Hurst Review Questions (2)

The primary healthcare provider's prescription for a client instructs the nurse to give digoxin 0.125 mg intravenously as a one-time dose. The available medication is in a concentration of 0.5 mg/2 mL. How many milliliters should the nurse give? Round answer using one decimal point.

0.5 mL

How should the nurse respond to a pregnant client who asks, "How will I know when it is time to go to the hospital?" 1. "Go to the hospital immediately if your membranes rupture." 2. "You should leave for the hospital as soon as you lose your mucus plug." 3. "Go to the hospital when you have a burst of energy followed by a backache." 4. "You need to go to the hospital when contractions are 2 minutes apart."

1. "Go to the hospital immediately if your membranes rupture."

The school nurse has educated a group of teens concerned about acquiring the Ebola virus. Which statement by the students would indicate to the nurse that further teaching is necessary? 1. "I can get a vaccine to prevent getting the Ebola virus." 2. "Ebola is not spread through casual contact, so my risk of getting the virus is low." 3. "The Ebola virus is passed from person to person through blood and body fluid." 4. "Ebola viruses are mainly found in primates in Africa."

1. "I can get a vaccine to prevent getting the Ebola virus."

A client has recently been diagnosed with systemic scleroderma. Which of the following client complaints would be of most concern to the homecare nurse? 1. "I feel like food gets stuck in my throat when I eat." 2. "I have a hard time brushing my teeth properly." 3. "My fingers burn when I go outside in the winter." 4. "I get short of breath whenever I exercise."

1. "I feel like food gets stuck in my throat when I eat."

A client diagnosed with hypertension has been prescribed metoprolol. Which statement by the client indicates that the client's medication instruction for metoprolol has been effective? 1. "I should not stop taking this drug immediately." 2. "I will need to rinse my mouth with water 3 times a day." 3. "I can decrease my aerobic exercises from 3 to 2 times per week." 4. "I will report irregular heartbeats, if they continue for more than 3 days."

1. "I should not stop taking this drug immediately."

The home care nurse is caring for an elderly client status post total hip replacement and a history of cirrhosis. Which statements by the client's spouse indicates that teaching regarding pain management has been successful? Select all that apply 1. "If the pain increases, I must let the nurse know immediately." 2. "I should have my spouse try the breathing exercises to help control pain." 3. "This narcotic causes very deep sleep, which is what my spouse needs." 4. "If constipation is a problem, increased fluids will help." 5. "My spouse can have one glass of wine to help promote pain relief."

1. "If the pain increases, I must let the nurse know immediately." 2. "I should have my spouse try the breathing exercises to help control pain." 4. "If constipation is a problem, increased fluids will help."

A nurse has completed education on safe sexual practices to a group of college students. Which comments by the students would indicate that education has been successful? Select all that apply 1. "The best way to prevent HIV is to abstain from sex." 2. "Contraceptives should contain spermicide N-9." 3. "Douching is recommended after intercourse." 4. "Drinking too much alcohol can increase the risk exposure to sexually transmitted disease (STDs)." 5. "If my partner will not use a condom, I will."

1. "The best way to prevent HIV is to abstain from sex." 4. "Drinking too much alcohol can increase the risk exposure to sexually transmitted disease (STDs)." 5. "If my partner will not use a condom, I will."

When providing instructions, the nurse asks the client to repeat the techniques for crutch walking. The nurse is aware that further teaching is needed when the client makes which statement? 1. "The elbows should be flexed at 10 degrees." 2. "I should not lean on the crutches with my armpit." 3. "When going upstairs, my non-surgical leg goes up first." 4. "Both crutches are held in one hand when sitting down".

1. "The elbows should be flexed at 10 degrees."

A client has arrived in the emergency department with partial thickness burns to 52 percent of the body. Which central venous pressure (CVP) reading would the nurse anticipate? 1. 1 mm of Hg 2. 2 mm of Hg 3. 6 mm of Hg 4. 10 mm of Hg

1. 1 mm of Hg

Which nursing statements about a client reflect correct documentation in the hospital medical record? Select all that apply 1. 20% of breakfast consumed. 2. 4 inch by 2 inch wound noted on right arm. 3. Enema administered. 4. Appears upset at spouse. 5. Lying in bed.

1. 20% of breakfast consumed. 2. 4 inch by 2 inch wound noted on right arm.

The nurse is caring for a client being treated for hypertensive crisis and suspects that the client may be developing an abdominal aortic aneurysm (AAA). Which assessment findings by the nurse suggest that the client is developing this complication? Select all that apply 1. Abdominal bruit 2. Upper back pain 3. Hoarseness 4. Pulsations around umbilicus 5. Shortness of breath

1. Abdominal bruit 4. Pulsations around umbilicus

A client has been admitted to the telemetry unit with a diagnosis of a cerebral vascular accident. What should the nurse assess to determine the client's risk for aspiration? Select all that apply 1. Ability to swallow 2. Gag reflex 3. Level of consciousness 4. Cough reflex 5. Ability to follow commands

1. Ability to swallow 2. Gag reflex 3. Level of consciousness 4. Cough reflex

A client with renal failure has returned to the unit post kidney transplant. Which postoperative interventions should the nurse provide? Select all that apply 1. Administer furosemide. 2. Maintain fluid replacement at 150 ml per hour for 8 hours. 3. Measure abdominal girth every 24 hours. 4. Weigh daily. 5. Measure urine output every 30 - 60 minutes.

1. Administer Furosemide 4. Weigh daily. 5. Measure urine output every 30 - 60 minutes.

When assessing the client with acute myeloid leukemia the nurse notes the client has pain from mucositis, fatigue from slight activity, pulse rate 100, respiratory rate 22, blood pressure 130/64 mmHg, temperature 98.9 F, and petechiae on the arms. What action should the nurse take first? 1. Administer pain medicine. 2. Notify primary healthcare provider of petechiae. 3. Encourage fluid intake and foods high in protein. 4. Have the UAP assist the client when ambulating.

1. Administer pain medicine.

Two days after being prescribed enoxaparin the nurse notes hematemesis. Lab work has been obtained. Based on this data what action is most important for the nurse to take? Exhibit 1. Administer protamine sulfate. 2. Administer the next dose of enoxaparin. 3. Obtain vital signs. 4. Insert a nasogastric tube.

1. Administer protamine sulfate.

A client with an ischemic stroke was prescribed warfarin 5 mg daily by mouth 48 hours ago. At 0830 the international normalized ratio (INR) reading was 2.0. What action should the nurse take? 1. Administer warfarin. 2. Administer phytonadione. 3. Request the lab to run another INR. 4. Notify the primary healthcare provider about the INR level.

1. Administer warfarin.

A client has been admitted with folic acid deficiency anemia. Which referral would most likely be appropriate for the nurse to make? 1. Alcoholic Anonymous 2. American Sickle Cell Anemia Association 3. Pernicious Anemia Society 4. Aplastic Anemia Support Group

1. Alcoholic Anonymous

A client has been admitted to the unit with recurrent nephrotic syndrome. Which signs and symptoms does the nurse expect to find when examining the client? Select all that apply 1. Anasarca 2. Foamy urine 3. Hypotension 4. Periorbital edema 5. Proteinuria

1. Anasarca 2. Foamy urine 4. Periorbital edema 5. Proteinuria

Which sign/symptom would the nurse expect when assessing a client diagnosed with aortic valve stenosis? Select all that apply 1. Angina 2. Prominent S4 3. Reports being light-headed 4. Systolic murmur 5. Ventricular gallop

1. Angina 2. Prominent S4 3. Reports being light-headed 4. Systolic murmur

The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take? Select all that apply 1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. 5. Simply accept the assignment since overtime is mandatory.

1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action.

The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessments by the nurse suggest that the client is developing this complication? Select all that apply 1. Asterixis 2. Lethargy 3. Amnesia 4. Behavioral changes 5. Kussmaul respirations

1. Asterixis 2. Lethargy 3. Amnesia 4. Behavioral changes

The nurse is assisting a new mother with breastfeeding her newborn baby. The mother verbalizes concern that the baby is not getting adequate milk. Which observations by the nurse indicate adequate fluid intake? Select all that apply 1. Birth weight regained in 14 days 2. Fontanels soft and depressed 3. Pulse rate of 135/min 4. Six to eight wet diapers a day 5. Baby appears satisfied after feedings

1. Birth weight regained in 14 days 3. Pulse rate of 135/min 4. Six to eight wet diapers a day 5. Baby appears satisfied after feedings

The homecare nurse is visiting a client to assess the response to new medications ordered for benign prostatic hyperplasia (BPH). What symptoms reported by the client would indicate to the nurse the medications are not working? Select all that apply 1. Bladder pain 2. Fever with chills 3. Urinary frequency 4. Terminal dribbling 5. Nighttime sweats

1. Bladder pain 3. Urinary frequency 4. Terminal dribbling

A nurse is working in a walk-in clinic where a mother brings in her 6 year old child stating, "My child is just not right." The nurse notes an unusual odor to the child's breath, new onset of bed-wetting, and lethargy. What prescription by the primary healthcare provider should be performed first? 1. Blood glucose 2. Urinalysis for white blood cells (WBC) 3. Oxygen saturation 4. Toxicology screen

1. Blood glucose

Which action by a nurse would indicate that this nurse is following standard precautions? 1. Clean gloves while performing a heel stick on an infant. 2. Sterile gloves to empty a indwelling urinary catheter bag. 3. Shoe covers when entering the room of a client with influenza. 4. Clean gloves while inserting a urinary catheter.

1. Clean gloves while performing a heel stick on an infant.

Which client would be appropriate for the charge nurse to assign to a room with a client who has undergone debulking of a tumor? 1. Client who is one day post laminectomy. 2. Client scheduled for a bone marrow transplant. 3. Client admitted with neutropenia. 4. Client being treated with intracavity radiation therapy.

