyperglycemia B. Fluid volume excess C. Aspiration D. Constipation

C. Aspiration

A client who has experienced a stroke is unable to move without help. Which intervention should the nurse perform to reduce this client's risk for developing a common complication of immobility? A. Change the client's position every 1 to 2 hours. B. Perform passive range-of-motion (ROM). C. Increase the client's fluid intake. D. Instruct the client to use a footboard.

A. Change the client's position every 1 to 2 hours.

The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 50 ml (8 a.m.)(0800), 60 ml (9 a.m.) (0900). Based on these amounts, what should the nurse do? A. Continue to monitor and record hourly urine output. B. Notify the physician. C. Irrigate the indwelling urinary catheter. D. Increase the I.V. fluid infusion rate.

A. Continue to monitor and record hourly urine output.

A 54-year-old client who was admitted to the psychiatric unit during an acute phase of schizophrenia has hardly eaten and hasn't bathed or changed his clothes for 3 weeks. He undergoes 4 weeks of psychotherapy and medication adjustment. Which statement by the client indicates that he's ready for discharge? A. "I know a sign of my disease is not bathing and maintaining my personal appearance." B. "God tells me that I only need to bathe during the full moon." C. "I bathe and brush my teeth daily just like that voice tells me to." D. "I'll make sure I change my clothes every 3 days when I return home."

A. "I know a sign of my disease is not bathing and maintaining my personal appearance."

A nurse is performing a focused abdominal assessment. When can the nurse document that her client's bowel sounds are absent after listening for how long over each quadrant? A. 5 minutes B. 4 minutes C. 3 minutes D. 2 minutes

A. 5 minutes

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? A. Acute pain related to biliary spasms B. Deficient knowledge related to prevention of disease recurrence C. Anxiety related to unknown outcome of hospitalization D. Imbalanced nutrition: Less than body requirements related to biliary inflammation

A. Acute pain related to biliary spasms

Which action should the nurse include in the plan of care for a 2-month-old infant with heart failure? A. Allow the infant to rest before feeding. B. Bathe the infant and administer medications before feeding. C. Weigh and bathe the infant before feeding. D. Feed the infant when he cries.

A. Allow the infant to rest before feeding.

The client calls the nurse in the clinic and states that the cast feels very rough around the edges and is scratching the skin. What is the best response by the nurse? A. Apply moleskin or pink tape around the edges. B. Elevate the limb above the level of the heart. C. Break off the rough area and file it down. D. Distribute pressure evenly.

A. Apply moleskin or pink tape around the edges.

Which nursing action should be included in the care plan to promote comfort in a 4-year-old child hospitalized with meningitis? A. Avoid making noise when in the child's room. B. Rock the child frequently. C. Let the child's 2-year-old sibling stay in the room. D. Keep the lights on brightly so that the child can see the parent.

A. Avoid making noise when in the child's room.

During a routine prenatal visit, a pregnant client in her third trimester reports heartburn. To minimize her discomfort, the nurse should include which suggestion in the plan of care? A. Eat small, frequent meals. B. Decrease fluid intake. C. Drink milk at the end of every meal. D. Take an over the counter antacid.

A. Eat small, frequent meals.

The nurse is preparing to insert a nasogastric tube. What position would best facilitate insertion? A. Fowler's B. prone C. side-lying D. supine

A. Fowler's

A 14-year-old with type 1 diabetes is admitted with ketoacidosis for the second time in 3 months. The parent states, "I don't know why this keeps happening." Which response by the nurse is best? A. "Adolescents need strict rules to make sure they adhere to their treatment plans." B. "Adolescents sometimes become overwhelmed by adhering to dietary restrictions and taking medications." C. "You'll need to keep a closer eye on your child to make sure that they adheres to the treatment plan." D. "You should notify the school nurse so that they can monitor your child closely while at school."

B. "Adolescents sometimes become overwhelmed by adhering to dietary restrictions and taking medications."

A pregnant client tells the nurse that she doesn't like milk and can't possibly drink three to four glasses per day as recommended by her health care provider. What is the best response by the nurse? A. "I did not like milk either, but I drank it during pregnancy." B. "Are there any dairy products that you do like?" C. "It is important for the baby that you drink your milk." D. "Do not worry; you can just take calcium supplements."

