NCLEX PN-Comprehensive Study

The nurse is providing dietary instructions to a client with gout. The nurse would tell the client to avoid which food item? 1.Scallops 2.Chocolate 3.Cornbread 4.Macaroni products

1. Scallops

In the well-child clinic, the nurse observes an infant, age 10 months, playing with toys, bringing them to his mouth, and passing the toys from one hand to the next. The nurse determines the child is in which Jean Piaget's first developmental stage? 1. Sensorimotor 2. Preoperational 3. Formal operational 4. Concrete operational

1. Sensorimotor

Which would be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? 1. The return of distal pulses 2. Decreasing edema formation 3. Brisk bleeding from the injury site 4. The formation of granulation tissue

1. The return of distal pulses

The nurse is caring for a client with a diagnosis of chronic kidney disease who is receiving dialysis. Epoetin alfa has been prescribed for the client. How would the nurse prepare to administer the medication? 1. The subcutaneous route 2. Shaking the vial before drawing up the medication 3. Obtaining the medication from the medication freezer 4. Mixing the medication with 0.1 mL of heparin before administration to prevent clotting

1. The subcutaneous route.

The nurse has gathered data regarding an older client. The nurse recognizes that which indicator of fluid imbalance is least likely to be reliable for a client in this age group? 1. Thirst 2. Skin turgor 3. Intake-output differences 4. Appearance of oral mucosa

1. Thirst

The nurse is caring for a client who has just died. Which end-of-life information needs to be documented in the client's medical record? Select all that apply. 1. Time and date of death 2. Time of body transfer and destination 3. Family members present at the time of death 4. Medical tubes, devices, or lines left in the body 5. Name of primary health care provider certifying death

1. Time and date of death 2. Time of body transfer and destination 4. Medical tubes, devices, or lines left in the body 5. Name of primary health care provider certifying death

The medication is an intramuscular dose of 400,000 units of penicillin G benzathine. The medication label reads penicillin G benzathine 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank and record the answer using one decimal place.

1.3 mL

The medication prescribed is methylprednisolone acetate 60 mg intramuscularly. The medication label states methylprednisolone acetate 40 mg/1 mL. How many milliliters will the nurse prepare to administer to the client? Fill in the blank.

1.5 mL

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to consult with the registered nurse if the client is also taking which medications? Select all that apply. 1.Warfarin 2.Glimepiride 3.Amlodipine 4.Simvastatin 5.Hydrochlorothiazide

1.Warfarin 2.Glimepiride 3.Amlodipine

A primary health care provider (PHCP) prescribes potassium chloride (KCl) elixir, 20 mEq orally daily. The medication label states potassium chloride (KCl), 30 mEq/15 mL. How many milliliters should the nurse prepare to administer the dose? Fill in the blank.

10 mL

The primary health care provider (PHCP) has prescribed an antibiotic for a child. The average adult dose is 500 mg. The child has a body surface area (BSA) of 0.63 m2. What is the dose for the child? Fill in the blank.

182 mg

The medication prescription reads phenytoin 0.2 g orally, twice daily. The medication label states 100-mg capsules. The nurse prepares how many capsule(s) to administer one dose? Fill in the blank.

2 capsules

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value? 1. 3 mg/dL (1.05 mmol/L) 2. 15 mg/dL (5.25 mmol/L) 3. 29 mg/dL (10.15 mmol/L) 4. 35 mg/dL (12.25 mmol/L)

2. 15 mg/dL (5.25 mmol/L)

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)? 1. A client who requires wound irrigation 2. A client who requires frequent ambulation 3. A client who is receiving continuous tube feedings 4. A client who requires frequent vital signs after a cardiac catheterization

2. A client who requires frequent ambulation

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse would tell the client that which food item is least likely to contain calcium? 1. Milk 2. Butter 3. Spinach 4. Collard greens

2. Butter

A client's spouse becomes distraught when thinking about his wife's terminal prognosis. Which action would the nurse implement to best assist the spouse? 1. Promote acceptance that their loss is real. 2. Encourage development of realistic goals. 3. Encourage establishing new relationships. 4. Promote the expression of positive outcomes.

2. Encourage development of realistic goals.

A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. The nurse is asked to assist in preparing a plan of care for this child. During this developmental time period, which factor would the nurse take into account? 1. Sibling rivalry will cause regression to occur. 2. Fears of separation and mutilation are present. 3. Embarrassment of voiding irregularities is common. 4. Concern over size and function of the penis is present.