1. Client who is one day post laminectomy.

Which victim would the nurse decontaminate first in a biological terrorist event? 1. Client who was exposed but is exhibiting no symptoms 2. Client who has an open leg fracture and head injury 3. Client who is not breathing and has no palpable pulse 4. Client with minor cuts and abrasions

1. Client who was exposed but is exhibiting no symptoms

A client admitted to the inpatient mental health unit asks if mail can be received from family. Which statement by the nurse indicates adequate understanding of client rights? 1. Clients can receive and send mail, but staff must check for hazards. 2. Clients are not allowed to receive mail while hospitalized. 3. Receiving mail from family is not encouraged. 4. Clients are allowed to send or receive mail after the first 72 hours after admission.

1. Clients can receive and send mail, but staff must check for hazards.

The nurse is planning an educational seminar on ophthalmic health. Which risk factors for cataract formation should be included in the discussion? Select all that apply 1. Diabetes mellitus. 2. Cigarette smoking. 3. Family history of glaucoma. 4. Long-term use of corticosteroids. 5. Thin cornea.

1. Diabetes mellitus. 2. Cigarette smoking. 4. Long-term use of corticosteroids.

A client is admitted with atrial fibrillation and heart failure secondary to chronic hypertension. Current medications include: Digoxin, Captopril, Carvedilol, Furosemide, and Warfarin. Based on this profile, what lab work is essential for the nurse to monitor? Select all that apply 1. Digoxin level 2. Potassium level 3. PT/INR 4. aPTT 5. CPK-MB

1. Digoxin level 2. Potassium level 3. PT/INR

A client with a history of schizophrenia was admitted with abdominal pain and has been undergoing diagnostic tests. When the nurse enters the room, the client is alone and looking at the wall and states "Why should I hurt them?" What would be an appropriate intervention by the nurse? Select all that apply 1. Directly ask the client "Are you hearing voices?" 2. State "Tell the voice that you do not want to hurt anyone." 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 5. Tell the client "You know that you are not being told to hurt someone." 6. Inquire about what the client believes he or she is being told to do.

1. Directly ask the client "Are you hearing voices?" 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 6. Inquire about what the client believes he or she is being told to do.

Which information should the nurse plan to teach family members of a client diagnosed with hepatitis B? 1. Do not share personal items with the client, such as razors or toothbrushes. 2. Wash dishes separately from the rest of the family's. 3. Wear a surgical mask when in close proximity to the client. 4. Use a separate bathroom from the client.

1. Do not share personal items with the client, such as razors or toothbrushes.

The nurse is talking with a new parent regarding activities that promote attachment between the parents and the newborn. What activities should the nurse include? Select all that apply 1. Feed baby on demand. 2. Put baby in bed to sleep with parents. 3. Allow baby to cry for at least 5 minutes. 4. Sing to the baby. 5. Stroke baby's face.

1. Feed baby on demand. 4. Sing to the baby. 5. Stroke baby's face.

Which discharge referral would be a priority for the nurse to make in order to promote continuity of care for a client following a colectomy and colostomy formation due to colon cancer? 1. Home health 2. Meals on Wheels 3. Hospice care 4. Registered dietitian

1. Home health

Which signs/symptoms does the nurse expect to note when caring for a client with a suspected cystitis? Select all that apply 1. Incontinence 2. Urgency 3. Frequency 4. Hematuria 5. Nocturia 6. Flank pain

1. Incontinence 2. Urgency 3. Frequency 4. Hematuria 5. Nocturia

A client has been admitted to the medical unit after sustaining a stroke. The admitting nurse initiates a nursing diagnosis of unilateral neglect related to a decrease in visual field and hemianopia from cerebrovascular problems as evidenced by consistent inattention to stimuli on the affected side. What nursing interventions should the nurse initiate for this client? Select all that apply 1. Instruct client to scan from left to right to visualize the entire environment. 2. Encourage client to practice exercises independently. 3. Position bed in room so that individuals approach the client on the unaffected side. 4. Apply splints to achieve stability of affected joints. 5. Touch unaffected shoulder when initiating conversation with client. 6. Position personal items within view on the unaffected side.

1. Instruct client to scan from left to right to visualize the entire environment. 3. Position bed in room so that individuals approach the client on the unaffected side. 5. Touch unaffected shoulder when initiating conversation with client. 6. Position personal items within view on the unaffected side.

The charge nurse walks into the client's room as the staff nurse is preparing the client for discharge. The charge nurse overhears the staff nurse giving the client her phone number. The staff nurse says, "Call me when you get home, and maybe we can get together sometime." What should the charge nurse do first? 1. Interrupt the staff nurse and complete the discharge. 2. Tell the staff nurse in the client's presence that the action is inappropriate. 3. Make no comment, and let the staff nurse continue to talk with the client. 4. Stay with the client until ready to leave the unit.

1. Interrupt the staff nurse and complete the discharge.

What information about care of a plaster cast during the first 24 hours should the nurse provide to the client? Select all that apply 1. Keep the cast uncovered until it is completely dried. 2. Use the palms of your hands to position the cast for the first 24 hours. 3. Place an ice pack on top of the cast. 4. Elevate the extremity on a non-plastic pillow. 5. Do not do anything that would cause an indention on the cast.

1. Keep the cast uncovered until it is completely dried. 2. Use the palms of your hands to position the cast for the first 24 hours. 4. Elevate the extremity on a non-plastic pillow. 5. Do not do anything that would cause an indention on the cast.

The client with a new diagnosis of hypertension has been instructed to maintain a low sodium diet. Which foods does the nurse plan to teach the client to include on a low sodium diet? Select all that apply 1. Lemonade 2. Broccoli 3. Apple 4. Smoked sausage 5. Boiled shrimp 6. Tomato soup

1. Lemonade 2. Broccoli 3. Apple

The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What interventions should the nurse initiate? Select all that apply 1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint. 4. Place a trochanter roll at the hip. 5. Perform passive range of motion exercises once daily. 6. Monitor for pain by assessing Homan's sign.

1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint.

A community health nurse is planning to teach a group of caregivers about early warning signs of Alzheimer's Disease (AD). What signs should the nurse include? Select all that apply 1. Mild disorientation 2. Difficulty with words and numbers 3. Poor personal hygiene 4. Agitation 5. Visual agnosia 6. Dysgraphia

1. Mild disorientation 2. Difficulty with words and numbers

A nurse is planning to provide information to a group of adults considering smoking cessation. What information should the nurse include? Select all that apply 1. Nicotine is the drug in tobacco products that produces dependence. 2. Withdrawal symptoms may include irritability, difficulty concentrating, and increased appetite. 3. Stopping smoking reduces the risk of coronary heart disease. 4. All smokers need to have a prescription for bupropion SR in order to quit. 5. Refer to smoking quit-lines that offer free support, advice, and counseling from experienced coaches.

1. Nicotine is the drug in tobacco products that produces dependence. 2. Withdrawal symptoms may include irritability, difficulty concentrating, and increased appetite. 3. Stopping smoking reduces the risk of coronary heart disease. 5. Refer to smoking quit-lines that offer free support, advice, and counseling from experienced coaches.

The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? 1. Patency of endotracheal tube. 2. Adventitious breath sounds. 3. Fluid in the ventilator tubing. 4. Ventilator settings.

1. Patency of endotracheal tube.

What interventions would be appropriate for the nurse to make for a child who is in Bryant's traction? Select all that apply 1. Perform neurovascular checks every 2 hours. 2. Maintain hip flexion at 90 degrees with buttocks raised 1 inch (2.54 cm) off the bed. 3. Reposition child infrequently so that traction is maintained. 4. Place child prone for one hour daily to prevent contractures. 5. Remove adhesive traction straps daily to prevent skin breakdown. 6. Use wrist restraints to keep child from turning over.

1. Perform neurovascular checks every 2 hours. 2. Maintain hip flexion at 90 degrees with buttocks raised 1 inch (2.54 cm) off the bed.

A client has been admitted to the orthopedic floor following application of a long leg cast for a fractured femur. What nursing action takes priority? 1. Perform neurovascular checks of the extremities. 2. Cover the edge of the cast near the groin area. 3. Instruct client not to insert anything into cast. 4. Use palms of hands to lift and position the cast.

1. Perform neurovascular checks of the extremities.

A nurse manager has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the manager take regarding this issue? Select all that apply 1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 5. Dock pay of staff who do not maintain proper infection control. 6. Provide mandatory in-service sessions on infection control for every shift.

1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 6. Provide mandatory in-service sessions on infection control for every shift.

A 37 week pregnant woman presents to triage with reports of a headache and begins to have a seizure. What actions should the nurse take? Select all that apply 1. Place the client's head in the nurse's lap. 2. Administer oxygen. 3. Monitor tonic-clonic activity. 4. Place an oral airway into the client's mouth. 5. Administer diazepam.

1. Place the client's head in the nurse's lap. 2. Administer oxygen. 3. Monitor tonic-clonic activity.

The nurse has completed newborn discharge teaching with the parents. Which statements by the parents would indicate accurate understanding of proper CPR for infants? Select all that apply 1. Place the infant on a firm, flat surface. 2. Use the palm of one hand to do compressions. 3. Give compressions at a rate of at least 1 per second. 4. Compress about one third the anterior-posterior diameter of the chest. 5. Give one breath after every 15 compressions. 6. Time to give breaths should not take longer than 10 seconds.

1. Place the infant on a firm, flat surface. 4. Compress about one third the anterior-posterior diameter of the chest. 6. Time to give breaths should not take longer than 10 seconds.

A client receiving torsemide 20 mg every day reports an onset of cramping in the lower extremities. Based on this report, what current lab finding would the nurse expect? 1. Potassium level of 3.1 mEq/L (3.1 mmol/L) 2. Calcium level of 11 mg/dL (2.75 mmol/L) 3. Sodium level of 140 mEq/L (140 mmol/L) 4. pH level of 7.40

1. Potassium level of 3.1 mEq/L (3.1 mmol/L)

A client arrives at the Emergency Department after receiving 3rd degree burns to the upper chest, neck, and face area. What would be the priority nursing intervention? 1. Prepare for endotracheal intubation. 2. Monitor hourly urinary output. 3. Treatment of the open burn wounds. 4. Assessment and management of pain.