B. "Are there any dairy products that you do like?"

A nurse reinforces preoperative instructions for a client who is scheduled for a left above-the-knee amputation. Which statement made by the client indicates an understanding of the instructions? A. "Physical therapy will be started 3 weeks after I am discharged from the hospital." B. "Isometric exercise will help me to maintain the muscle tone of my remaining limb." C. "I will be assisted out of bed immediately after the postanesthesia recovery period is over." D. "A continuous passive motion machine will assist with maintaining range-of-motion in my hip."

B. "Isometric exercise will help me to maintain the muscle tone of my remaining limb."

Following a liver transplant a client develops ascites. The nurse should teach the client to: A. increase water intake. B. brace the abdomen with a pillow during coughing. C. perform 10 leg raises every waking hour. D. reduce requests for pain medicine.

B. brace the abdomen with a pillow during coughing.

When plotting height and weight on a growth chart, which observation by the nurse would indicate that a 4-year-old child has a growth hormone deficiency? A. upward shift of 1 percentile or more B. upward shift of 5 percentiles or more C. downward shift of 2 percentiles or more D. downward shift of 1 percentile or more

C. downward shift of 2 percentiles or more

The student nurse describes how to position a client for a lumbar puncture to the primary care nurse. Which description indicates that the student nurse understands the correct positioning for the procedure? A. prone, with the head turned to the right B. supine, with the knees raised toward the chest C. lateral recumbent, with flexed knees D. lateral, with the right leg extended

C. lateral recumbent, with flexed knees

A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should the nurse include in a bladder retraining program? A. Establishing a predetermined fluid intake pattern for the client B. Encouraging the client to increase the time between voidings C. Restricting fluid intake to reduce the need to void D. Assessing present elimination patterns

D. Assessing present elimination patterns

When caring for a client during the second stage of labor, which action would be most appropriate? A. Assisting the client with ambulation B. Encouraging the client to void every 2 hours C. Allowing the client clear liquids D. Assisting the mother with pushing

D. Assisting the mother with pushing

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? A. Putting slippers on the client's feet B. Crossing the client's ankles every 2 hours C. Placing hand rolls on the balls of each foot D. Attaching braces or splints to each foot and leg

D. Attaching braces or splints to each foot and leg

A nurse is teaching newborn care to expectant parents. Which information about sleep should the nurse include in the teaching plan? A. Infants should not sleep in a bed with another person. B. Only use soft bedding in the crib. C. Infants should be put to sleep in their own room. D. Infants should be placed in the prone position for sleep.

A. Infants should not sleep in a bed with another person.

Which of the following is the most numerous type of white blood cell (WBC)? A. Neutrophil B. Eosinophil C. Basophil D. Lymphocyte

A. Neutrophil

To verify the placement of a nasogastric feeding tube, what action should the nurse perform? A. Obtain a chest X-ray. B. Instill 30 mL of water while listening with a stethoscope. C. Test the client for the presence of the gag reflex. D. Properly measure the tube before insertion.

A. Obtain a chest X-ray.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? A. Relieving abdominal pain B. Preventing fluid volume overload C. Maintaining adequate nutritional status D. Teaching about the disease and its treatment

A. Relieving abdominal pain

While caring for a client who's immobile, the nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." When creating the nursing care plan, which diagnosis would the nurse select to accurately reflect this information? A. Risk for impaired skin integrity related to immobility B. Impaired skin integrity related to immobility C. Constipation related to immobility D. Disturbed body image related to immobility

A. Risk for impaired skin integrity related to immobility

A client with Alzheimer's disease has a nursing diagnosis of Imbalanced nutrition: less than body requirements related to forgetfulness. What nursing intervention should be included in the care plan to encourage adequate nutritional intake for this client? A. Stay with the client and encourage him or her to eat. B. Help the client fill out the menu. C. Give the client privacy during meals. D. Fill out the menu for the client.

A. Stay with the client and encourage him or her to eat.

When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of foods such as: A. bananas and potatoes. B. milk and yogurt. C. deli meats. D. cereals and grains.

A. bananas and potatoes.

A nurse is caring for a client with a neuromuscular condition who is unable to receive oral nutrition. Which nursing action is a priority when providing continuous enteral feeding? A. elevating the head of the bed at least 30 degrees B. positioning the client supine on the left side C. warming the formula before administration D. hanging a full day's worth of formula at one time

A. elevating the head of the bed at least 30 degrees

A client with a sprained ankle comes to the emergency department. When bandaging the client's ankle, the nurse should use which technique? A. figure-eight B. circular C. recurrent D. spiral reverse

A. figure-eight

The nurse is caring for a child with acute rheumatic fever. Which data does the nurse anticipate in this child? A. leukocytosis B. normal electrocardiogram C. normal red blood cell count D. normal erythrocyte sedimentation rate