2. Fears of separation and mutilation are present.

The nurse is preparing to perform an abdominal examination. Which step would be taken first? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

2. Inspection

The nurse is reinforcing instructions to a client regarding the administration of lypressin. The nurse instructs the client that the medication will be taken by which routes? 1. Oral 2. Intranasal 3. Subcutaneous 4. Intramuscular

2. Intranasal

The nurse is caring for a client with terminal cancer who is close to death. In reviewing the plan of care, the nurse determines that which action is a priority? 1. Keep the client well sedated so the client is totally unaware of what is actually happening. 2. Maintain the client's dignity and self-esteem, and make the client as comfortable as possible. 3. Make sure that the family has privacy and is kept informed of what is happening at all times. 4. Carry out the primary health care provider's prescriptions so that all prescribed treatments are carried out on time.

2. Maintain the client's dignity and self-esteem, and make the client as comfortable as possible

A 1-month old child is hospitalized following a motor vehicle accident in which the parents are seriously injured. The nurse would select which toys for this child? Select all that apply. 1. Large puzzle 2. Nursery mobile 3. Jack-in-the-box 4. Strings of big beads 5. A pastel-colored stuffed animal 6. A mobile that swings and plays music

2. Nursery mobile 6. A mobile that swings and plays music

The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client? 1. Sclera 2. Oral mucosa 3. Soles of the foot 4. Palms of the hand

2. Oral mucosa

The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who had an orchiopexy procedure done to treat cryptorchidism. The nurse would determine the parents understood the discharge instructions if they state which play activity is best for the child after this procedure? 1. Riding a tricycle 2. Playing with clay 3. Using a jumping seat 4. Sitting on a rocking horse

2. Playing with clay

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 1. Positive patch test 2. Positive culture results 3. Abnormal biopsy results 4. Wood's light examination indicative of infection

2. Positive culture results

A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the need for further teaching? 1. Taking a rectal temperature for a client who has undergone nasal surgery 2. Taking an oral temperature for a client with a cough and nasal congestion 3. Taking an axillary temperature on a client who has just consumed hot coffee 4. Taking a temporal temperature on the neck behind the ear on a client who is diaphoretic

2. Taking an oral temperature for a client with a cough and nasal congestion

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition? 1. Diarrhea 2. Traumatic burn 3. Cushing's syndrome 4. Overuse of laxatives

2. Traumatic burn

The intravenous prescription is 1000 mL of 0.9% NaCl (normal saline) to run over 12 hours. The drop factor is 15 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and record the answer to the nearest whole number.

21 gtts/min

The intravenous prescription is 3000 mL of 5% dextrose in water (D5W) to run over a 24-hour period. The drop factor is 10 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and record the answer to the nearest whole number.

21 gtts/min

A postoperative client has a prescription to receive an intravenous (IV) infusion of 1000 mL normal saline solution over a period of 10 hours. The drop (gtt) factor for the IV infusion set is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank.

25 gtts/min

During a well-child checkup for a 4-month-old, the nurse reinforces instructing the mother how to introduce solid foods into her child's diet. Which statement indicates the mother needs further teaching? 1. "I will begin offering solids between 4 and 6 months of age." 2. "I will introduce one new food over several days beginning with cereal." 3. "I will start giving home-prepared orange juice when my child is 3 months old." 4. "I will wait to introduce meat to the diet until after my child has eaten cereal, fruit, and vegetables."

3. "I will start giving home-prepared orange juice when my child is 3 months old."

The nurse determines an adolescent is showing progress toward completing Erikson's psychosocial developmental stages if the adolescent makes which statement? 1. "I can't decide whether or not college is what's best for me." 2. "When I look back on my life, I think I've done well, despite my problems." 3. "I've met people who like that kind of music and we're going to a concert next week." 4. "I believe I have finally met the person I truly would like to spend the rest of my life with."

3. "I've met people who like that kind of music and we're going to a concert next week."

The nurse is assisting with data collection for a parent and son during a well-child visit. The nurse determines the child is in the phallic stage of Sigmund Freud's theory of personality development if the parent makes which comment? 1. "My child is finally toilet trained." 2. "I've noticed my child is developing pubic hair." 3. "Yesterday my son asked me why he looked different from his sister." 4. "My son hangs around other boys, and they've started saying girls have cooties."

3. "Yesterday my son asked me why he looked different from his sister."

The nurse is caring for a 5-year-old child who has been placed in traction after a fracture of the femur. Which is the most appropriate activity for this child? 1. Blocks 2. A music video 3. A 10-piece puzzle 4. Large picture books

3. A 10-piece puzzle

The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would be the nurse obtain? 1. A straight catheter 2. A Coudé tip catheter 3. A triple-lumen catheter 4. A double-lumen catheter

3. A triple-lumen catheter

The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident? 1. Place the incident report in the client's chart. 2. Make a copy of the incident report for the PHCP. 3. Document a complete entry in the client's record concerning the incident. 4. Document in the client's record that an incident report has been completed.