1. Prepare for endotracheal intubation.

A client has been admitted to Hospice Care. The hospice nurse is reviewing the nursing care plan for interventions to promote comfort for the terminally ill client. Which nursing interventions for the terminally ill client would the nurse implement? Select all that apply 1. Provide oral care every 2 hours. 2. Provide supportive environment. 3. Encourage 3 meals a day. 4. Administer optical lubricants as needed. 5. Encourage client to ambulate every 4 hours.

1. Provide oral care every 2 hours. 2. Provide supportive environment. 4. Administer optical lubricants as needed.

A child is brought into the emergency department (ED) after accidently ingesting 3 grams of acetylsalicylic acid. Initial assessment reveals lethargy, excessive sweating, hyperventilation, and hyperthermia. What interventions should the nurse initiate? Select all that apply 1. Provide tepid water sponge bath. 2. Start an IV for fluid resuscitation. 3. Insert a nasogastric tube. 4. Pad side rails. 5. Obtain blood gases. 6. Administer ipecac syrup orally.

1. Provide tepid water sponge bath. 2. Start an IV for fluid resuscitation. 3. Insert a nasogastric tube. 4. Pad side rails. 5. Obtain blood gases.

The nurse is planning care for a preschool child who is being treated in the hospital for respiratory syncytial virus (RSV). What should the nurse recognize as the child's likely view of this illness in order to properly plan care? 1. Punishment 2. Disturbance to body image 3. Rejection from parents 4. Change in routine with friends

1. Punishment

What action by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply 1. Returning clean unused linens for a client to the linen supply closet. 2. Tying the linen bag securely and tightly at the top. 3. Filling the linen bag with as much soiled linen as possible. 4. Shaking linens after removing from the bed to check for personal items. 5. Washing hands after removing linens from the bed.

1. Returning clean unused linens for a client to the linen supply closet. 3. Filling the linen bag with as much soiled linen as possible. 4. Shaking linens after removing from the bed to check for personal items.

A client admitted to ICU has a prescription for an arterial line insertion to the right radial artery. What assessment findings by the nurse would be of concern? Select all that apply 1. Right sided mastectomy 2. Inability to abduct fingers of right hand 3. Negative Allen's test 4. Radial pulse 3+/4+ 5. Presence of A-V shunt to right forearm

1. Right sided mastectomy 3. Negative Allen's test 5. Presence of A-V shunt to right forearm

A nurse is educating the family of a client in the middle stages of Alzheimer's disease how to encourage independence during meals. What points should the nurse include? Select all that apply 1. Serve meal in a quiet environment 2. Give 30 minutes to eat 3. Serve finger foods 4. Serve one dish at a time 5. Do not worry about neatness

1. Serve meal in a quiet environment 3. Serve finger foods 4. Serve one dish at a time 5. Do not worry about neatness

Which action by the nurse administering intravenous ciprofloxacin would require intervention by the charge nurse? 1. Sets IV pump to administer ciprofloxacin over a period of 30 minutes. 2. Educates client that medication may cause dizziness. 3. Instructs client to notify nurse for any tendon pain. 4. Administers ciprofloxacin through 20 gauge catheter into the cephalic vein.

1. Sets IV pump to administer ciprofloxacin over a period of 30 minutes.

Which client would be most appropriate for the emergency department charge nurse to obtain a social service consult? 1. Six year old who ingested diluted bleach. 2. Ten year old who suffered burns in a house fire. 3. Twelve year old who fractured his arm in a fight at school. 4. A 16 month old without any oral intake for the last 12 hours.

1. Six year old who ingested diluted bleach.

The nurse is talking with parents of school-aged children about promoting healthy eating in their children. What information should the nurse provide? Select all that apply 1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 4. Enforce rule that child must eat food even if they do not like it. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals.

1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals.

What risk factors should the nurse include when teaching a group of clients about osteoarthritis? Select all that apply 1. Sports injury to joint 2. Genetic predisposition 3. Obesity 4. Male sex 5. Repetitive joint stress

1. Sports injury to joint 2. Genetic predisposition 3. Obesity 5. Repetitive joint stress

A nurse is observing two unlicensed assistive personnel (UAP) changing sheets for an immobile, obese client. What unacceptable action by the UAPs would require the nurse to intervene? 1. Stands straight with feet together. 2. Asks client to lift head off the bed. 3. Pulls draw sheet with both hands. 4. Faces slightly towards head of bed.

1. Stands straight with feet together.

A nurse is teaching a client the advantages of having a PICC line inserted rather than a peripheral IV. What information should the nurse include? Select all that apply 1. TPN may be infused using a PICC line. 2. Use of a PICC can allow for early client discharge. 3. PICC lines do not have to be replaced as often as a peripheral IV line. 4. PICC lines have the same risk of infection as a peripheral IV line. 5. PICC lines do not need to be flushed as frequently. 6. PICC placement decreases the need for skin puncture when blood sampling is needed.

1. TPN may be infused using a PICC line. 2. Use of a PICC can allow for early client discharge. 3. PICC lines do not have to be replaced as often as a peripheral IV line. 6. PICC placement decreases the need for skin puncture when blood sampling is needed.

Which intervention would the nurse recommend to a client with rheumatoid arthritis to best help relieve joint stiffness? 1. Take a warm shower prior to performing activities of daily living. 2. Take an aspirin after activity to help decrease inflammation. 3. Lose 10 pounds of weight. 4. Apply cold compresses to joints for 30-45 minutes.

1. Take a warm shower prior to performing activities of daily living.

Which activity should the nurse recognize as increasing the risk for a client developing a community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection? 1. Taking wrestling classes at the gym once a week. 2. Traveling on an airplane next to someone coughing. 3. Eating raw fruits without washing them. 4. Working in close proximity to several co-workers.

1. Taking wrestling classes at the gym once a week.

The nurse is caring for a client who has an active herpes simplex 1 lesion on the lip. What measures should be implemented by the nurse? Select all that apply 1. Tell the client to avoid touching the lesion. 2. Scrub the lesion gently with soap and water prior to meals. 3. Apply a thin layer of acyclovir to the lesion 5 times a day. 4. Wear sterile gloves when applying medication to lesion. 5. Ask client to discard lip balm until lesion is resolved.

1. Tell the client to avoid touching the lesion. 3. Apply a thin layer of acyclovir to the lesion 5 times a day. 5. Ask client to discard lip balm until lesion is resolved.

Which clients should the nurse recommend receive the human papillomavirus (HPV) vaccine? Select all that apply 1. Twelve year old male. 2. Eight year old female. 3. Twenty-five year old bisexual male. 4. Twenty-two year old female with compromised immune system. 5. Twenty-nine year old male who has not received the HPV vaccine.

1. Twelve year old male. 3. Twenty-five year old bisexual male. 4. Twenty-two year old female with compromised immune system.

Which interventions should be included in the nutritional teaching plan to accomplish the goal of a diet lower in fat? Select all that apply 1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 3. Eat more red meat instead of fish. 4. Incorporate plant sources of protein. 5. Use olive oil instead of vegetable oil when frying.

1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 4. Incorporate plant sources of protein.

Which finding indicates to the nurse that a client is at risk for skin breakdown? 1. Weakness requiring assistance to move in bed. 2. Daily intake of at least 85 percent of food offered. 3. Occasional forgetfulness. 4. Continent of bowel and bladder.

1. Weakness requiring assistance to move in bed.

The emergency room nurse is assessing a client with an eye injury that occurred while chopping wood. The client states the chain saw caused a log to splinter, sending slivers of wood into the right eye. While waiting for the eye specialist, the nurse discusses future safety precautions for such an activity. What safety precautions are most important for the nurse to include in client teaching? Select all that apply 1. Wear heavy gloves. 2. Stand with feet together. 3. Use steel-toed boots. 4. Wear unbreakable googles. 5. Use ear covers and plugs. 6. Wear loose-fitting clothing.

1. Wear heavy gloves 4. Wear unbreakable googles. 5. Use ear covers and plugs.

Arterial blood gases (ABGs) reflect a pH of 7.28, PaCO2 of 30, and HCO3 of 18. To which client would these ABGs most likely belong? 1. Weight loss of 20% in past month 2. Highly anxious with a panic attack 3. Alzheimer's with recent overdose of acetylsalicylic acid 4. Post-op with gastric suction

1. Weight loss of 20% in past month

A client was admitted with a diagnosis of Type II diabetes. The primary healthcare provider initiated the Insulin Sliding Scale Protocol for Type II Diabetic Clients. The prescription regimen was to begin at the high dose regimen with regular insulin AC & HS. How much insulin should the nurse administer at 2100 hours?

10 units

The primary healthcare provider has prescribed KCL 20 mEq by mouth once a day. The pharmacy has dispensed KCL 8 mEq/5 mL. How many mL will the nurse administer? Round answer using one decimal point.

12.5

The nurse is caring for a client receiving an intravenous infusion of normal saline that is prescribed at 150 milliliters per hour. Using a tubing that has a drop factor of 60, how many drops per minute should the nurse deliver? Round answer to the nearest whole number.

150 (150 x 60 / 60)

An elderly client diagnosed with terminal cancer is the sole caregiver to a developmentally delayed adult child. The client is worried that the child, with a developmental age of seven years old, will need permanent placement in a long term care facility. What statement by the nurse is most accurate? 1. "Your child will need to be under constant supervision." 2. "A supervised group home would be an ideal setting." 3. "Maybe we could find someone to take in your child." 4. "We should start getting the child used to living alone."

2. "A supervised group home would be an ideal setting."

A client arrives to the after hours clinic with reports of palpitations and skipping heart beats. The nurse notes the client to be alert and oriented with a BP of 124/76, HR irregular at 95 beats per minute, respirations at 18 breaths per minute, and is afebrile. Cardiac monitoring is initiated. Based on this data, what questions should the nurse ask the client? Exhibit Select all that apply 1. "Have you been prescribed a tricyclic antidepressant?" 2. "Have you been experiencing more stress than usual in your life?" 3. "Does this generally begin when you are having a bowel movement?" 4. "How many cups of coffee do you drink each day?" 5. "What over the counter medications do you take?" 6. "Have you been running a fever?"

