NCLEX

A child has discomfort and swelling around the IV insertion site. Which assessment should the nurse make first? 1. if the angiocatheter has come out of the vein 2. how long the IV site has been used 3. any history of allergies to the plastic in the angiocatheter 4. signs that the rate of fluid administration is too rapid for the vein size

1

A client experienced a pneumothorax after the placement of a central venous pressure line. Which assessment supports a diagnosis of pneumothorax? 1.sudden, sharp pain on the affected side 2.tracheal deviation toward the affected side 3.bradypnea and elevated blood pressure 4.presence of crackles and wheezes

1

The nurse is evaluating a client who is using a flow incentive spirometer following abdominal surgery 1 day ago. The client is performing the procedure correctly when the client does what? Select all that apply. 1.inhales before using the spirometer 2.inhales for 3 seconds following fully expanding the lungs 3.coughs after using the spirometer 4.uses the spirometer once every 8 hours 5.exhales passively before using the spirometer again 6.sits upright

2, 3, 5, 6

A child is admitted with a fracture of the femur and placed in skeletal traction. What should the nurse assess first? 1. the pull of traction on the pin 2. the elastic bandage 3. the pin sites for signs of infection 4. the dressings for tightness

1

A nurse is instructing a client about using nitroglycerin patches to prevent tolerance to the drug. What should the nurse instruct the client to do? 1.Remove the patch every night. 2.Use the patch only when chest pain occurs. 3.Change the site of the patch every day. 4.Apply the patch only on alternate days.

1

The nurse obtains a blood sample to screen a neonate for phenylketonuria. From what site should the nurse obtain the sample? 1.heel 2.radial artery 3.scalp vein 4.brachial artery

1

While assisting the healthcare provider with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. How should the nurse interpret this finding? 1.intrauterine infection 2.fetal meconium staining 3.erythroblastosis fetalis 4.normal amniotic fluid

1

A 5-month-old infant is brought to the emergency department with vomiting and diarrhea, which the parent states started 3 days ago. The nurse should conduct a focused assessment for which signs and symptoms? Select all that apply. 1.decreased or absent tearing 2.dry mucous membranes 3.sunken fontanel 4.clear, pale yellow urine 5.bounding pulse

1, 2, 3

There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported immediately to a burn center for treatment? Select all that apply. 1. an 8-year-old with third-degree burns over 10% of the body surface area (BSA) 2. a 20-year-old who inhaled the smoke of the fire 3. a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area (BSA) 4. a 30-year-old with second-degree burns on the back of the left leg (about 9% of body surface area (BSA) 5. a 40-year-old with second-degree burns on the right arm (about 10% of BSA)

1, 2, 3

The nurse-manager is teaching the staff about the medication reconciliation policy. The nurse teaches the staff that reconciliation is needed to ensure that clients are on the correct medications in which situations? Select all that apply. 1.admission to the hospital 2.transfer to the nursing home 3.transfer of a client from surgery to the surgical unit 4.admission to a home health agency from the hospital 5.move to a different room on the same unit

1, 2, 3, 4

A client is admitted to the emergency department with sudden onset of chest pain. Which prescriptions should the nurse implement immediately? Select all that apply. 1.Provide oxygen. 2.Administer nitroglycerin. 3.Administer aspirin. 4.Insert a Foley catheter. 5.Administer morphine. 6.Administer acetaminophen.

1, 2, 3, 5

When teaching a client about self-care following placement of a new permanent pacemaker to the left upper chest, the nurse should include which information? Select all that apply. 1.Take and record daily pulse rate. 2.Avoid air travel because of airport security alarms. 3.Immobilize the affected arm for 4 to 6 weeks. 4.Avoid using a microwave oven. 5.Avoid lifting anything heavier than 3 lb (1.36 kg).

1, 5

The nursing staff has safely and successfully secluded and restrained a client with acute mania who threatened the nurse and threw a chair against the wall in the community room. Which statement by the nurse is most helpful to the client at this time? 1."Threatening others and throwing furniture is not allowed." 2."You've been restrained until you can manage your behavior." 3."Since you've been here before, you know what the rules are." 4."We're only doing this for your own good, so calm down."

2

The nurse is measuring a child for crutches. What factors should the nurse consider? Select all that apply. 1. type of gait child will be using 2. degree of child's elbow flexion 3. space above the crutch to child's axilla 4. weight of the child 5. whether child has to use the stairs

2, 3

A child who is 18 months of age is brought to the emergency department by her babysitter. The babysitter states, "She fell from the sofa an hour ago and hasn't been herself since." On questioning, the babysitter appears to be unsure of time and other facts about the incident. Which question would be most effective in obtaining more information about the child's injuries? 1."Why did you leave the child alone on the couch?" 2."Have you taken a course in safe babysitting?" 3."Tell me what was happening before she fell." 4."Where are her parents? Do they know this happened?"

3

A client has an increased intracranial pressure of 20 mm Hg. What intervention should the nurse implement? 1.Give the client a warming blanket. 2.Administer low-dose barbiturates. 3.Encourage the client to take deep breaths to hyperventilate. 4.Restrict fluids.

3

A client receiving chemotherapy for metastatic colon cancer is admitted to the hospital because of prolonged vomiting. Assessment findings include irregular pulse of 120 bpm, blood pressure 88/48 mm Hg, respiratory rate of 14 breaths/min, serum potassium of 2.9 mEq/L (2.9 mmol/L), and arterial blood gas—pH 7.46, PCO245 mm Hg (6.0 kPA), PO295 mm Hg (12.6 kPa), bicarbonate level 29 mEq/L (29 mmol/L). The nurse should implement which prescription first? 1.oxygen at 4L per nasal cannula 2.repeat laboratory work in 4 hours 3.5% Dextrose in 0.45% normal saline with KCl 40 mEq/L at 125 mL/h 4.12-lead ECG

3

A client with diabetes mellitus that is well controlled reports that she participated in strenuous aerobic exercise before becoming pregnant. She asks the nurse if she can continue exercising. What is the nurse's best response? 1."You probably should discontinue your strenuous exercise program while you're pregnant so you don't injure the fetus." 2."You need to curtail your exercise program a little so that you don't overexert yourself while you're pregnant." 3."You can continue exercising while pregnant, but make sure that you eat a carbohydrate or protein snack before exercising." 4."It's probably a good idea for you to check your blood sugar before beginning any exercise program."

3

A father tells the nurse that his adolescent son spends lots of time in his room, his grades are falling and he has given away a few of his favorite video games. What is the most appropriate action for the nurse? 1.Give the father the telephone number for the local crisis hotline. 2.Have the father take the adolescent to the nearest mental health outpatient facility now. 3.Make a same-day appointment for the adolescent with his usual healthcare provider. 4.Obtain more history information from the distraught father before making a decision.

3

A frail older adult client with a hip fracture is to use an alternating air pressure mattress at home to prevent pressure ulcers while recovering from surgery. The nurse is assisting the client's family to place the mattress (see image). What should the nurse instruct the family to do? 1.Turn the mattress over so the air cells face the mattress of the bed, and cover the mattress with a bed sheet. 2.Put a thick pad over the pressure mattress to prevent soiling, and place the bed sheet on top of the pad. 3.Make the bed with the bed sheet on top of the pressure mattress. 4.Make the bed, and then remove the pillow to allow full use of the mattress on the neck.