3. Document a complete entry in the client's record concerning the incident.

A child remarks, "I share my toys and snacks with my friends so they will like me more." The nurse determines the child is in which stage of moral development? 1. Egocentric judgment 2. Law-and-order orientation 3. Good boy-nice girl orientation 4. Social contract and legalistic orientation

3. Good boy-nice girl orientation

The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? 1. Phlebitis 2. Infection 3. Infiltration 4. Thrombosis

3. Infiltration

An adult female client has a hemoglobin level of 10.8 g/dL (108 g/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history? 1. Dehydration 2. Heart failure 3. Iron deficiency anemia 4. Chronic obstructive pulmonary disease

3. Iron deficiency anemia

A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure? 1. Prone position 2. Lithotomy position 3. Left lateral Sims' position 4. Right lateral Sims' position

3. Left lateral Sims' position

The nurse in the delivery room is caring for a newborn delivered 10 minutes ago. The nurse assists in preparing which medications that will be prescribed to be given within the first hour of life? Select all that apply. 1. Naloxone 2. Surfactant 3. Phytonadione 4. Hepatitis A vaccine 5. Hepatitis B vaccine 6. Erythromycin eye drops

3. Phytonadione 6. Erythromycin eye drops

The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply. 1. Depression in an older person is rarely treatable. 2. Depression in an older person is considered a normal finding. 3. Suicide is a frequent cause of death among the older population. 4. Some indications of dementia may actually originate as depression. 5. Depression in an older person is likely to have physical manifestations.

3. Suicide is a frequent cause of death among the older population. 4. Some indications of dementia may actually originate as depression. 5. Depression in an older person is likely to have physical manifestations.

The parents of a 2-year-old arrive at the hospital to visit their child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2-year-old child indicates which characteristic about the child? 1. The child is withdrawn. 2. The child is upset with the parents. 3. The child is exhibiting a normal pattern. 4. The child has adjusted to the hospitalized setting.

3. The child is exhibiting a normal pattern.

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse would identify which as a priority concern? 1. The client's report of not eating or sleeping 2. The presence of bruises on the client's body 3. The client's report of self-destructive thoughts 4. The family member's disapproval of the treatment

3. The client's report of self-destructive thoughts

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a modified left lateral recumbent position. The nurse explains that this positioning is preferred because of which reason? 1. The nurse is right handed. 2. The rectal sphincter will relax. 3. The enema will flow into the bowel easily. 4. The client is more likely to retain the enema solution.

3. The enema will flow into the bowel easily.

The nurse is developing a nutritional plan for an assigned client. Which is the most critical piece of data to collect before formulating the plan? 1.A dietary diary 2.Food preferences 3.The presence of food allergies 4.Medical history of conditions related to nutritional deficits

3. The presence of food allergies.

The nurse is performing a safety assessment in the home of a mother with two children. The ages of the children are 1 and 3 years. Which observation noted during the assessment would present the greatest hazard to the children? 1. A small dog as a house pet 2. The water heater set above 120° F 3. Toys with small loose parts in the playroom 4. A gate placed at the stairs of the second floor

3. Toys with small loose parts in the playroom

The nurse is caring for a client at the end of life. Which skin changes would the nurse expect to note? Select all that apply. 1. Dry skin 2. Warm skin 3. Waxlike texture 4. Mottling of arms, legs, hands, and feet 5. Cyanosis of the nose, nail beds, and knees

3. Waxlike texture 4. Mottling of arms, legs, hands, and feet 5. Cyanosis of the nose, nail beds, and knees

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the client's white blood cell count was which value? 1. 2000 mm3 (2.0 × 109/L) 2. 5800 mm3 (5.8 × 109/L) 3. 8400 mm3 (6.4 × 109/L) 4. 11,500 mm3 (11.5 × 109/L)

1. 2000 mm3 (2.0 × 109/L)

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply. 1. A premature infant 2. A 101-year-old man 3. A client with heart failure 4. A client with diabetes mellitus 5. A client receiving renal dialysis 6. A 29-year-old client with pneumonia

1. A premature infant 2. A 101-year-old man 3. A client with heart failure 5. A client receiving renal dialysis

The nurse is assessing a 36-month-old male child during a wellness visit to the pediatrician. The child weighs 43 pounds and is 41 inches tall. After plotting the measurements on the standardized growth charts for a 36-month-old, which should the nurse do next? 1. Assess the parents' body shape and stature. 2. Document these as expected findings for a 3-year-old child. 3. Counsel the parent on appropriate physical activities and exercises. 4. Refer the child and the parents for nutritional counseling related to obesity.