A. leukocytosis

An adolescent is diagnosed with iron deficiency anemia. After emphasizing the importance of consuming dietary iron, the nurse asks the child to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources? A. Grapefruit and white toast B. Pancakes and a banana C. Ham and eggs D. Bagel and cream cheese

C. Ham and eggs

Which nursing diagnosis takes priority for a client diagnosed with anorexia nervosa? A. Deficient knowledge B. Disturbed body image C. Imbalanced nutrition: Less than body requirements D. Social isolation

C. Imbalanced nutrition: Less than body requirements

Which of the following would be appropriate for a client with arterial blood gas (ABG) values of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3- 24 mEq/L, and PaO2 94 mm Hg? A. Administer a prescribed decongestant. B. Instruct the client to breathe into a paper bag. C. Offer the client fluids frequently. D. Administer prescribed supplemental oxygen.

B. Instruct the client to breathe into a paper bag.

The nurse is performing tracheal suction for a client as indicated due to a "gurgling" sound with respirations. Which nursing action is correct for performing this procedure? A. Apply suction during insertion of the catheter. B. Limit suctioning to 10 to 15 seconds' duration. C. Resterilize the suction catheter in alcohol after use. D. Repeat suctioning intervals every 15 minutes until clear.

B. Limit suctioning to 10 to 15 seconds' duration.

The nurse is caring for a client with a cast on his left arm. Which data collection finding is most significant for this client? A. Normal capillary refill in the great toe B. Presence of a normal popliteal pulse C. Intact skin around the cast edges D. Ability to move all toes

C. Intact skin around the cast edges

When assisting to plan nursing care to maintain skin integrity for an adult female bed-bound client, which interventions should the nurse include? Select all that apply. A. Apply a pleasantly scented dusting powder to the axillae and groin, beneath the breasts, and between the toes. B. Monitor the skin for breakdown daily during client's bath. C. Apply deodorant or antiperspirant immediately after shaving under the arms. D. Keep skin clean and dry to prevent breakdown. E. Always use alcohol for back rubs. F. Turn and reposition the client every two hours.

B. Monitor the skin for breakdown daily during client's bath. D. Keep skin clean and dry to prevent breakdown. F. Turn and reposition the client every two hours.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate? A. Encourage the client to close his eyes. B. Notify the physician. C. Turn out the lights in the room. D. Instill artificial tears.

B. Notify the physician.

A client expressed interest in using complementary alternate modalities for health benefits and asks the nurse to provide information about meditation. The nurse would provide which appropriate response to this client? A. "It is seen as natural and promotes health through the use of plants and herbs." B. "It consists of deep personal thoughts and breath control to help decrease anxiety." C. "It teaches that each person is surrounded by an energy field and helps restore harmony." D. "It applies external pressure to the energy points for pain control between acupuncture treatments."

B. "It consists of deep personal thoughts and breath control to help decrease anxiety."

A nurse is caring for an older adult client who was admitted with a hip fracture. The client is occasionally confused and has incidents of urinary incontinence. The nurse overhears the unlicensed assistive personnel state, "I am tired of changing that client's bed linen because she can't hold her urine. The client is with it mentally most of the time." Which response by the nurse is most appropriate? A. "This may be because the client can't get out of bed because of the hip fracture." B. "Let's go to a private area so that we can talk more about your frustration." C. "Can you tell me more about why you are so upset about changing the client's linen?" D. "Tell me what makes you feel that way about older adults with urinary incontinence?"

B. "Let's go to a private area so that we can talk more about your frustration."

A client is admitted to the hospital in the manic phase of bipolar disorder. Which foods are most appropriate for this client? A. A bowl of soup, crackers, and a dish of peaches B. A cheese sandwich, carrot sticks, grapes, and cookies C. Roasted chicken, mashed potatoes, and peas D. A tuna sandwich, an apple, and a dish of ice cream

B. A cheese sandwich, carrot sticks, grapes, and cookies

A 32-year-old homeless client is referred to an outpatient treatment program for delusional behavior. A nurse notes during the history-taking process that the client eats only one meal a day, which is high in fat and contains no vegetables. The client also states that she rarely eats fruit. Which approach can the nurse use to help the client eat more nutritious meals? A. Provide the client with reading material about nutrition. B. Provide the client with a nutritional lunch and arrange for the nutritionist and psychiatrist to see the client after lunch. C. Request that the client keep a food diary, and then schedule a follow-up appointment in 1 week. D. Provide the client with food from the local food bank; then schedule a follow-up appointment in 1 week.