2. "Have you been experiencing more stress than usual in your life?" 4. "How many cups of coffee do you drink each day?" 5. "What over the counter medications do you take?"

A home health nurse is visiting an adolescent with a myelomeningocele. The nurse realizes more instruction is needed when the client makes what statement? 1. "I might need to get glasses." 2. "I catheterize myself twice a day." 3. "I drink bottled water all day long." 4. "I do upper arm exercises every day."

2. "I catheterize myself twice a day."

A client is preparing to be discharged after a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. The nurse recognizes that education has been successful if the client makes which statement? 1. "Ulcerative colitis cannot be cured." 2. "I look forward to having the ileostomy closed." 3. "I am going to eat a hamburger and fries for dinner." 4. "Because of this surgery, I am at a higher risk of developing colon cancer."

2. "I look forward to having the ileostomy closed."

A client with severe depression and a previous history of attempted suicide has been receiving inpatient therapy for months. The nurse notes at breakfast the client is showered, in clean clothes with hair combed. What response by the nurse is most therapeutic at this time? 1. "You look very pretty so you must be feeling better." 2. "I see you are wearing a bright blue sweater today." 3. "Has something changed in your life this morning?" 4. "Today must be a very special occasion for you."

2. "I see you are wearing a bright blue sweater today."

A home health nurse is educating a female client about home care considerations for intermittent catheterization. Which statement by the client would let the nurse know that the client understands what has been taught? 1. "After insertion, I will tape the tubing to my lower abdomen." 2. "I will wash the rubber catheter thoroughly with soap and water after use." 3. "It is important that I keep the drainage bag below the level of my bladder." 4. "Catheterization should be done hourly."

2. "I will wash the rubber catheter thoroughly with soap and water after use."

A clinic nurse completed teaching the parents of a 9 month old baby how to prevent otitis media infections in their baby. Which statement by the parents indicates to the nurse that further teaching is necessary? 1. "Our baby should sit up for feedings." 2. "It is fine to prop up a juice bottle for our baby to drink at night." 3. "Since our baby has ear tubes, ear plugs should be worn when swimming." 4. "We need to keep our baby away from people who are smoking."

2. "It is fine to prop up a juice bottle for our baby to drink at night."

A client receiving electro-convulsive therapy (ECT) tells the nurse, "I don't know if I can take another treatment." What is the nurse's best response? 1. "Remember to focus on the fact that you will be fine after you complete all of your treatments." 2. "The therapy must be difficult for you at times. How do you feel about your progress at this point?" 3. "Hang in there. It's for your own good and times will get better." 4. "What makes you say that? You know it will make you well."

2. "The therapy must be difficult for you at times. How do you feel about your progress at this point?"

A new nurse is anxious about being assigned to a a client with violent episodes. Which statement by the charge nurse would address the new nurse's anxiety? 1. "What you really mean is that you fear a client with violent episodes." 2. "Though it is difficult, the staff needs to remain relaxed, but conscious of the client's violent episodes." 3. "I will instruct the staff to monitor the client's behavior for any signs of violent behavior." 4. "You attended an in-service during orientation on dealing with the client with violent behavior."

2. "Though it is difficult, the staff needs to remain relaxed, but conscious of the client's violent episodes."

A new mother asks the clinic nurse why her baby should receive recommended vaccinations. What is the best response by the nurse concerning vaccinations? 1. "Vaccinations give antibodies to your baby to protect them from disease." 2. "Vaccinations will help your baby produce antibodies against disease causing organisms." 3. "Federal law requires that your baby receive recommended vaccinations." 4. "There is no reason not to vaccinate your baby since only mild, uncomfortable reactions can occur."

2. "Vaccinations will help your baby produce antibodies against disease causing organisms."

The nurse is reviewing discharge instructions with the spouse of client following a laminectomy. When the nurse explains the need to log roll the client, the spouse expresses doubt about the ability to do so independently. What statement by the nurse is appropriate? 1. "Many spouses have been able to learn this procedure." 2. "Which part of this procedure has you most concerned?" 3. "Don't you have any family to help you with this procedure?" 4. "Are you worried about caring for your spouse?"

2. "Which part of this procedure has you most concerned?"

During a physical assessment of a client who was started on haloperidol 5 days ago, the nurse notes restlessness, muscle weakness, drooling, and a shuffling gait. What should be the nurse's first action? 1. Hold the next haloperidol dose. 2. Administer the prn benztropine mesylate. 3. Notify the primary healthcare provider to discontinue the haloperidol. 4. Draw a blood sample for drug level.

2. Administer the prn benztropine mesylate.

The nursing supervisor of a long-term care facility is planning to update emergency response plans for the large dementia unit. Staff has been asked to submit suggestions or concerns regarding current evacuation protocols which may need updated. The nursing supervisor is aware what exit procedure would be least helpful during an emergency evacuation? 1. All clients should be assisted to a central staging area. 2. Ambulatory clients should be directed to nearest exit. 3. Staff must visually check rooms to verify clients exited. 4. Clients exiting upper floors must use stairs, not elevator.

2. Ambulatory clients should be directed to nearest exit.

The nurse has observed that the client on the skilled nursing unit has been consuming fewer calories over the past three days. There has been no other change in the client's condition. Which intervention is most important for the nurse to initiate? 1. Suggest that the family seek an appointment with the primary healthcare provider. 2. Ask the dietician to visit the client and discuss food preferences. 3. Note any weight loss over the next month. 4. Continue to monitor intake over the next couple of weeks

2. Ask the dietician to visit the client and discuss food preferences.

A client with a total hip arthroplasty (THA) 36 hours ago is scheduled to ambulate in the room. The nurse should initiate which of the following nursing interventions prior to ambulating the client. Select all that apply 1. Keep pressure off heels 2. Assess amount of drainage 3. Instruct on use of mobility aids 4. Encourage flexion hip greater than 90 degrees 5. Teach isometric quadriceps and gluteal setting exercises

2. Assess amount of drainage 3. Instruct on use of mobility aids 5. Teach isometric quadriceps and gluteal setting exercises

A 16 year old female student is escorted to the school nurse after fainting in gym class. The student tells the nurse, "I just got weak from running." Upon examination, the nurse notes poor skin turgor, dry mucous membranes, and erosion of tooth enamel from her front teeth. Height is 5'4" (162.56 cm) and weight is 110 lbs (50 kg). The student reports muscle pain in the legs. Based on this data, what should the nurse suspect? 1. Anorexia Nervosa 2. Bulimia Nervosa 3. Obesity 4. Physical violence

2. Bulimia Nervosa

The nurse is providing care to a client who is post laparoscopic cholecystectomy. Which finding would be of concern? Select all that apply 1. Right upper quadrant abdominal discomfort 2. Clay colored stool 3. Light yellow urine 4. Pruritus 5. Icteric sclera

2. Clay colored stool 4. Pruritus 5. Icteric sclera

The charge nurse on the Labor and Delivery unit is making morning assignments. What client would be most appropriate for a newly hired licensed practical nurse (LPN)? 1. Assist with bottle feeding newborns in the nursery. 2. Completing perineal care for post-delivery clients. 3. Observing a Cesarean section for co-joined twins. 4. Ambulate client to bathroom following delivery.

2. Completing perineal care for post-delivery clients.

A client with a history of alcoholism arrives at the clinic reporting severe abdominal pain with nausea and vomiting. What additional findings would make the nurse suspect the client may have pancreatitis? Select all that apply 1. Afebrile 2. Cullen's Sign 3. Pain relieved after eating 4. Positive Chvostek's sign 5. Tachycardia.

2. Cullen's Sign 5. Tachycardia.

A child diagnosed with AIDS is scheduled for grade school immunizations. Which immunizations are safe for the nurse to administer to the child? Select all that apply 1. MMR (measles, mumps, rubella) 2. DTaP (diphtheria, tetanus, pertussis) 3. VAR (varicella) 4. HiB (haemophilus influenza) 5. OPV (oral polio virus)

2. DTaP (diphtheria, tetanus, pertussis) 4. HiB (haemophilus influenza)

The nurse is checking a 2 month old's developmental status. What finding would be of concern to the nurse? 1. Not able to hold head steady. 2. Does not bring hands to mouth. 3. Not able to roll over in either direction. 4. Does not push down with legs when feet are placed on a hard surface.

2. Does not bring hands to mouth.

The nurse is talking with the mom of a preschooler at the well-child visit. The mom reports that her 3 year old has a lot of energy and sleeps 9 hours per night. What assessment questions should the nurse ask in response to this comment? Select all that apply 1. Nothing, as this is normal for preschoolers. 2. Does your child take naps during the day? 3. Does your child wake up spontaneously or do you wake her? 4. Does your child appear rested upon awakening? 5. Does your child have trouble settling down for sleep?

2. Does your child take naps during the day? 3. Does your child wake up spontaneously or do you wake her? 4. Does your child appear rested upon awakening? 5. Does your child have trouble settling down for sleep?

A client being treated in the intensive care unit following methamphetamine intoxication states, "Snakes are crawling all over the room, get me out of here!" How does the nurse document this assessment finding? 1. Delusions 2. Hallucinations 3. Flashbacks 4. Depersonalization

2. Hallucinations

A client has just had a bone marrow biopsy. What is the nurse's priority intervention post procedure? 1. Apply ice pack to needle site. 2. Hold pressure on needle site for at least 5 minutes. 3. Observe needle insertion site every 2 hours. 4. Advise client to avoid activities that may result in trauma to the site for 48 hours.