3

A septic preterm neonate's IV was removed due to infiltration. The nurse prioritizes restarting the IV to help which complication? 1. fever 2. hyperkalemia 3. hypoglycemia 4. tachycardia

3

The nurse administers a bolus tube feeding to a client with cancer. What should the nurse do to decrease the risk of aspiration? 1.Place the client on bed rest with the head of the bed elevated to 60 degrees for 2 hours. 2.Turn the client on the left side with the head of the bed at 45 degrees for 15 minutes. 3.Assist the client out of bed to sit upright in a chair for 1 hour. 4.Ask the client to rest in bed with the head of the bed elevated to 30 degrees for 20 minutes.

3

The nurse is preparing to administer platelets. What should the nurse do first? 1. Check the ABO compatibility. 2. Administer the platelets slowly. 3. Gently rotate the bag. 4. Use a whole blood tubing set.

3

Which nursing intervention would most likely promote self-care behaviors in the client with a hiatal hernia? 1.Introduce the client to other people who are successfully managing their care. 2.Include the client's daughter in the teaching so that she can help implement the plan. 3.Ask the client to identify other situations in which the client changed healthcare habits. 4.Provide reassurance that the client will be able to implement all aspects of the plan successfully.

3

Which structure should be closed by the time the child is 2 months old? (image on back) 1.A 2.B 3.C 4.D

3

A 30-year-old G3, T2, P0, A0, L2 is being monitored internally. She is being induced with IV oxytocin because she is postterm. The nurse notes the pattern below. The client is wedged to her side while lying in bed and is approximately 6-cm dilated and 100% effaced. What should the nurse do first? 1.Continue to observe the fetal monitor. 2.Anticipate rupture of the membranes. 3.Prepare for fetal oximetry. 4.Discontinue the oxytocin infusion.

4

The nurse is auscultating S1 and S2 in a client. Identify the area where the nurse should hear S1 the loudest.

4

The nurse reviews the BMI for age growth chart of a 6-year-old girl (see exhibit). How does the nurse classify the girl's BMI? 1.underweight 2.normal weight 3.overweight 4.obese

3

The nurse is irrigating a client's colostomy. The client has abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse do first? 1.Stop the flow of solution. 2.Reposition the client on the right side. 3.Remove the irrigation tube. 4.Massage the abdomen gently.

1

The nurse is participating in a blood pressure screening event. After three separate readings taken at least 2 minutes apart, the nurse determines that a client has a blood pressure of 160/90 mm Hg. What should the nurse advise the client to do? 1. Have blood pressure evaluated within 1 month. 2. Begin an exercise program. 3. Examine lifestyle to decrease stress. 4. Schedule a complete physical immediately

1

When integrating the concepts underlying the cognitive-behavioral model into a client's plan of care, the nurse should focus on what area? 1.substitution of rational beliefs for self-defeating thinking and behaving 2.insight into unconscious conflicts and processes 3.analysis of fears and barriers to growth 4.reduction of bodily tensions and stress management

1

The newborn nurse has just received shift report about a group of newborns and is to receive another admission in 30 minutes. In order to provide the safest care and plan for the new admission, the nurse should do which tasks in order of first to last? All options must be used. 1.Review notes from shift report, and prioritize all clients; make rounds on the most critical first. 2.Move quickly from room to room, and assess all clients. 3.Log on to the clinical information system, and determine if there are new orders. 4.Check the room to which the new client will be admitted to ensure all supplies and equipment are available.

1, 2, 3, 4

A nurse is instructing a client with an ileal conduit about skin care around the stoma. What should the nurse tell the client about stoma care? Select all that apply. 1."The stoma will shrink to a normal size in 4 to 6 weeks." 2."You can take a shower or a bath with the appliance on or off." 3."You should wash around the stoma with an antibacterial soap." 4."You can use an electric razor to remove the hair around the stoma." 5."You should remove the collection bag every day to inspect the stoma for infection."

1, 2, 4

A client is being discharged with a home oxygen delivery device. Which comments indicate that the client understands safety regarding home oxygen? Select all that apply. 1. "No one can smoke within 10 feet (3 meters) of the oxygen." 2. "I can carry my oxygen in a bag for easy portability." 3. "I need to keep my oxygen away from electrical sources." 4. "I should keep my oxygen away from direct heat." 5. "I'll keep my oxygen out of the sun in all circumstances."

1, 3, 4

A six-month-old infant is being admitted with a diagnosis of bacterial meningitis. What considerations should be made, by the nurse, regarding the infant's room assignment? Select all that apply. 1.The child will need to be on droplet precautions. 2.The infant's parents will not be allowed in the room. 3.A private room is required. 4.The room should be near the nurses' station. 5.There must be a window in the door to view the child.

1, 3, 4

The nurse notices drops of a liquid on the hallway floor of a health care facility. What should the nurse do first? 1. Place paper towels over the drops of liquid. 2. Don clean gloves and wipe up the drops of liquid. 3. Post "wet floor" signs around the area. 4. Call the Environmental Services Department.

2

A client who comes to the crisis center in a very distressed state tells the nurse, "I just can't get over being fired last week. I've asked for help. I've talked to friends. I've tried everything to get through this, but nothing's working. Help me!" Which initial crisis intervention strategy should the nurse use? 1.referral for counseling 2.support system assessment 3.emotion management 4.unemployment assistance

3

An unlicensed assistive personnel (UAP) is taking care of a child in the arm restraint shown in the figure (on back of card). How should the nurse instruct the UAP to provide care for this client? 1.Unpin the restraint and perform range-of-motion exercises. 2.Unwrap the restraint, and bathe the arm using warm water. 3.Leave the restraint, in its current position. 4.Remove one tape at a time while bathing the child's arm.

3

The healthcare team has noticed an increase in IV infiltrations on the pediatric floor. As part of a Plan, Do, Study, Act quality improvement plan, the team should perform the actions in which order? All options must be used. 1.Analyze the data. 2.Perform chart audits. 3.Decide to monitor IV gauges. 4.Write a new IV insertion policy.

3, 2, 1, 4

Prior to going to surgery, the client tells the nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? 1.Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken. 2.Tell the client that she will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up. 3.Explain to the client that she will have a premedication that will make her sleepy before she goes to surgery and she will not need to hear. 4.Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery.

4

The nurse is making rounds and observes the client receiving oxygen. What should the nurse do next? 1.Position the mask lower on the client's nose. 2.Verify that the reservoir bag remains deflated. 3.Confirm that the flow rate is set to deliver oxygen at 6 to 10 L/min. 4.Loosen the elastic band on the client's face.

3

The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the medical record for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 1530 is 75% taken on the infant's right wrist. What should the nurse do first? 1. Administer oxygen via mask. 2. Obtain a pulse oximeter reading in a lower extremity. 3. Reassess the oximetry reading in 30 minutes. 4. Draw blood gases for oxygen and carbon dioxide levels.