B. Provide the client with a nutritional lunch and arrange for the nutritionist and psychiatrist to see the client after lunch.

A child, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention would be appropriate? A. Administering digestive enzymes before meals as prescribed B. Providing small, frequent meals C. Administering antibiotics with meals as prescribed D. Providing high-fiber snacks

B. Providing small, frequent meals

The parents of an 11-month-old are concerned because the frequency of their infant's bowel movements has decreased from three to four each day to one to two each day. Which response by the nurse is best? A. "The pediatrician might order a barium enema to make sure your baby doesn't have Hirschsprung's disease." B. "You should increase the amount of fruit in your infant's diet." C. "By age 11 months, most infants have one to two bowel movements per day." D. "You should increase the amount of water you give to your baby."

C. "By age 11 months, most infants have one to two bowel movements per day."

A 45-year-old client with schizophrenia expresses a fear of sleeping because voices become threatening when she attempts to sleep. To avoid sleeping the client reports drinking 40 cups of coffee a day. Which response by the nurse is appropriate? A. "Forty cups of coffee! You really need to consider cutting way back on your consumption immediately." B. "You need to stop drinking that much coffee immediately; it isn't good for your health." C. "I know that you're afraid to sleep; let's discuss the effect of caffeine on your voices." D. "A cup of herbal tea might help you sleep better."

C. "I know that you're afraid to sleep; let's discuss the effect of caffeine on your voices."

During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which client statement indicates an accurate understanding of the nurse's instructions? A. "I'll decrease my intake of green, leafy vegetables." B. "I'll limit fluid intake to four 8-oz glasses." C. "I'll increase my intake of unrefined grains." D. "I'll take iron supplements regularly."

C. "I'll increase my intake of unrefined grains."

A client who experienced a stroke has left-sided facial droop. During mouth care, the client begins to cough violently. What should the nurse do? A. Avoid providing mouth care. B. Maintain the client on nothing-by-mouth status. C. Make sure a tonsil suction device is readily available while providing mouth care. D. Continue providing mouth care because the client's gag reflex is intact.

C. Make sure a tonsil suction device is readily available while providing mouth care.

A client has been diagnosed with hyperthyroidism. In assisting with the plan of care, the nurse should give priority to which goal? A. Keep the client warm. B. Reduce the client's calorie intake. C. Provide adequate rest and sleep. D. Force fluids and roughage.

C. Provide adequate rest and sleep.

Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis? A. Imbalanced nutrition: Less than body requirements related to poor intake B. Disturbed sleep pattern related to external stimuli C. Impaired skin integrity related to pruritus D. Acute pain related to sickle cell crisis

D. Acute pain related to sickle cell crisi

An unconscious client is admitted to the emergency department. During rapid data collection, which pulse will the nurse palpate in this client? A. Radial B. Brachial C. Femoral D. Carotid

D. Carotid

The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein? A. Baked beans, hamburger, and milk B. Spaghetti with cream sauce, broccoli, and tea C. Bouillon, spinach, and soda D. Chicken cutlet, spinach, and soda

A. Baked beans, hamburger, and milk

The nurse is instructing unlicensed assistive personnel (UAP) on the proper care of a client in Buck's extension traction following a fracture of his left fibula. Which observation indicates that the education was effective? A. The weights are allowed to hang freely over the end of the bed. B. The UAP lifts the weights when assisting the client to move up in bed. C. The leg in traction is kept externally rotated. D. The UAP instructs the client to perform ankle rotation exercises.

A. The weights are allowed to hang freely over the end of the bed.

A client has a tumor of the posterior pituitary gland. The nurse assisting with the development of the plan of care should include which nursing interventions? (Select all that apply.) A. Weigh the client daily. B. Restrict fluids. C. Measure urine specific gravity. D. Encourage intake of coffee or tea. E. Monitor intake and output.

A. Weigh the client daily. E. Monitor intake and output.

A nurse is reinforcing education to parents who are planning to give growth hormone to their child at home. What is the best time to administer growth hormone in order to achieve optimal dosing? A. at bedtime B. after dinner C. in the middle of the day D. first thing in the morning

A. at bedtime

D. The nursing instructor asks the nursing student to describe the anatomic position. How would the student correctly respond? A. "The client's body is supine." B. "The client's arms are elevated at shoulder level." C. "The client's palms are turned forward." "The client's body is facing backward."