2. Hold pressure on needle site for at least 5 minutes.

The nurse is caring for a client diagnosed with heat exhaustion. Which finding by the nurse suggests a problem? 1. Temperature 101 degrees F (38.3 degrees C) 2. Hot, dry skin 3. Profuse sweating 4. Headache

2. Hot, dry skin

Which signs/symptoms noted by the nurse would support a client history of chronic emphysema? Select all that apply 1. Atelectasis. 2. Increased anteroposterior (AP) diameter. 3. Breathlessness. 4. Use of accessory muscles with respiration. 5. Leans backwards to breathe. 6. Clubbing of fingernails

2. Increased anteroposterior (AP) diameter. 3. Breathlessness. 4. Use of accessory muscles with respiration. 6. Clubbing of fingernails

Two hours after admission, a client reports palpitations, chest discomfort, and light-headedness. The nurse connects the client to a cardiac monitor and notes a weak, thread pulse, and a BP of 90/50. Which action should the nurse take? Select all that apply. Exhibit Select all that apply 1. Administer Lidocaine 50 mg intravenous push (IVP). 2. Initiate oxygen at 2 liters per nasal cannula. 3. Apply oxygen saturation monitor to client. 4. Prepare for immediate synchronized cardioversion. 5. Perform carotid massage. 6. Begin cardiopulmonary resuscitation.

2. Initiate oxygen at 2 liters per nasal cannula. 3. Apply oxygen saturation monitor to client. 4. Prepare for immediate synchronized cardioversion.

A client who must use crutches, is being taught by the nurse how to perform a three-point gait. What information should the nurse provide? 1. Move right crutch forward, then left foot. Next move left crutch forward, then right foot. 2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward. 3. Move left crutch and right foot forward together, then move the right crutch and left foot forward together. 4. Move both crutches ahead together, then lift body weight by the arms and swing both legs to the crutches.

2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward.

After reinforcing dietary teaching to a client diagnosed with Crohn's Disease, the nurse recognizes client understanding when the client selects which low-residue foods? Select all that apply 1. Broccoli 2. Oatmeal 3. Green peas 4. Spaghetti 5. Cantaloupe 6. Raisins

2. Oatmeal 4. Spaghetti 5. Cantaloupe

A client with a deep partial-thickness burn to the right forearm has returned from surgery with a skin graft to the burned area. Which graft site intervention would the nurse implement within the first 24 hours? 1. Monitor temperature every 12 hours. 2. Position arm to prevent pressure to the graft site. 3. Prepare to change the 1st dressing within 24 hours. 4. Perform passive range of motion exercises to the right arm.

2. Position arm to prevent pressure to the graft site.

The nurse is preparing to administer a dose of potassium iodide 300 mg by mouth to a client diagnosed with hyperthyroidism. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client and drug reference information supports the nurse's decision to hold the potassium iodide dose and notify the primary healthcare provider? Glucose- 98 mg/dl (5.4 mmol/L) Sodium- 139 mEq/L (139 mmol/L) Potassium- 5.5 mEq/L (5.5 mmol/L) Creatinine - 0.9 mg/dL (79.5 µmol/L) Creatinine Clearance 110 mL/min Losartan 50 mg one by mouth daily Select all that apply 1. Creatinine - 0.9 mg/dL (79.5 µmol/L) 2. Potassium- 5.5 mEq/L (5.5 mmol/L) 3. Glucose- 98 mg/dl (5.4 mmol/L) 4. Taking losartan 50 mg one by mouth daily. 5. Currently taking methimazole 10 mg by mouth daily. 6. Creatinine Clearance 110 mL/min

2. Potassium- 5.5 mEq/L (5.5 mmol/L) 4. Taking losartan 50 mg one by mouth daily. 5. Currently taking methimazole 10 mg by mouth daily.

A client with a history of myasthenia gravis (MG) has been discharged from the hospital following a thymectomy. When teaching the client how to prevent complications, the home care nurse emphasizes what daily actions are most important? Select all that apply 1. Include daily weight lifting exercises. 2. Practice stress reduction techniques. 3. Complete chores early in the day. 4. Take medications on time and prior to meals. 5. Eat three large meals daily.

2. Practice stress reduction techniques. 3. Complete chores early in the day. 4. Take medications on time and prior to meals.

Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Which actions should be instituted by each unit's charge nurse? Select all that apply 1. Turn on local news for up-to-date information on the train derailment. 2. Prepare a list of clients who could quickly be discharged or transferred. 3. Determine which personnel could be sent to the command center. 4. Notify clients that the disaster plan has been put into effect. 5. Alert all off-duty personnel to stand by in case of call- in.

2. Prepare a list of clients who could quickly be discharged or transferred. 3. Determine which personnel could be sent to the command center. 5. Alert all off-duty personnel to stand by in case of call- in.

How would a tendency toward stereotyping and countertransference affect the nurse's ability to complete a client's cultural assessment? 1. Facilitate the care planning process 2. Promote decisions based on the nurses value system 3. Utilize an open honest approach while responding to the client's concerns 4. Develop an unbiased approach to care.

2. Promote decisions based on the nurses value system.

The nurse is providing care to a 5 year old client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client? 1. Encourage the client to talk about the pain. 2. Provide distraction by turning on the TV. 3. Contact the primary healthcare provider for a pain medication prescription. 4. Request that the parents leave the room.

2. Provide a distraction by turning on the TV.

At a monthly staff meeting in a long-term care facility, the charge nurse requests staff input to create new activities for the clients. An RN has been assigned to gather information for staff consideration. What method would provide the RN with the best data for this project? 1. Ask clients' families which activities they would like to have available. 2. Research professional articles for guidelines to activities in long-term care. 3. Have clients peruse a variety of games and select what interests them. 4. Contact other facilities to inquire what types of programs they provide.

2. Research professional articles for guidelines to activities in long-term care.

The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. What should the nurse do first? 1. Feed the client after warming the food. 2. Speak to the UAP to determine what happened with the feeding. 3. Pick up the tray and tell the UAP that they didn't do a good job. 4. Provide a between meal supplement to the client.

2. Speak to the UAP to determine what happened with the feeding.

What would the nurse expect to see when performing a neurological assessment on a 1 day old neonate suspected of having asphyxia in utero? 1. Grasps nurse's finger when placed in neonate's hand. 2. Toes curl downward when soles of feet stroked. 3. Turn's toward nurse's finger when cheek is touched. 4. Extends arms when nurse claps hands.

2. Toes curl downward when soles of feet stroked.

The primary healthcare provider (PHP) informs a client that cancer was identified in the large intestine, and surgery should be scheduled as soon as possible. After the PHP leaves the room, the client turns their head away from the nurse and begins to cry. Which action by the nurse is appropriate? 1. Exit the room quietly. 2. Touch the client's shoulder. 3. Notify the client's family. 4. Begin preoperative instruction.

2. Touch the client's shoulder.

A nurse monitors the heart rates of four children on a pediatric unit. Which client requires additional assessment by the nurse? 1. One year old child who has a heart rate of 150 bpm and is crying 2. Two year old child who has a heart rate of 165 bpm and is being rocked 3. Five year old child who has a heart rate of 100 bpm and is playing quietly 4. Thirteen year old adolescent who has a heart rate of 90 and is watching television

2. Two year old child who has a heart rate of 165 bpm and is being rocked

A client has been admitted to the labor and delivery unit with a diagnosis of preeclampsia. During afternoon rounds, which assessment finding by the nurse should be reported to the primary healthcare provider immediately? 1. Deep tendon reflexes of plus three. 2. Urine output of 80 mL over four hours. 3. Respiratory rate of 24 breaths/minute. 4. Severe headache with blurred vision.

2. Urine output of 80 mL over four hours.

A hospitalized client has developed diabetes insipidus and is given desmopressin. The nurse is aware which laboratory result indicates an improvement in the client's condition? 1. White blood cells of 7,000 mm3 (7 x 10^9) 2. Urine specific gravity of 1.010 3. Hemoglobin of 22 g/dL (220 g/L) 4. Serum sodium of 148 mEq/L (148 mmol/L)

2. Urine specific gravity of 1.010

Which meal option should the client diagnosed with gout select? 1. Tuna salad on bed of lettuce, apple slices, coffee 2. Vegetable soup, whole wheat toast, skim milk 3. Roast beef with gravy sandwich, baked chips, diet coke 4. Spinach salad with chick peas and asparagus, apple, tea

2. Vegetable soup, whole wheat toast, skim milk

The primary healthcare provider prescribed diazepam 12.5 mg IM to a client. The pharmacy dispenses diazepam 5 mg/mL. How many mL will the nurse administer? Round answer using one decimal point.

2.5

A 35 year old client, concerned about weight, asks a clinic nurse, "What is my BMI?" The client weighs 135 pounds and is 5 feet 2 inches tall. Determine the client's BMI to the nearest tenth?

24.7 Rationale:Formula: BMI = (703 x weight in pounds) ÷ (height in inches)^2 BMI = (703 x 135) ÷ (62)^2 BMI = (94,905) ÷ (3,844) BMI = 24.689 BMI = 24.7

The nurse is preparing to administer 500 mL Normal Saline to a client over the next two hours per infusion pump. What number should the nurse set the pump at to deliver the prescribed amount per hour?

250

A client with a new colostomy is learning to perform a colostomy irrigation. The nurse knows the teaching was successful when the client makes what statement? 1. "My spouse can verbalize all the steps in order." 2. "I have attended all the sessions on ostomy care." 3. "I can do the irrigation if I refer to the instructions." 4. "I don't need to irrigate if the ostomy is making stool."

3. "I can do the irrigation if I refer to the instructions."

A nurse is caring for a client admitted with a diagnosis of depression and suicidal thoughts. The client states, "My husband doesn't love me anymore, and so life is just not the same." What would be the most appropriate response by the nurse? 1. "Even though your husband does not love you, life can still be very meaningful." 2. "Many couples go through difficult times in their marriage, but you should not assume that he does not love you anymore." 3. "Tell me what has led you to believe that your husband doesn't love you anymore." 4. "You really need to try not to let your husband make you depressed and feel that life is not worth living."

3. "Tell me what has led you to believe that your husband doesn't love you anymore."