1

The nurse observes the cardiac rhythm (see below) for a client who is being admitted with a myocardial infarction. Which action should the nurse take first? 1.Prepare for immediate cardioversion. 2.Begin cardiopulmonary resuscitation. 3.Check for a pulse. 4.Prepare for immediate defibrillation.

3

The healthcare team wishes to establish a policy regarding sleep positions for infants with gastroesophageal reflux disease. The first step should be to search for which information? 1.policies from other hospitals 2.data from retrospective studies 3.published national standards 4.expert opinions

3

A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for which intervention? 1.initiating IV sedation 2.starting a high-protein diet 3.providing pain medication 4.increasing the ventilator rate

1

A client with diabetes is explaining to the nurse how he cares for his feet at home. Which statement indicates the client needs further instruction on how to care for the feet properly? 1. "I inspect my feet once a week for cuts and redness." 2. "I'm not allowed to use a heating pad on my feet." 3. "It's important to dry my feet carefully after my bath." 4. "I shouldn't go barefoot, even in my home."

1

An unconscious client in the emergency department is given IV naloxone due to an overdose of heroin. Which findings would indicate a therapeutic response to the naloxone? Select all that apply. 1. decreased pulse rate 2. warm moist skin 3. dilated pupils 4. increased respirations 5. consciousness

4, 5

The primary care provider prescribes cefepime 250 mg every 6 hours for a child weighing 20 kg who had infected burns. The normal dosage for this antibiotic and condition is 20 to 50 mg/kg per 24 hours. Which action would be most appropriate? 1.Carry out the prescription because the prescribed dose is acceptable. 2.Give the dose recommended by the pharmacy reference material. 3.Question the prescription because the dose is too low. 4.Question the prescription because the dose is a toxic amount.

1

What should the nurse discuss when teaching a client about lithium therapy? 1.maintaining an adequate sodium intake 2.discontinuing sodium in the diet 3.buying foods labeled "low in sodium" 4.increasing sodium in the diet

1

The nurse is caring for a client who is using a portable wound suction unit. Six hours following surgery, the drainage unit is full. What should the nurse do first? 1. Remove the drain from the incision. 2. Notify the surgeon. 3. Empty drainage. 4. Record the amount in the unit as output on the client's medical record.

3

The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. What information should be included in the plan? Select all that apply. 1. Splint or support the incision to promote maximal comfort. 2. Inhale slowly through the nostrils; exhale through pursed lips. 3. Hold the breath for about 5 seconds to expand the alveoli. 4. Repeat this breathing method 5 to 10 times hourly. 5. Close one nostril while inhaling.

1, 2, 3, 4

A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output? Select all that apply. 1.weighing and recording all wet diapers 2.changing breastfeedings to bottle-feedings 3.obtaining an accurate daily weight 4.restricting fluids prior to weighing the child 5.obtaining an accurate stool count

1, 3, 5

A nurse is caring for a client who is undergoing chemotherapy. Current laboratory values are noted on the medical record. Which action would be most appropriate for the nurse to implement? 1.wearing a protective gown and particulate respiratory mask when completing treatments 2.washing hands before and after entering the room 3.restricting visitors 4.contacting the healthcare provider for a prescription for hematopoietic factors such as erythropoietin

2

A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of hemophilia A in her family. The nurse informs the client that she will need to wait until she is at 15 weeks' gestation for the amniocentesis. Which is the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation? 1. Fetal development needs to be complete before testing. 2. The volume of amniotic fluid needed for testing will be available by 15 weeks. 3. Cells indicating hemophilia A are not produced until 15 weeks' gestation. 4. Performing an amniocentesis prior to 15 weeks' gestation carries a greater infection rate.

2

An 80-year-old client had spinal anesthesia for a transurethral resection of the prostate and received 4,000 mL of room temperature isotonic bladder irrigation. He now has continuous irrigation through a three-way indwelling urinary catheter. Which postoperative nursing intervention is most important to include in his plan of care? 1.Empty the catheter drainage bag. 2.Cover the client with warm blankets. 3.Hang new bags of irrigation. 4.Turn the client.

2

For the child diagnosed with an asthma attack, which manifestation would best correlate with the child's arterial blood gas results, which include pH of 7.46, bicarbonate of 21 mEq/L (21 mmol/L) and a partial pressure of carbon dioxide (PCO2) of 33 mm Hg (4.4 kPa)? 1.greatly diminished breath sounds 2.tingling sensation in the fingertips 3.heart rate of 68 bpm 4.absence of urination for several hours

2

The client received electroconvulsive therapy (ECT) an hour ago and now has a headache. Which response by the nurse is best? 1."A headache is common after ECT." 2."I'll get some acetaminophen for you." 3."A nap will help you feel better." 4."Eat your breakfast, and then let me know how you feel."

2

The parents of a child with sickle cell anemia ask about the chances of sickle cell disease occurring in future children. The nurse responds based on the knowledge that both parents are carriers. What is the risk of one of their children having the disease? 1.one chance in five for each pregnancy. 2.one chance in four for each pregnancy. 3.one chance in three for each pregnancy. 4.one chance in two for each pregnancy.

2

The nurse is using a needleless port to administer an intravenous medication through a PICC line (view the figure). Which is the correct technique with this system? Select all that apply. 1.Remove the tape prior to injecting the medication. 2.Aspirate the line and flush with saline. 3.Use a separate syringe to administer the medication. 4.Change gloves before administering the medication. 5.Dispose of the syringe in a recyclable trash container.

2, 3

The nurse is providing discharge instructions about dietary limitations to a client with gout. Which foods should the client avoid? Select all that apply. 1. orange juice 2. sardines 3. red wine 4. beer 5. hard cheeses

2, 3, 4

A client who had a hip replacement at 0900 is receiving an autologous blood transfusion that was started at 1100. At the change of shift (1500), the nurse working on the day shift reports that there is 50 mL of the unit of blood remaining to be infused. Which is a priority nursing action for the nurse working on the evening shift? 1.Keep the blood transfusing at the same rate. 2.Increase the rate so it will infuse by 1600. 3.Discontinue the blood transfusion at the beginning of the shift. 4.Maintain the current rate, and discontinue the blood transfusion at 1700.

3

A client who had a transurethral resection of the prostate (TURP) has a three-way indwelling urinary catheter with continuous bladder irrigation. In which circumstance should the nurse increase the flow rate of the continuous bladder irrigation? 1.when drainage is continuous but slow 2.when drainage appears cloudy and dark yellow 3.when drainage becomes bright red 4.when there is no drainage of urine and irrigating solution

3

A client who is on nothing-by-mouth status is constantly asking for a drink. Which nursing intervention is the most appropriate? 1.Re-explain to the client why she cannot drink. 2.Offer ice chips every hour to decrease thirst. 3.Offer the client frequent oral hygiene care. 4.Divert the client's attention by turning on the television.