C. "The client's palms are turned forward."

During chemotherapy, a boy, age 10, loses his appetite. When teaching the parents about his food intake, the nurse should include which instruction? A. "Offer dry toast and crackers." B. "Withhold all food and fluids." C. "Ignore your child's lack of food intake." D. "Let your child eat any food he wants."

D. "Let your child eat any food he wants."

The nurse is reviewing a client's plan of care. The following statement appears on the client's plan of care: "Client will ambulate in the hall without assistance within 4 days." What does the nurse recognize this statement as an example of? A. A nursing diagnosis B. A client outcome C. Subjective data D. A nursing intervention

B. A client outcome

A client in the early stages of active labor wants to get out of bed and walk around the room. Which action by the nurse is best? A. Calling the physician and requesting an order to allow the client to ambulate B. Assisting the client to ambulate in the room C. Putting up the side rails and refusing to allow the client to get out of bed D. Medicating the client for pain, then assisting her with ambulation

B. Assisting the client to ambulate in the room

The parent of a 6-month-old infant with atopic dermatitis asks for advice on bathing the child. Which instructions or information should the nurse give to the parent? A. Bathe the infant twice daily. B. Bathe the infant every other day. C. Use bubble baths to decrease itching. D. The frequency of the infant's baths isn't important in atopic dermatitis.

B. Bathe the infant every other day.

The nurse is caring for a terminally ill client with cancer who is receiving hospice services with an advance directive. Which nursing action is a priority? A. Maintain hydration status with IV fluids. B. Care for elimination needs. C. Assist with the administration of chemotherapeutic agents. D. Monitor airway status and prepare to assist with intubation.

B. Care for elimination needs.

A nurse is caring for a client who had abdominal surgery 3 days ago. The client states, "I haven't moved my bowels, but I am passing gas." What nursing action is appropriate for this client? A. Apply moist heat to the client's abdomen. B. Encourage the client to ambulate. C. Administer a tap-water enema. D. Notify the healthcare provider.

B. Encourage the client to ambulate.

One day after undergoing a traditional cholecystectomy, a client is scheduled to stand at the bedside and walk. What should a nurse teach the client to do before standing and walking for the first time after surgery? A. Place the bed in the flat position before getting out of bed. B. Flex her legs when moving to a sitting position. C. Maintain a slightly flexed-at-the-waist position when walking. D. Relax her buttock muscles when rising to a standing position.

B. Flex her legs when moving to a sitting position.

When collecting data on a child with impetigo, the nurse expects which findings? A. Small, brown, benign lesions B. Honey-colored, crusted lesions C. Linear, threadlike burrows D. Circular lesions that clear centrally

B. Honey-colored, crusted lesions

During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis? A. Recommending that the client discontinue chemotherapy B. Providing a solution of hydrogen peroxide and water for use as a mouth rinse C. Monitoring the client's platelet and leukocyte counts D. Checking regularly for signs and symptoms of stomatitis

B. Providing a solution of hydrogen peroxide and water for use as a mouth rinse

The nurse is preparing to feed the infant. Which actions by the infant indicate readiness to feed? Select all that apply. A. burping B. hand to mouth C. lies quietly awake D. rooting E. mouthing

B. hand to mouth

A 40-year-old client with mild dementia related to end-stage acquired immunodeficiency syndrome (AIDS) is preparing for discharge. She has decided against further curative treatment. Before discharge, she develops ocular cytomegalovirus (CMV). Her physician recommends treatment with a ganciclovir-impregnated implant, which requires a surgical procedure. The client's husband feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which response best answers the husband's question while promoting client advocacy? A. "The implant won't cure the virus. I'll tell the physician that you don't want her to have the procedure." B. "The implant won't cure the virus, but it may protect her sight. Just because your wife has dementia, doesn't mean she shouldn't be given the opportunity to see." C. "The implant won't cure the virus in your wife's eye. The dementia she has means she is terminally ill. You're right to refuse further treatments because nothing more will help her." D. "The implant won't cure the virus, but it may help preserve her vision. If she can't see you or her surroundings, it may worsen her dementia and make caring for her at home more difficult."

D. "The implant won't cure the virus, but it may help preserve her vision. If she can't see you or her surroundings, it may worsen her dementia and make caring for her at home more difficult."

A nurse in the emergency department is caring for a client with an ankle injury that occurred while playing football. Which nursing action takes priority? A. Apply cold immediately. B. Wrap with a compression bandage. C. Elevate the extremity. D. Inspect for visible deformity.

D. Inspect for visible deformity.