When preparing an intramuscular injection for a neonate, which needle should a nurse select? 1. 18 G, 7/8 inch 2. 21 G, 1 inch 3. 25 G, 5/8 inch 4. 25 G, 1.5 inch

3. 25 G, 5/8 inch

An emergency room nurse is triaging multiple victims from a bus versus tractor trailer accident. Which client would be considered priority? 1. A client with an open femur fracture, bleeding profusely. 2. A client with multiple rib fractures, respiratory rate 32 and shallow. 3. A client unconscious and responding only to painful stimuli. 4. A client with a crushed left leg with no palpable pedal pulse.

3. A client unconscious and responding only to painful stimuli.

The nurse has received the change-of-shift report. What client should the nurse assess first? 1. A client with fibromyalgia reporting generalized pain of 7 out of 10. 2. A client diagnosed with rheumatoid arthritis needing discharge teaching. 3. A client with a fractured right humerus who reports the cast is too tight. 4. A client with an above the knee amputation reporting phantom pain.

3. A client with a fractured right humerus who reports the cast is too tight.

The nurse is assigned five clients on a medical floor. When planning care, the nurse recognizes which clients to be at greatest risk for ineffective oral hygiene? Select all that apply 1. A client who has just had knee surgery taking opioids for pain. 2. A right handed client who had a stroke affecting the right hemisphere of the brain. 3. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. 4. An elderly client experiencing loss of appetite. 5. A client who takes phenytoin for partial seizures.

3. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. 5. A client who takes phenytoin for partial seizures.

The nurse is caring for a client who is receiving weekly infusions of Factor VIII for Hemophilia. What assessment finding by the nurse related to the client's skin is indicative of a therapeutic response? 1. An absence of jaundice 2. The presence of petechiae 3. A reduction of bruising 4. A capillary refill time of < 3 seconds

3. A reduction of bruising

When planning post procedure care for a client who is having a barium enema, what must the nurse include? 1. Cardiac monitoring for potential arrhythmias 2. Monitoring urinary output 3. Administration of a laxative or enema after the procedure 4. Reordering the client's diet

3. Administration of a laxative or enema after the procedure

After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. The RN requests reassigning at least one of the clients to another nurse. What is the best response by the charge nurse? 1. Offer to take one of the clients. 2. Notify the nursing supervisor of the situation. 3. Ask the RN why the assignment is too heavy. 4. Explain to the RN that all the nurses have the same number of clients.

3. Ask the RN why the assignment is too heavy.

The nurse is caring for a burn client 48 hours after the burn occurred. What would be the nurse's priority assessment? 1. Measure the abdominal girth. 2. Administer pain medication. 3. Auscultate the lungs every 2 hours. 4. Inspect the burn for infection.

3. Auscultate the lungs every 2 hours.

A nurse is to administer a time release capsule to a client who has difficulty swallowing. Which intervention would be the best course of action for the nurse to take? 1. Open the capsule and sprinkle it on applesauce. 2. Melt the capsule in juice or water. 3. Call the primary healthcare provider to change the order. 4. Break the capsule in half using a pill splitter.

3. Call the primary healthcare provider to change the order.

What information should the nurse include when providing community teaching on burn prevention strategies? Select all that apply 1. Have chimney professionally inspected every 5 years. 2. Microwave a baby bottle rather than heating on the stove. 3. Clean the lint trap on the clothes dryer after each use. 4. Keep anything that can burn at least 3 feet (0.91 meters) away from space heaters. 5. Hold a hot beverage or hold a child, not both at the same time. 6. Home hot water heater should be set at a maximum of 120°F (48.8°C).

3. Clean the lint trap on the clothes dryer after each use. 4. Keep anything that can burn at least 3 feet (0.91 meters) away from space heaters. 5. Hold a hot beverage or hold a child, not both at the same time. 6. Home hot water heater should be set at a maximum of 120°F (48.8°C).

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? 1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms

3. Clear urine

The charge nurse has received word that a mass casualty has occurred and beds are needed in the hospital. This will require discharging some current clients. Which client would be appropriate to seek permission from the healthcare provider to be discharged? Select all that apply 1. Client admitted with chest pain and has an elevated Troponin level. 2. Client with blood glucose of 500 mg/dL and pH of 7.3 receiving IV insulin. 3. Client admitted with hemothorax but no chest tube drainage in last 14 hours. 4. Client who underwent a laminectomy for spinal stenosis 12 hours earlier. 5. Elderly client who fell and is developing increased confusion.

3. Client admitted with hemothorax but no chest tube drainage in last 14 hours. 4. Client who underwent a laminectomy for spinal stenosis 12 hours earlier.

The school nurse has been observing a 13 year-old student during the past few months as the student has steadily lost weight. Which assessment finding would be the best indication of the beginning of an eating disorder? 1. Clothing size has decreased by 2 sizes. 2. Student eats most meals with peers. 3. Client reports a fear of gaining weight. 4. Diet consists mostly of fruit or raw vegetables.

3. Client reports a fear of gaining weight.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Encourage client to express grief related to loss of independence. 2. Irrigate a client's ear canal. 3. Disconnect client's nasogastric (NG) tube suction to allow ambulation. 4. Show client who has conjunctivitis how to clean the eyes.

3. Disconnect client's nasogastric (NG) tube suction to allow ambulation.

The nurse is discharging a client post right radial percutaneous transluminal coronarey angioplasty (PTCA) with stent insertion. Which instructions should the nurse give the client to reduce the risk of complications? Select all that apply 1. Do not use the wrist to lift more than 5 pounds (2.27 kg) for 24 hours. 2. Stop taking aspirin in one week. 3. Drink at least 8 glasses of water a day. 4. Wear loose fitting sleeves. 5. Do not shower or soak in a tub for one week. 6. Take short walks around your house.

3. Drink at least 8 glasses of water a day. 4. Wear loose fitting sleeves. 6. Take short walks around your house.

The nurse is reinforcing proper use of the walker with partial weight-bearing to a client with a total hip arthroplasty. Which action would indicate to the nurse that the client is using the walker correctly? 1. Leaning over the walker. 2. Using a walker with 4 wheels. 3. Elbows positioned at 30 degrees. 4. Lifts the walker when climbing steps.

3. Elbows positioned at 30 degrees.

A client has been taking tranylcypromine for approximately two weeks. The client is visiting the nurse at the local mental health center for follow up and group therapy. Which client comment indicates a lack of understanding of the medication that could result in a medical emergency? 1. I know that I must take this medication until my primary healthcare provider tells me to stop. 2. It is frustrating to have to follow dietary restrictions. 3. I am getting a cold, and I am going to take some over the counter cold medicine. 4. I am going to have broccoli salad and roasted turkey for lunch today.

3. I am getting a cold, and I am going to take some over the counter cold medicine.

The parents of a toddler ask the nurse how to stop their child's temper tantrums when they occur. What is the best advice the nurse should provide? 1. Spank the child gently when the tantrum occurs. 2. Promise the child a new toy if the child stops the tantrum. 3. Ignore the tantrum if the child is safe. 4. Restrain the child during a tantrum.

3. Ignore the tantrum if the child is safe.

A client is admitted to the emergency department following a motor vehicle accident (MVA). The client reports abdominal discomfort, weakness, and nausea. Vital signs: BP 88/52, HR 118/min, RR 24/ min. Which healthcare provider prescription should the nurse implement first? 1. Administer ondansetron 2 mg IV. 2. Insert a foley catheter in order to obtain hourly urinary outputs. 3. Infuse lactated ringers (LR) at 200 mL per hour. 4. Type and cross match for four units of packed red blood cells.

3. Infuse lactated ringers (LR) at 200 mL per hour.

A nurse is caring for client with a left above the knee amputation 48 hours postop. The client is experiencing left lower leg pain on a scale of 6 out of 10. Which pain relief intervention would the nurse implement? 1. Position the client in a supine position. 2. Rewrap the ace bandage on the stump. 3. Instruct the client in guided imagery techniques. 4. Initiate range of motion exercises to the knee.

3. Instruct the client in guided imagery techniques.

The nurse is caring for a client who presents to the mental health unit following a violent altercation with the spouse. The client has numerous bruises on the face, chest, and back. There is one laceration where spouse "came at me" with a knife. At this time, what is most likely to be the mood of the perpetrator in this situation? 1. Extreme anger 2. Anxiety 3. Kindness 4. Irritability

3. Kindness

A client from a long-term care facility arrives in the emergency department by ambulance with altered level of consciousness. The primary healthcare provider instructs the respiratory therapist to prepare for intubation. The nurse discovers a Do Not Resuscitate (DNR) bracelet on the client's wrist during the initial assessment. Which immediate action should the nurse take to advocate appropriately for this client? 1. Assist the respiratory therapist to prepare the client for immediate intubation. 2. Attempt to contact the client's family. 3. Notify the primary healthcare provider immediately of the client's DNR bracelet. 4. Notify the charge nurse immediately of the client's DNR bracelet.

3. Notify the primary healthcare provider immediately of the client's DNR bracelet.

A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? pH - 7.5 PaO2 - 94% PaCO2 - 58 HCO3 - 35 1. Partially compensated metabolic acidosis 2. Partially compensated respiratory alkalosis 3. Partially compensated metabolic alkalosis 4. Partially compensated respiratory acidosis

3. Partially compensated metabolic alkalosis

A client with a diagnosis of embolic stroke is admitted to the medical unit. After 2 hours on the unit the client presents with agitation. Which nursing intervention would the nurse initially implement? 1. Assess the client for any seizure activity 2. Assess the client with the Glasgow Coma Scale 3. Place the client's neck in the midline position 4. Adjust the head elevation to 15 degrees

3. Place the client's neck in the midline position

Which immediate action should a nurse take if a client's chest tube is accidentally disconnected from the disposable water-seal system? 1. Have client hold breath 2. Administer oxygen 3. Place the tubing coming from the client into sterile water 4. Raise the head of the bed

3. Place the tubing coming from the client into sterile water

What intervention should the nurse take when providing oral care for the unconscious client? 1. Brush teeth with a stiff toothbrush. 2. Use thumb and index finger to hold the client's mouth open while brushing teeth. 3. Position the client on their side. 4. Rinse by injecting water into the center of client's mouth.