3

After a child returns from the postanesthesia care unit after surgery, what should the nurse assess first? 1.the IV fluid access site 2.the child's level of pain 3.the surgical site dressing 4.the functioning of the nasogastric tube

3

The parent of a child with spastic cerebral palsy and a communication disorder tells the nurse, "He seems so restless. I think he's in pain." Which action is most indicated? 1.Assess the child for pain using the Faces, Legs, Activity, Cry, Consolability (FLACC) scale. 2.Assess the child using the pediatric FACES scale. 3.Administer prescribed pain medication. 4.Notify the healthcare provider of the change in behavior.

3

The nurse is taking care of a client who has an IV infusion pump. The pump alarm rings. What should the nurse do in order from first to last? All options must be used. 1.Determine if the infusion pump is plugged into an electrical outlet. 2.Assess the client's access site for infiltration or inflammation. 3.Silence the pump alarm. 4.Assess the tubing for hindrances to flow of solution.

3, 2, 4, 1

Which are appropriate identifiers to use when providing care or administering medications or treatments? Select all that apply. 1.room number 2.bed number 3.medical record number 4.name band 5.social security number

3, 4

A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds, and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action? 1.Move to the entrance of the hospital and check each person leaving. 2.Go to the obstetrics unit to determine if they need help with the situation. 3.Call the nursery to ask which baby is missing. 4.Observe individuals in the area for large bags or oversized coats.

4

A pregnant woman at 22 weeks' gestation is diagnosed with gonorrhea. The healthcare provider (HCP) prescribes doxycycline. What should the nurse do first? 1.Instruct the client about the effects of the drug. 2.Make sure the record notes that the baby must receive eye drops when born. 3.Have the HCP add a single dose of ceftriaxone. 4.Discuss with the HCP the need to change the prescription.

4

An older adult is admitted to the hospital with sudden onset of severe pain in the back, flank and abdomen. The client reports feeling weak; the blood pressure is 68/31 mm Hg. There has been no urine output. Bilateral leg pulses are weak, although bruit and pulsation are noted at the umbilicus. What action should the nurse takefirst? 1.Obtain consent for emergency surgery. 2.Assess leg pulses with a Doppler test. 3.Palpate the abdomen for presence of a mass. 4.Start an IV infusion.

4

The nurse determines that a client's abdominal wound has eviscerated. What should the nurse do first? 1.Notify the healthcare provider. 2.Reinsert the protruding viscera into the abdominal cavity. 3.Place the client in reverse Trendelenburg's position. 4.Cover the wound with sterile saline-moistened dressings.

4

The nurse discovers that a client's TPN solution was running at an incorrect rate and is now 2 hours behind schedule. Which action is most appropriate for the nurse to take to correct the problem? 1. Readjust the solution to infuse the desired amount. 2. Continue the infusion at the current rate, but run the next bottle at an increased rate. 3. Double the infusion rate for 2 hours. 4. Notify the healthcare provider.

4

When assessing a client who is receiving tricyclic antidepressant therapy, which finding should alert the nurse to the possibility that the client is experiencing anticholinergic effects? 1.tremors and cardiac arrhythmias 2.sedation and delirium 3.respiratory depression and convulsions 4.urine retention and blurred vision

4

After the nurse teaches the parent of a child with a spica cast about skin care, which parental action would indicate the need for additional teaching? 1.application of powder to the skin under the cast 2.inspection of the cast edges for smoothness 3.application of plastic film to cover the perineal cast area 4.inspection of areas inside the cast

1

The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, what should the nurse's documentation include? Select all that apply. 1. nutrition and hydration needs 2. capillary refill 3. continued need for restraints 4. need for medication 5. skin integrity

1, 2, 3, 5

When a client cannot read or write but is of sound mind, the nurse should read the informed consent to the client in the presence of two witnesses and do what next? 1.Have the client's next-of-kin sign the informed consent. 2.Have the client put an "X" on the signature line. 3.Have a court appoint a guardian for the client. 4.Have a hospital quality management coordinator sign for the client.

2

A client is being admitted with nursing home-acquired pneumonia. The unit has four empty beds in semiprivate rooms. The room that would be most suitable for this client is the one with which other client? 1. 60-year-old client admitted for investigation of transient ischemic attacks 2. 45-year-old client with abdominal hysterectomy 3. 24-year-old client with non-Hodgkin's lymphoma 4. 55-year-old client with alcoholic cirrhosis

1

When assessing a 13-year-old adolescent, what is an expected finding? 1.Tanner stage 1 of development 2.decision about a career 3.primarily one friend 4.subjective judgments of right and wrong

4

Which client statement indicates that the client has coped effectively with a relationship problem? 1. "My wife will be happy to know that I can spend less time at work now." 2. "My wife and I are talking about our likes and dislikes in activities." 3. "I can understand how my wife and I see things differently." 4. "We're really listening to each other about our different views on issues."

4

Which client would benefit from the application of warm, moist heat? 1.a client with appendicitis 2.a client with a recently sprained joint 3.a client with a suspected malignancy 4.a client with low back pain

4

Which instructions should the nurse include in the teaching plan for a 30-year-old multiparous client who will be using an intrauterine device (IUD) for family planning? 1. Amenorrhea is a common adverse effect of IUDs. 2. Additional conception protection will be needed. 3. IUDs are more costly than other forms of contraception. 4. Severe cramping may occur when the IUD is inserted.

4

The nurse is planning care for a client who is at low risk for falling. What information would be included in the care plan? Select all that apply. 1.Place call bell within easy reach. 2.Secure locks on beds, stretchers, and wheelchairs. 3.Remain with client during toileting. 4.Keep the bed in the lowest position when possible. 5.Place a commode next to bed for easy access. 6.Employ a seat belt whenever a wheelchair is in use.

1, 2, 4

The nursing team on an oncology unit consists of a registered nurse, a licensed practical/vocational nurse, and one unlicensed assistive personnel. Which client should be assigned to the registered nurse? 1. a 52-year-old client with lung cancer admitted for acute dyspnea 2. a 45-year-old client receiving tube feedings 3. a 28-year-old client being evaluated for a bone marrow transplant 4. a 65-year-old client diagnosed with endometrial cancer who underwent an abdominal hysterectomy 3 days ago

1

While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. What should the charge nurse do? 1.Report this to the nursing supervisor immediately. 2.Report this to the head nurse upon arrival in the morning. 3.Ask the nurse if they have been drinking. 4.Assess the nurse's behavior for signs of intoxication.

1

An older adult client with a diagnosis of chronic renal failure is being discharged to home with the client's partner. The home health nurse visits the hospital before discharge to discuss home safety with the client, who reports decreased mobility and a need for greater assistance with activities of daily living. The nurse focuses her home safety teaching on which factors? 1.having adequate lighting, removing cluttered paths and using nonskid bathroom surfaces 2.avoiding unsteady ladders, overloaded electrical outlets and pesticides 3.properly storing plastic bags and guns and replacing steps without handrails 4.replacing defective smoke detectors, storing flammable liquids properly and repairing steps with broken concrete

1

Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 0200, 0530, 0800, 1100, 1400, 1630, 2000 and 2230. What is the total amount of calories the infant received today? 1.240 2.280 3.360 4.540

1

The nurse is serving on the hospital ethics committee that is considering a proposal for the nursing staff to search the room of a client diagnosed with substance abuse disorder while the client is off the unit and without the client's knowledge. What should be considered concerning the relationship between ethical and legal standards of behavior? 1.Ethical standards are generally higher than those required by law. 2.Ethical standards are equal to those required by law. 3.Ethical standards bear no relationship to legal standards for behavior. 4.Ethical standards are irrelevant when the health of a client is at risk.

1

A registered nurse instructs the unlicensed assistive personnel (UAP) to check the urine intake and output (I&O) on clients of the oncology unit at the end of the 8-hour shift. It is important for the nurse to instruct the UAP to do what? 1.Ask the clients if they are thirsty when calculating the I&O. 2.Report back to the nurse immediately if any client has an output less than 240 mL. 3.Document the I&O results on the medical records. 4.Write the I&O results down for the nurse to give report to the next shift.

2

A client with a history of cocaine abuse is receiving intravenous therapy and exits the hospital "to visit a friend." The client returns to the nursing unit one hour later, agitated, aggressive, combative and reporting "chest pain." Place the nurse's actions in priority order from first to last. All options must be used. 1.Obtain a urine sample. 2.Initiate a referral to obtain drug rehabilitation counseling. 3.Obtain an ECG. 4.Contact the security department.

4, 3, 1, 2

The home health nurse is caring for a client receiving chemotherapy. The client reports anorexia and has a weight loss of 15 pounds (6.8 kilograms) over 6 weeks. Which client teaching would be helpful? Select all that apply. 1. Eat large meals when hungry. 2. Obtain calorie dense foods for snacks. 3. Cook a hot meal for lunch and dinner. 4. Have family prepare and deliver favorite meals. 5. Eat small portions of each food group. 6. Eat slowly and in a relaxed atmosphere.

2, 4, 5, 6

Which risk factor would most likely contribute to the development of a client's hiatal hernia? 1.having a sedentary desk job 2.being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg) 3.using laxatives frequently 4.being 40 years old

2

The parents of a 9-month-old bring the infant to the clinic for a regular checkup. The infant has received no immunizations. Which vaccine, if prescribed, would the nurse question? 1.diphtheria, tetanus and acellular pertussis (DTaP) 2.haemophilus influenzae type B (Hib) 3.measles, mumps and rubella (MMR) 4.inactivated influenza (Flu)

3

The nurse is instructing the unlicensed assistive personnel (UAP) how to care for a client who is receiving chemotherapy. What selfcare precautions should the nurse tell the UAP to take when caring for the client? 1. Call the hazardous waste management team for safe disposal. 2. Universal precautions are sufficient. 3. Gowns, mask, and gloves are required for any contact with the client. 4. Wear protective gloves when handling client's fluids.

4

Because both parents are nearsighted, the mother is concerned that her 4-year-old child may be nearsighted. She says that he likes to look at books and knows some of the alphabet. Which assessment techniques should the nurse use to test the child's visual acuity? 1.cover and crossover test 2.Allen picture cards 3.Snellen alphabet chart 4.Ishihara test

2

The healthcare provider prescribes intermittent fetal heart rate monitoring for a 20-year-old primigravid client at 40 weeks' gestation in the first stage of labor. The nurse should monitor the client's fetal heart rate pattern at which interval? 1.every 15 minutes during the latent phase 2.every 30 minutes during the active phase 3.every 60 minutes during the pushing phase 4.every 2 hours during the transition phase

2

A 15-year-old client needs life-saving emergency surgery, but the relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response? 1.Send the client to surgery without the consent. 2.Call the family for a consent over the telephone, and have another nurse listen as a witness. 3.No action is necessary in this case because consent is not needed. 4.Have the family sign the consent form as soon as they arrive.

2

A client diagnosed with obsessive-compulsive disorder has been taking sertraline but would like to have more energy every day. At the monthly checkup, the client asks about using St. John's wort to help relieve symptoms of depression. 1."St. John's wort is a harmless herb that might be helpful in this instance." 2."Combining St. John's wort with the sertraline can cause a serious reaction called serotonin syndrome." 3."If you take St. John's wort, we will have to decrease the dose of your sertraline. " 4."St. John's wort is not very effective for depression, but we can increase your sertraline dose."

2

A client has anemia resulting from bleeding from ulcerative colitis and is to receive two units of packed red blood cells (PRBCs). The client is receiving an infusion of total parenteral nutrition (TPN). In preparing to administer the PRBCs, what should the nurse do to ensure client comfort and safety? 1.Discontinue the TPN infusion. 2.Start an IV infusion of normal saline. 3.Administer PRBCs in the same IV as the TPN. 4.Use the same IV line to infuse the PRBCs after the TPN is done.

2

A client has on a patient-controlled analgesia (PCA) infusion to manage postoperative pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 on a 0 to 10 pain scale. What should the nurse do first? 1.Check the PCA pump function. 2.Inspect the infusion site. 3.Assess vital signs. 4.Notify the healthcare provider.

2

The nurse assesses the results of a gentamicin trough blood level for an adolescent with cystic fibrosis who has had been treated with gentamicin several times over the last year. The drug level is high. What is the nurse's primary concern? 1.The child may develop liver dysfunction. 2.The child may suffer hearing loss. 3.The medication may have been administered incorrectly. 4.The child may need to have a different antibiotic.

2

The nurse has received a change of shift report on clients. Which client should the nurse assess first? 1. a client with COPD with a PaO2 of 56 mm Hg who is being discharged home on oxygen 2. a client with asthma with respirations of 36 breaths/min whose wheezing has diminished 3. a client with asthma who has a heart rate of 90 bpm and whose beta blocker is scheduled to be administered now 4. a client who is scheduled for an angiogram now and is ready to be transported

2

At 0500, the nurse on the antepartum unit reviews all remaining tasks to complete before giving the change of shift handoff at 0700. In what order from first to last should the nurse complete the tasks? All options must be used. 1. Draw magnesium sulfate at 0600. 2. Monitor fetal monitor strip for one-half hour every shift. 3. Administer point-of-care blood glucose and sliding scale insulin due at 0700, 1100, 1600, and bedtime. 4. Check documentation, and perform a final check of each client.

2, 1, 4, 3

Crisis intervention plays a major role in the management of care for clients with chronic mental illnesses. Although the safety of the client and others is always a priority, these clients typically need crisis intervention in which situations? Select all that apply. 1. inability to keep outpatient appointments 2. signs of relapse and decompensation 3. threat of eviction from housing 4. unpaid bills and lack of food 5. occasionally missing a dose of medication

2, 3, 4

Several clients come to the emergency department with suspected contamination by the Ebola virus. What should the nurse do? Select all that apply. 1.Call in extra staff to assist with the possibility of more clients with the same condition. 2.Isolate all the suspected clients in the emergency department in one area. 3.Call housekeeping for diluted household bleach. 4.Restrict visitors from the emergency department. 5.Quarantine all contacts.