3. Position the client on their side.

A client with recurrent angina and hypertension has been started on new medications. When reviewing the admission forms, the nurse should immediately question which prescription? Spironolactone 50 mg. PO once daily Metoprolol 25 mg. PO once daily Diltiazem 120 mg. PO once daily Potassium 10 meq PO once daily 1. 2 gm sodium diet 2. Metoprolol 25 mg PO once daily 3. Potassium 10 meq PO once daily 4. Diltiazem 120 mg PO once daily

3. Potassium 10 meq PO once daily

The nurse is caring for a client immediately following a bilateral salpingo-oophorectomy. Which position would be best for this client? 1. Fowler's 2. Modified Sims 3. Side-lying 4. Supine

3. Side-lying

A client is being discharged with halo traction. What should the nurse teach the client and family about home management of this traction? Select all that apply 1. Showering is permitted once a week with assistance. 2. Apply baby lotion under the halo vest to prevent irritation. 3. Sleep in whatever position is found to be most comfortable. 4. Never pull on any part of the halo traction. 5. Clean around pins at least once daily with a new q-tip for each pin site.

3. Sleep in whatever position is found to be most comfortable. 4. Never pull on any part of the halo traction. 5. Clean around pins at least once daily with a new q-tip for each pin site.

A client being discharged home following hip surgery is prescribed to use a walker. While observing the client walk across the room, the nurse is most concerned when the client does what? 1. Applies shoes securely before ambulating with walker. 2. Checks walker to be certain the legs are securely locked. 3. Slides walker slowly forward when walking across the room. 4. Places walker to right of the chair after sitting down in chair.

3. Slides walker slowly forward when walking across the room.

The nurse is caring for four clients. Which client should the nurse see first? 1. The client hospitalized with dehydration related to diarrhea. 2. The seizure client who is currently in the postictal phase. 3. The post-op client who received Morphine 4 mg IV 15 minutes ago. 4. The client who is due pre-op medication now.

3. The post-op client who received Morphine 4 mg IV 15 minutes ago.

The nursing unit manager is reviewing cardiopulmonary resuscitation protocols with a group of new nurses. When the unit manager asks for an indication of effective CPR on an adult, what new nurse response would be most accurate? 1. Chest wall visibly rises with rescue breathing. 2. Skin color and temperature becomes pink and warm. 3. There is a palpable femoral pulse with a compression. 4. A sinus beat appears on monitor during compression.

3. There is a palpable femoral pulse with a compression.

What would the nurse include when teaching a client newly prescribed timolol maleate eyedrops for glaucoma? 1. The medication works by causing the pupils to constrict 2. The medication will dilate the canals of Schlemm 3. This medication decreases the production of aqueous humor 4. The medication improves ciliary muscle contraction

3. This medication decreases the production of aqueous humor

A client tells a clinic nurse of plans to travel to Europe by plane. What tips should the nurse provide the client regarding prevention of clot formation? Select all that apply 1. Do not cross legs longer than 15 minutes at a time. 2. Get up and move around the plane every 4 hours. 3. Wear compression stockings while traveling. 4. Frequently move legs while sitting. 5. Avoid coffee while traveling.

3. Wear compression stockings while traveling. 4. Frequently move legs while sitting. 5. Avoid coffee while traveling.

A client asks, "I would like to view my medical records." Which response made by the nurse is most appropriate? 1. You will first need to contact your primary healthcare provider. 2. You may view your electronic health records on a weekly basis. 3. You have the right to view the medical records that pertain to your care. 4. You want to view your medical records?

3. You have the right to view the medical records that pertain to your care.

The nurse is preparing to give a client's prescribed ceftazidime dose. How many mL will the nurse give to the client? Answer to the first decimal place. Answer with numbers and decimal only. Ceftazidime 1 gm IM every 6 hours 1 gram = 3.0 mL diluent and 3.6 approximate available volume and 280mg/mL approximate average concentration for IM injection

3.6

A client scheduled for an amniocentesis expresses concerns about the procedure to the nurse, despite having signed the consent form. What statement by the nurse would be most appropriate for the client? 1. "Don't worry, it's a very simple procedure." 2. "You have already signed the consent form." 3. "I will tell the doctor you need to talk more." 4. "Can you tell me what most concerns you?"

4. "Can you tell me what most concerns you?"

The nurse is talking to the parent of a 3 year old child who was constipated 1 week earlier. The child is on a regular diet. What statement by the parent indicates to the nurse that the prescribed treatment for constipation has been effective? 1. "My child drinks 1000 mL of fluids daily." 2. "My child is eating more fruit every day." 3. "I administered the prescribed oil-retention enema 6 days ago to my child." 4. "My child has had a soft, formed, brown stool every day for 6 days without straining."

4. "My child has had a soft, formed, brown stool every day for 6 days without straining."

The nurse is caring for a client with a diagnosis of major depression. The client began taking a selective serotonin reuptake inhibitor (SSRI) three days ago. The client says, "I am just not feeling well. My medicine is not working." Which reply by the nurse indicates adequate understanding of treatment? 1. "I agree, your medication is not working." 2. "Your treatment may have to be changed." 3. "Most SSRIs take about 5 days to work." 4. "You should reach the desired effect in 1-3 weeks."

4. "You should reach the desired effect in 1-3 weeks."

A medical-surgical LPN has been sent to a short-staffed pediatric unit. The charge nurse knows what client would be most appropriate for this LPN? 1. 3 month old child with nonorganic failure to thrive. 2. 14 year old with exacerbation of cystic fibrosis. 3. 5 year old newly admitted with epiglottitis. 4. 10 year old with type 1 diabetes mellitus.

4. 10 year old with type 1 diabetes mellitus.

An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment? 1. 15 2. 30 3. 45 4. 90

4. 90

A client is admitted for management of ulcerative colitis. What sign/symptom would be of immediate concern to the nurse? 1. Tenesmus 2. Hyperactive bowel sounds 3. Ten bloody diarrhea stools in 8 hours 4. Abdominal guarding

4. Abdominal guarding

The morning assessment of a client admitted with congestive heart failure reveals a weight gain of 2.5 pounds (1.14 kg) since the previous day, crackles in lung fields bilaterally, dyspnea, sacral edema, and bounding peripheral pulses. Which prescription by the healthcare provider should be the nurse's priority? 1. Maintain accurate intake and output. 2. Restrict sodium in the diet. 3. Limit fluids to 1500 mL per day. 4. Administer furosemide 40 mg IV push.

4. Administer furosemide 40 mg IV push.

The emergency room nurse is assessing a client reporting severe abdominal pain for several hours prior to arrival at the hospital. Assessment findings include slight mottling of the lower extremities and a pulsating mass near the umbilicus. Which actions should the nurse implement immediately? Select all that apply 1. Position client on the left side. 2. Apply warm blankets to legs. 3. Administer I.M. pain medication. 4. Alert the operating room staff. 5. Notify the primary healthcare provider. 6. Palpate mass to determine size.

4. Alert the operating room staff. 5. Notify the primary healthcare provider.

The nurse is initiating the admission assessment on a client diagnosed with Parkinson Disease. The client is slow to answer questions and appears to be frustrated trying to find the right words. Which communication technique by the nurse is appropriate? 1. Share with the client that all will be OK. 2. Introduce another health issue to discuss with the client. 3. Identify other clients who have had communication issues. 4. Allow the client the opportunity to organize their response.

4. Allow the client the opportunity to organize their response.

A client has been admitted with a diagnosis of portosystemic encephalopathy (PSE) secondary to Laennec's cirrhosis. The client is lethargic with slurred speech and is oriented only to self. Assessment findings include grossly distended abdomen, bruised and jaundiced skin, fine bibasilar crackles and +4 pitting edema to lower extremities. The nurse is aware that what lab result is most likely responsible for the client's neurological deterioration? Exhibit 1. Albumin 2.0 gm/dl 2. Sodium 129 meq/L 3. Bilirubin 2.0 gm/dl 4. Ammonia 80 mcg/dl

4. Ammonia 80 mcg/dl

The client with obsessive-compulsive disorder (OCD) asks the nurse for help with a repetitive behavior. What is the most likely origin of this behavior? 1. Fear 2. Depression 3. Delusions 4. Anxiety

4. Anxiety

The pediatric nurse is assessing a child following an appendectomy. What is the nurse's main priority following surgery? 1. Obtain vital signs every four hours. 2. Assess the need for pain medication. 3. Tally intake and output every eight hours. 4. Auscultate lung sounds every four hours.

4. Auscultate lung sounds every four hours.

A nurse is caring for a client who has been prescribed sucralfate. Which client education intervention would the nurse include for the client prescribed sucralfate? 1. Take medication 1 hour after meals. 2. Crush tablets prior to taking medication. 3. Consume 1000 mL of fluid every 24 hours. 4. Avoid antacids 1 hour before and after this medication.

4. Avoid antacids 1 hour before and after this medication.

Which medication should the nurse administer first after receiving the morning shift report? 1. Levothyroxine to the client with hypothyroidism and a thyroid stimulating hormone (TSH) level of 2.8 mU/L 2. Amlodipine to the client with hypertension and a blood pressure of 150/86 3. Regular insulin sliding scale dose to the client with diabetes and a 210 mg/dL (11.7 mmol/L)blood glucose level. 4. Cefotaxime intravenous piggyback to the newly admitted client with a diagnosis of pneumonia and a white blood cell count (WBC) of 12,000mm3 (12 (10^9L)

4. Cefotaxime intravenous piggyback to the newly admitted client with a diagnosis of pneumonia and a white blood cell count (WBC) of 12,000mm3 (12 (10^9L)

A pregnant woman who has just been admitted to the labor and delivery room states that her "water just broke". What should the nurse do immediately? 1. Confirm that fluid is amniotic fluid with a pH test strip 2. Obtain maternal vital signs 3. Observe amniotic fluid color 4. Check fetal heart rate (FHR) pattern

4. Check fetal heart rate (FHR) pattern

An alcoholic client was admitted to the medical unit with substance-withdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What is the priority nursing intervention at this time? 1. Hide the client's clothes so that he cannot leave. 2. Administer the ordered sedative. 3. Place restraints on the client. 4. Determine why the client wants to leave.