2, 3, 4

The nurse in the intensive care unit gives a report to the nurse in the postsurgical unit about a client who had a gastrectomy. Which method does the first nurse select to best assure essential information about the client is reported? 1.Give the report face-to-face with both nurses in a quiet room. 2.Audiotape the report for future reference and documentation. 3.Use a printed checklist with information individualized for the client. 4.Document essential transfer information in the client's electronic health record.

3

A client with a history of myocardial infarction 3 years ago was admitted at 0700 for a cholecystectomy scheduled at 0900. The client has been NPO since midnight. At 0830 the client reports having has chest pains. At 0700 the client's vital signs were pulse, 80 bpm; respirations, 14 breaths/min; blood pressure, 110/70 mm Hg. At 0830 the nurse takes the vital signs again: pulse is 110 bpm; respirations, 20 breaths/min; blood pressure, 90/60 mm Hg. The nurse calls the surgeon and, using SBAR communication protocol, should discuss which information with the surgeon? Select all that apply. 1. that the client has remained NPO 2. history of myocardial infarction and current report of chest pains 3. the change in vital signs 4. the type of surgery scheduled 5. request for ECG 6. request to administer nitroglycerine tablet

2, 3, 5, 6

A 17-year-old high school senior calls the clinic because she thinks she might have gonorrhea. She wants to be seen but wants assurances that no one will know. Which is the most appropriate response by the nurse? 1."Because you are underage, we will need your parent's consent to treat you." 2."We can treat you without your parents' consent, but they have the right to review your medical record." 3."We can see you without your parents' consent but have to report any positive results to the public health department." 4."We can see you, treat any infections, and will not share your results with anyone."

3

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? 1. every 5 minutes 2. every 10 minutes 3. every 15 minutes 4. every 20 minutes

3

A client is brought to the hospital's emergency department by a friend, who states, "I guess he had some bad heroin today." The nurse should assess the client further for which signs and symptoms? 1.increased heart rate, dilated pupils and fever 2.tremulousness, impaired coordination, increased blood pressure and ruddy complexion 3.decreased respirations, constricted pupils and pallor 4.eye irritation, tinnitus and irritation of nasal and oral mucosa

3

As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which action should the nurse take first? 1. Insert an airway to improve oxygenation. 2. Note the time when the seizure begins and ends. 3. Call for immediate assistance. 4. Turn the client to her left side.

3

The nurse is assisting another member of the healthcare team who is placing a peripherally inserted central catheter in a 10-year-old with peritonitis from a ruptured appendix. The family is present in the treatment room to support the child. The nurse observes that the other team member has contaminated a sterile glove. What should the nurse do next? 1. Discuss the incident with the team member after the event. 2. Report the incident to the nursing unit manager. 3. Tell the team member the glove is contaminated. 4. Ask the family to leave before confronting the team member.

3

The nurse is developing a primary disease prevention program for older adults. Which topic is the most appropriate? 1.blood glucose screening for diabetes 2.diet and exercise for people with heart disease 3.immunizations for influenza 4.range-of-motion exercises

3

Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which client? 1.an 84-year-old client with diabetes admitted with new-onset confusion who reportedly fell at home last week, is currently on bedrest, and has normal saline infusing per saline lock 2.a 48-year-old alert and oriented client with quadriplegia admitted for wound care of a stage IV pressure ulcer, receiving IV antibiotics per a peripherally inserted central catheter 3.a 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during hospitalization has gotten out of bed without calling for assistance 4.a 27-year-old client with acute pancreatitis receiving morphine sulfate IV every 2 hours as needed for pain; no significant medical history; smokes two packs of cigarettes per day; may be up independently; and has steady gait

3

The nurse is preparing to suction a tracheostomy for a client with methicillin-resistant Staphylococcus aureus (MRSA) (see figure). What should the nurse do next? 1. Wear a powered air purifying respirator (PAPR) face shield. 2. Use goggles that include the hairline. 3. Change to a surgical mask. 4. Proceed to suction the client's tracheostomy.

4

A client with a hemorrhagic stroke is slightly agitated, heart rate is 118 bpm, respirations are 22 breaths/min, bilateral rhonchi are auscultated, SpO2is 94%, blood pressure is 144/88 mm Hg, and oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased intracranial pressure and maintain adequate cerebral perfusion? All options must be used. 1.Suction the mouth. 2.Hyperoxygenate. 3.Provide sedation. 4.Suction the airway.

3, 2, 4, 1

The nurse reads the new medication prescriptions for a 4-year-old child with nephrotic syndrome on the chart as shown. What should the nurse do? Prescriptions: D/C prednisone 40 mg PO daily Prednisone 30 mg PO QOD 1.Discontinue the prednisolone 40 mg and give the 30-mg dose today. 2.Check the medication record first to see when the last dose of prednisolone was given. 3.Start the 30-mg dose tomorrow. 4.Contact the prescriber for clarification.

4

A client is receiving total parenteral nutrition (TPN) solution. The nurse should assess a client's ability to metabolize the TPN solution adequately by monitoring the client for which sign? 1.tachycardia 2.hypertension 3.elevated blood urea nitrogen concentration 4.hyperglycemia

4

A client is to receive peritoneal dialysis. What should the nurse do to prepare for the procedure? 1.Assess the dialysis access for a bruit and thrill. 2.Insert an indwelling urinary catheter, and drain all urine from the bladder. 3.Ask the client to turn toward the left side. 4.Warm the dialysis solution in the warmer.

4

A community health nurse working with a group of 5th grade girls is planning a primary prevention to help the girls avoid developing eating disorders during their teen years. The nurse should focus on which factor? 1.working with the school nurse to closely monitor the girls' weight during middle school 2.limiting the girls' access to media images of very thin models and celebrities 3.telling the girls' parents to monitor their daughters' weight and media access 4.helping the girls accept and appreciate their bodies and feel good about themselves

4

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. The client is incontinent and has a tarry stool. Their blood pressure is 90/50 mm Hg, and hemoglobin is 10 g. Which nursing intervention is a priority for this client? 1. checking stools for occult blood 2. performing range-of-motion (ROM) exercises on the left side 3. keeping skin clean and dry 4. elevating the head of the bed to 30 degrees

4

During a preparation for parenting class, one of the participants asks the nurse, "How will I know if I'm really in labor? " What should the nurse tell the participant about true labor contractions? 1. "Walking around helps to decrease true contractions." 2. "True labor contractions may disappear with rest or sleep." 3. "The duration and frequency of true labor contractions remain the same." 4. "True labor contractions are felt first in the lower back, then the abdomen."

4

The client with dual diagnoses of major depression and alcohol abuse states, "I only drink when I can't sleep." Which outcome is important for the client to achieve first? 1.Describe adaptive methods of coping to induce sleep. 2.Verbalize negative effects of alcohol on the body. 3.Describe dangerous effects when combining alcohol and antidepressant medication. 4.Verbalize the desire to stop drinking alcohol.

4

The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse? 1."This type of stool indicates the infant may have diarrhea and should be seen in the office today." 2."The stool will transition into a soft, brown, formed stool within a few days and is appropriate for breastfeeding." 3."The stool results from the gassy food eaten by the mother. Refrain from eating these foods while breastfeeding." 4."Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding."

4

What should the nurse teach the client to do to reduce the risk of dumping syndrome? 1.Sit upright for 30 minutes after meals. 2.Drink liquids with meals, avoiding caffeine. 3.Avoid milk and other dairy products. 4.Decrease the carbohydrate content of meals.

4

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first? 1.Administer the prescribed preanesthetic medication. 2.Note this new allergy prominently on the medical record. 3.Contact the scrub nurse in the operating room. 4.Inform the anesthesiologist.

4

When preparing a 20-month-old for removal of a foreign body in the nasal passage by the healthcare provider, the nurse should use which method of restraint? 1. jacket restraint 2. elbow restraint 3. use of father to hold 4. papoose board

4

The nurse notices a fire in a wastebasket in a client's room. In which order of priority from first to last should the nurse perform the actions? All options must be used. 1.Extinguish the fire. 2.Confine the fire by closing the door to the client's room. 3.Pull the fire alarm at the alarm pull station. 4.Remove the client from the room.

4, 3, 2, 1

The nurse is taking care of a client with Clostridium difficile. To prevent the spread of infection, what should the nurse do? Select all that apply. 1. Wear a particulate respirator. 2. Wear sterile gloves when providing care. 3. Cleanse hands with alcohol-based hand sanitizer. 4. Wash hands with soap and water. 5. Wear a protective gown when in the client's room.

4, 5

There has been an increase in medication errors and errors in prescribing laboratory studies in the emergency department. The nurse manager is conducting a staff education session on when to use "read-back" procedures. "Read-back" procedures should be performed in which situations? Select all that apply. 1.when a medication prescription or critical laboratory result is received verbally or over the telephone 2.when any verbal or phone prescription is received 3.whenever a written prescription or printed critical test result is received 4.when the unit secretary takes a phone prescription 5.when the agency uses computerized health care records

1, 2

A female client who has diagnosis of borderline personality disorder is manipulative and very disruptive on the hospital unit. She is not dangerous to herself or others, but she is clearly not making any therapeutic progress. She consistently refuses any medications. The nurse realizes that legally this client has which option? 1.Refuse treatment. 2.Receive forced treatment if the nursing team concurs. 3.Be medicated if her family signs permission for treatment. 4.Be guided to accept treatment recommendations by threatening loss of privileges.

1

The nurse observes a consent form signed by a client indicating permission for the insertion of a feeding tube before the beginning of chemotherapy. One hour before the procedure, the client states, "I've changed my mind, and now I don't want the feeding tube." What would be the most appropriate response by the nurse? 1."You have a right to withdraw consent, so let's discuss your decision." 2."You must have the feeding tube inserted before the chemotherapy." 3."After you've given consent in writing, you can't change your mind." 4."Changing your mind now would be really inconvenient for the surgeon."

1

The nurse is assessing a client who is 2 years of age and in the emergency department for burns on both feet, both lower legs, and the buttocks. The only area not burned from the waist down is the inside of the back of the knee. The parents inform the nurse that the child stepped into the bathtub and then sat down in the water when the water was too hot. What should the nurse do in order of priority from first to last? All options must be used. 1.Assess burn depth in the different areas. 2.Provide fluid resuscitation and pain medications. 3.Document parent-child interactions. 4.Report the incident to the authorities.

1, 2, 3, 4

Which questions should the nurse include in a cultural assessment? Select all that apply. 1. "What do you think is causing your illness?" 2. "To what religion do you belong?" 3. "What do you do to promote good health?" 4. "Do you have a particular name for this illness?" 5. "What do you think about religions other than yours?"

1, 2, 3, 4

The nurse has been assigned to a client who is hearing impaired and reads speech. Which strategies should the nurse incorporate when communicating with the client? Select all that apply. 1.Avoid being silhouetted against strong light. 2.Do not block out the person's view of the speaker's mouth. 3.Face the client when talking. 4.Have bright light behind so the individual can see. 5.Ensure the client is familiar with the subject material before discussing. 6.Talk to the client while performing other nursing procedures.

1, 2, 3, 5

The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below the prescribed rate. In addition to adjusting the infusion rate and notifying the healthcare provider, what is the most important action by the nurse? 1.Complete an incident report. 2.Discuss the matter with the night nurse the next time the nurseworks. 3.Ask the charge nurse if an incident report is necessary. 4.Evaluate the client's blood pressure for 4 hours before making a decision.

1

The nurse is teaching two unlicensed assistive personnel (UAP) who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when one of the UAPs makes which statement? 1."I need to check the client precisely at 15-minute intervals." 2."Documenting suicide checks is absolutely necessary." 3."Clients on one-to-one suicide precautions can never be left alone." 4."All clients using razors must be supervised by staff."

1

The experienced licensed practical/vocational nurse (LPN/VN) under the supervision of the registered nurse (RN) team leader is providing nursing care for an infant with respiratory syncytial virus. Which tasks are appropriate for the RN to delegate to the LPN/VN? Select all that apply. 1.Auscultate breath sounds. 2.Administer prescribed aerosolized medications. 3.Initiate the nursing care plan. 4.Check oxygen saturation using pulse oximetry. 5.Complete an in-depth admission assessment. 6.Evaluate the parent's ability to administer aerosolized medications.

1, 2, 4

The nurse is conducting a counseling session with a client experiencing posttraumatic stress disorder (PSTD) using a 2-way video telehealth system from the hospital to the client's home, which is 2 hours away from the nearest mental health facility. What are expected outcomes of using telehealth as a medium to provide health care to this client? Select all that apply. The client will: 1.save travel time from the house to the health care facility. 2.avoid reliving a traumatic event which might be precipitated by visiting a health care facility. 3.experience a shorter recovery time than by being treated on-site at a health care facility. 4.receive health care for this mental health problem. 5.obtain group support from others with a similar health problem.

1, 2, 4

A nurse administers cefazolin instead of ceftriaxone to an 8-year-old with pneumonia. The client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears disciplinary action from reporting the error. What should the charge nurse tell the nurse? 1."If you don't report the error, I'll have to." 2."Reporting the error helps to identify system problems to improve client safety." 3."Notify the client's healthcare provider to see if she wants this reported." 4."This is not a serious mistake, so reporting it will not affect your position."

2

After completing diagnostic testing, the surgeon has scheduled a newborn with the diagnosis of an imperforate anus for surgery the next day. The infant's parents do not want the surgery to take place unless the infant has first been baptized. What should the nurse ask the parents? 1."Are you worried your baby might die?" 2."How can I help arrange the baptism?" 3."Do you want to speak with the social worker?" 4."Would you prefer to wait for the surgery?"

2

A mother reports she cannot afford the antibiotic azithromycin, which was prescribed by the health care provider (HCP) for her toddler's otitis media. What is the nurse's best response? 1.Instruct the mother on the importance of the medication. 2.Ask the mother if she has considered using any medical assistance programs in her community. 3.Confer with the HCP about whether a less expensive drug could be prescribed. 4.Consult with the social worker.