4. Determine why the client wants to leave.

How should the nurse assist a post-operative client in transferring from the bed to a chair? 1. Have the client look down and watch their feet as they move. 2. Tell the client to bend at the waist to lower the center of gravity. 3. Place a walker away from the bed so the client can lean forward while standing. 4. Ensure the client's feet are as wide apart as the hips.

4. Ensure the client's feet are as wide apart as the hips.

The nurse discovers that a client was given the wrong medication. After verifying the client is stable, an incident report is completed. What is the proper disposition of the report? 1. Send a copy of the report to the primary healthcare provider. 2. Notify the State Board of Nursing about the incident report. 3. Document that a report was completed on the client's chart. 4. Give the report to the hospital's risk management team.

4. Give the report to the hospital's risk management team.

After making rounds on clients, a primary healthcare provider hands the nurse a client record and gives the following verbal order: Administer cisplatin 1 mg IV over 6 hours. What should be the first action by the nurse following this verbal prescription? 1. Call the pharmacy to prepare the drug. 2. Repeat the prescription back to the primary healthcare provider. 3. Ask the primary healthcare provider to spell the drug name for clarification. 4. Inform the healthcare provider that this medication requires a written prescription.

4. Inform the healthcare provider that this medication requires a written prescription.

A client with stage III uterine cancer is being discharged following a total abdominal hysterectomy and bilateral oophorectomy. The client asks about physical changes that may occur as a result of surgical menopause. What is the most important information the nurse should provide? 1. A papanicolaou (Pap) test will be needed every 3 months. 2. Intercourse must be avoided until chemotherapy is complete. 3. Estrogen medication will alleviate symptoms of menopause. 4. Lubrication will help decrease vaginal dryness and burning.

4. Lubrication will help decrease vaginal dryness and burning.

A client with chronic arterial occlusive disease has a bypass graft of the left femoral artery. Postoperatively, the client develops left leg pain and coolness in the left foot. What is the priority action by the nurse? 1. Elevate the leg. 2. Check distal pulses. 3. Increase the IV rate. 4. Notify the primary healthcare provider.

4. Notify the primary healthcare provider.

A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response? 1. Palliative care is a holistic way of finding a cure for a serious illness. 2. Palliative care begins when the client has 3 months or less to live. 3. Palliative care will require you to change to a palliative care healthcare provider. 4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about nutrition and maintaining body weight. Which instruction is most important for this client? 1. Do postural drainage just before meals. 2. Consume fluids only at meal times. 3. Prepare meals high in carbohydrates. 4. Plan rest periods before and after meals.

4. Plan rest periods before and after meals.

At a well-baby check, the parents of a 14 month old report how the child is doing and then excitedly share that they have purchased and are moving into a "fixer-up" home that was built in the mid-1960s. Based on the parent's report, what would be the priority concern for the nurse to address with the parents? 1. Fall risk due to increased mobility 2. Increased anxiety due to change in the environment 3. Speech consisting of only 4 words 4. Potential for lead poisoning

4. Potential for lead poisoning

The parents of a nine month old ask the nurse for toy recommendations. What recommendation should the nurse to make? 1. Mobile 2. Tricycle 3. Marbles 4. Pull toy

4. Pull toy

A post-operative client becomes anxious and reports acute onset of chest pain when taking a deep breath and shortness of breath. Initial vital signs obtained by the nurse reveals tachycardia, hemoptysis, and a pulse oximeter reading of 90%. What intervention should the nurse initiate first? 1. Administer oxygen. 2. Obtain a blood pressure reading. 3. Connect to cardiac monitor. 4. Raise head of bed to 90 degrees.

4. Raise head of bed to 90 degrees.

A client asks the nurse, "How is relaxation therapy going to help reduce my stress?" What would be the nurse's best response? 1. Relaxation therapy leads to more awareness of potential stressors 2. Relaxation therapy reduces stress by releasing small doses of epinephrine into the body. 3. Stress can be eliminated from your life when you use this therapy. 4. Relaxation therapy can counteract the flight or fight response.

4. Relaxation therapy can counteract the flight or fight response.

The obstetrics nurse notes minimal variability with a late deceleration on the electric fetal monitor of a client that is 38 weeks gestation. Which action will the nurse take first? 1. Notify the primary healthcare provider 2. Apply 10 L O2 per nasal canula 3. Prepare for an emergency cesarean section 4. Reposition the client to the left side

4. Reposition the client to the left side

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? pH - 7.49 PaO2 - 99% PaCO2 - 29 HCO3 - 23 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis

4. Respiratory alkalosis

Which finding should take priority when the nurse is assessing the skin of a client diagnosed with diabetes? 1. Vitiligo of the chest. 2. Scleroderma to scapula and posterior neck region. 3. Redness of face and upper chest. 4. Small abrasion on great toe.

4. Small abrasion on great toe.

An elderly client comes to the clinic for a check-up. The client's daughter tells the nurse that her father's dementia symptoms become increasingly more difficult to handle in the evening. How would the nurse document this symptom? 1. Confabulation 2. Apraxia 3. Pseudodementia 4. Sundowning

4. Sundowning

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Check client's bony prominences for redness. 2. Monitor client need for suctioning hourly. 3. Explain how to collect 24 hour urine to client. 4. Take a tympanic temperature on client every two hours. 5. Perform postural drainage and chest physiotherapy on client. 6. Report client's pulse oximetry reading every hour.

4. Take a tympanic temperature on client every two hours. 6. Report client's pulse oximetry reading every hour.

What should the nurse include in the plan of care for a child who is receiving chemotherapy for a diagnosis of leukemia? 1. Place the child in a negative pressure isolation room. 2. Administer prophylactic intravenous (IV) antibiotics. 3. Avoid high protein food intake. 4. Teach family and visitors handwashing techniques.

4. Teach family and visitors handwashing techniques.

A client admitted to the mental health unit for a suicidal attempt has been progressing slowly in treatment. Suddenly, the client has voiced a much more positive outlook and tells the nurse "I am going to be fine now." What is significant about this situation? 1. The nurse should expect that the treatment has been effective. 2. The client is developing a more positive outlook. 3. The client sees hope for the future. 4. The client may have decided to kill himself.

4. The client may have decided to kill himself.

A client is brought to the after hours clinic with a stab wound to the left leg, reporting it as "accidental". The nurse notes the odor of alcohol and marijuana on the client. The nurse is aware that client privacy rights do not apply to what action? 1. The right to refuse photos of the wound. 2. The right to refuse a blood alcohol test. 3. The right to refuse a tetanus injection. 4. The right to refuse police notification.

4. The right to refuse police notification.

An unlicensed assistive personnel (UAP) is asked to transfer a client with left hemiplegia from the bed to a wheelchair. The nurse tells the UAP the safest approach for this transfer is what method? 1. Lift client from edge of bed, supporting under arms and pivot to chair. 2. Utilize a slide board to transfer client from bed to the wheelchair. 3. Apply an ambulation belt around client's waist and pull into the chair. 4. Use a mechanical lift to move client from the bed into the wheelchair.

4. Use a mechanical lift to move client from the bed into the wheelchair.

Which type of comment should the nurse expect from a client exhibiting clang associations? 1. Concrete explanations for abstract ideas 2. Reporting very small details when explaining something 3. Comments that are illogically associated 4. Use of rhyming words when talking

4. Use of rhyming words when talking

The primary healthcare provider prescribes: Ceftriaxone sodium 50 mg/kg intramuscular now. The client weighs 22.5 pounds. According to the manufacturer's instructions, the concentration is 100 mg/mL. How many milliliters (mL) should the nurse administer? Provide your answer using numbers and decimal points only. Do NOT include words. (Round to the nearest tenth)

5.1

A client is prescribed 1.5 grams of levodopa daily. Available forms of this drug include tablets of 250 milligrams. How many tablets should this client be given to receive the proper amount of medication? Round answer to the nearest whole number.

6 (1.5/0.250)

An elderly client was admitted with a diagnosis of Type II diabetes. The primary healthcare provider initiated the Insulin Sliding Scale Protocol for Type II Diabetic Clients. The prescription regimen was to begin at the low dose regimen with regular insulin every 6 hours. The 2400 hours glucose level is 252 mg/dL (14.4 mmol/L). How much regular insulin should the nurse give the client at this time? Answer using numbers only.

8

A hospitalized client is being prepared for transport to the dialysis unit when the nurse receives new orders for a stat unit of packed red blood cells to be infused. In what order should the nurse implement these actions? a. Proceed to blood bank and sign out the unit of blood. b. Verify client's blood identification arm band is in place. c. Have dialysis nurse co-sign for the unit of blood. d. Allow client to proceed to the dialysis unit. e. Advise dialysis nurse that blood is to be infused.

b. Verify client's blood identification arm band is in place. e. Advise dialysis nurse that blood is to be infused. d. Allow client to proceed to the dialysis unit. a. Proceed to blood bank and sign out the unit of blood. c. Have dialysis nurse co-sign for the unit of blood.

The nurse inadvertently administered the wrong medication to a client. Place the tasks to be completed in order of priority. a. Complete an incident report. b. Alert the Unit Manager. c. Obtain the client's vitals. d. Report what happened to the health care provider.

c. Obtain the client's vitals. d. Report what happened to the health care provider. b. Alert the Unit Manager a. Complete an incident report.

During night time rounds, the nurse finds a client has cigarettes in bed and the room is filled with smoke. In what order should the nurse perform the following actions? a. Pull the fire alarm handle. b. Close the client's door. c. Notify hospital operator. d. Get the fire extinguisher. e. Remove client from room.

e. Remove client from room. a. Pull the fire alarm handle. c. Notify the hospital operator. b. Close the client's door. d. Get the fire extinguisher.