3

Even when the client understands problems and is motivated to change, the client may have fears about failing. Which intervention is most likely to facilitate change? 1.reality testing about the need for change 2.asking the client about fears that need to be overcome 3.teaching new communication skills 4.having the client practice new behaviors

4

The healthcare provider (HCP) prescribes carbamazepine extended release for a client with cerebral palsy who also has a seizure disorder. The client has a gastrostomy feeding tube, and carbamazepine is on the hospital's "no crush" list. What should the nurse do to administer the medication? 1.Cut the medication into four pieces that can be placed in the feeding tube. 2.Dissolve the medication in 30 mL of juice. 3.Ask the pharmacist for an oral suspension. 4.Contact the HCP to change the prescription.

4

A client diagnosed with posttraumatic stress disorder is readmitted for suicidal thoughts and continued trouble sleeping. She states that when she closes her eyes, she has vivid memories about being awakened at night. "My dad would be on top of me trying to have sex with me. I couldn't breathe." Which suggestions would be appropriate for the nurse to make for the insomnia? Select all that apply. 1.trying relaxation techniques to help decrease her anxiety before bedtime 2.staying in the dayroom and trying to sleep in the recliner chair near staff 3.listening to calming music as she tries to fall asleep 4.processing the content of her flashbacks no less than an hour before bedtime 5.leaving her door slightly open to decrease noise during the nightly checks

1, 3, 5

An older adult is taking seven prescribed drugs with varied dosing schedules. What should the nurse instruct the client to do to improve compliance and safe administration of the drugs? 1.Use over-the-counter medications. 2.Take all the medications at the same time. 3.Use a pill tray and place the medications in the compartment at the correct time and day. 4.Count the remaining pills in each bottle at the end of the day.

3

The nurse is planning an eating disorder protocol for hospitalized clients experiencing bulimia and anorexia. Which elements should be included in the protocol? Select all that apply. 1.Clients must eat within view of a staff member. 2.Clients are not told their weight and cannot see their weight while being weighed. 3.Clients are not allowed to discuss food or eating in groups or informal conversation with peers. 4.Clients may not go to the bathroom for one-half hour to an hour after eating. 5.Clients cannot participate in any groups after admission until they gain 1 lb(0.5 kg).

1, 2, 4

A toddler is scheduled to have tympanostomy tubes inserted. What should the nurse do when approaching the toddler for the first time? 1.Talk to the mother first so the toddler can get used to the new person. 2.Hold the toddler so the toddler becomes more comfortable. 3.Walk over and pick the toddler up right away so the mother can relax. 4.Pick up the toddler and take the child to the play area so the mother can rest.

1

After the nurse administers a prescribed medication to a client who becomes restless at night and has difficulty falling asleep, which nursing action is most appropriate? 1.sitting quietly with the client at the bedside until the medication takes effect 2.engaging the client in interaction until the client falls asleep 3.reading to the client with the lights turned down low 4.encouraging the client to watch television until the client feels sleepy

1

The nurse is working with a client who is distraught after being diagnosed with late-stage pancreatic cancer. In addition to practicing active listening, what nursing action is most appropriate? 1. Offer to facilitate a referral to spiritual care. 2. Assure the client that survival rates for pancreatic cancer are now measured in decades. 3. Teach the client progressive relaxation techniques and guided imagery. 4. Ask the provider to temporarily prescribe lorazepam as needed.

1

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? 1.Sit quietly with the client until the episode is over. 2.Ignore the behavior. 3.Attempt to divert the client's attention. 4.Tell the client that this behavior is unacceptable.

1

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which position is appropriate? SATA 1.placing a pillow in the axilla so the arm is away from the body 2.inserting a pillow under the slightly flexed arm so the hand is higher than the elbow 3.immobilizing the extremity in a sling 4.positioning a hand cone in the hand so the fingers are barely flexed 5.keeping the arm at the side using a pillow

1, 2, 4

The nurse has completed discharge teaching with new parents who will be bottle-feeding their normal term newborn. Which statement by the parents reflects the need for more teaching? 1."Our baby will require feedings through the night for several weeks or months after birth." 2."The baby should burp during and after each feeding with no projective vomiting." 3."Our baby should have one to three soft, formed stools a day." 4."We should weigh our baby daily to make sure he's gaining weight."

4

Which development is necessary for toilet training readiness for a 2-year-old? Select all that apply. 1.adequate neuromuscular development for sphincter control 2.appropriate chronological age 3.ability to communicate the need to use the toilet 4.desire to please the parents 5.ability to play with other 2-year-olds

1, 3, 4

A client on haloperidol has stiff muscles, restlessness and internal jumpiness. The client has all of the following medications prescribed as needed. Which medication would be most appropriate for the nurse to administer to decrease the client's symptoms? 1.lorazepam 2.benztropine 3.trazodone 4.olanzapine

2

The nurse observes a constant gentle bubbling in the water-seal column of a water-seal chest drainage system. What action should the nurse take? 1.Continue monitoring as usual; this is expected. 2.Check the connectors between the chest and drainage tubes and where the drainage tube enters the chest drainage system. 3.Decrease the suction, and continue observing the system for changes in bubbling during the next several hours. 4.Notify the healthcare provider.

2

A client who has been taking warfarin has been admitted with severe acute rectal bleeding and the following laboratory results: international normalized ratio, 8; hemoglobin, 11 g/dL (110 g/L); and hematocrit, 33% (0.33). After starting an IV infusion, in which order should the nurse implement the prescriptions? All options must be used. 1.Administer vitamin K 2.5 mg by mouth. 2.Administer IV normal saline. 3.Give 1 unit fresh frozen plasma. 4.Schedule the client for sigmoidoscopy.

2, 3, 1, 4

Captopril, furosemide and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 mm Hg, and the heart rate is 65 bpm. Prior to medication administration at 0900, the nurse reviews the lab tests (see exhibit). What should the nurse do next? 1.Administer the medications. 2.Request the furosemide dose be increased. 3.Withhold the captopril. 4.Question the metoprolol dose.

3

During assessment of a small infant admitted with a diagnosis of meningitis, the infant becomes less responsive to stimuli and exhibits bradycardia, slight hypertension, irregular respirations and a temperature of 103.2°F (39.6°C). The infant's fontanel is more tense than at the last assessment. What should the nurse do first? 1.Ask another nurse to verify the findings. 2.Notify the primary care provider of the findings. 3.Raise the head of the bed. 4.Administer an antipyretic.

3

During the evening shift on the day of a client's bowel resection surgery, the nasogastric tube drains 500 mL of green-brown fluid. What action should the nurse take? 1.Call the healthcare provider. 2.Increase the IV infusion rate. 3.Record the amount of drainage on the client's chart. 4.Irrigate the tube with normal saline solution.

3

On the day of surgery, a client with diabetes who takes insulin on a sliding scale is to have nothing by mouth and all medications withheld. The client's 0600 glucose level is 300 mg/dL (16.7 mmol/L). What should the nurse do? 1.Withhold all medications. 2.Administer the insulin dose dictated by the sliding scale. 3.Call the healthcare provider for specific prescriptions based on the glucose level. 4.Notify the surgery department.

3