1. Assess the parents' body shape and stature.

A primary health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication is going to be administered intrathecally. Which medication would the nurse expect to be prescribed and administered by this route? 1.Baclofen 2.Chlorzoxazone 3.Dantrolene sodium 4.Cyclobenzaprine hydrochloride

1. Baclofen

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet? 1. Baked turkey 2. Tomato soup 3. Boiled shrimp 4. Chicken gumbo

1. Baked Turkey

The nurse would implement which activity to promote reminiscence among older clients? 1. Having storytelling hours 2. Setting up pet therapy sessions 3. Displaying calendars and clocks 4. Encouraging client participation in a pottery class

1. Having storytelling hours

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and would be reported to the primary health care provider before the surgery? Select all that apply. 1. Is allergic to penicillin 2. Quit smoking 3 months earlier 3. History of tonsillectomy at the age of 7 years 4. Wonders if the surgery could cause incontinence 5. Takes daily multivitamin and calcium supplement. 6. History of deep venous thrombosis in right leg 10 years earlier

1. Is allergic to penicillin 2. Quit smoking 3 months earlier 4. Wonders if the surgery could cause incontinence 6. History of deep venous thrombosis in right leg 10 years earlier

The nurse is reinforcing instructions for a client on how to perform a testicular self-examination (TSE). Which instructions would the nurse include? Select all that apply. 1. Perform TSE after a shower or bath. 2. Perform TSE after emptying the bladder. 3. Perform TSE on the same day each month. 4. Observe for urethral discharge after performing TSE. 5. Perform TSE by rolling each testicle between the thumb and fingers.

1. Perform TSE after a shower or bath. 3. Perform TSE on the same day each month. 5. Perform TSE by rolling each testicle between the thumb and fingers.

The primary health care provider's prescription reads "phenytoin 0.2 g orally, twice daily." The medication label states 100-mg capsules. How many capsule(s) would the nurse plan to administer over a 24-hour period? Fill in the blank.

4 capsules

Sulfisoxazole 1 g orally four times daily is prescribed for an adolescent with a urinary tract infection. The medication label reads, "250-mg tablets." The nurse has determined that the prescribed dose is safe. How many tablets per dose would the nurse administer to the adolescent? Fill in the blank.

4 tablets

The nurse is assigned to care for four clients. When planning client rounds, which client would the nurse collect data from first? 1. A client scheduled for a chest x-ray 2. A client requiring daily dressing changes 3. A postoperative client preparing for discharge 4. A client receiving oxygen who is having difficulty breathing

4. A client receiving oxygen who is having difficulty breathing

The nurse reinforces teaching a client on how to administer enoxaparin subcutaneously. The nurse determines that the client understands the correct procedure if the client does which on a return demonstration? 1. Uses a 1-inch needle 2. Massages after injection 3. Aspirates before injection 4. Bunches the skin before injection

4. Bunches the skin before injection

To assess for the presence of the posterior tibialis pulse, the nurse would palpate which areas? 1. In the groove just below the inguinal ligament 2. Behind the knee and lateral to the medial tendon 3. Lateral to and parallel with the extensor tendon of the big toe 4. In the groove behind the medial malleolus and the Achilles tendon

4. In the groove behind the medial malleolus and the Achilles tendon

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. What would the nurse look for on the cardiac monitor as a result of this laboratory value? 1. ST elevation 2. Peaked P waves 3. Prominent U waves 4. Narrow, peaked T waves

4. Narrow, peaked T waves

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action? 1. Show acceptance of feelings. 2. Provide information needed for decision making. 3. Suggest a referral to a mental health professional. 4. Remain with the family member without discussing funeral arrangements.

4. Remain with the family member without discussing funeral arrangements.

The nurse has just been told by the primary health care provider that a prescription has been written to administer a heparin injection to a client every 12 hours. The nurse anticipates using which technique to administer the medication? 1.Z-track 2.Using a 20-gauge needle 3.Intramuscular using a 1-inch needle 4.Subcutaneous using the abdomen

4.Subcutaneous using the abdomen

The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath? 1. "Do you have any allergies?" 2. "Will you be able to wash your own hair?" 3. "Are there any areas you want us to spend more time bathing?" 4. "Do you have any preferences regarding how we help you bathe?"

1. "Do you have any allergies?"

The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response indicates an understanding of the anatomy of this structure? 1. "The uterus weighs about 2 ounces." 2. "The uterus weighs about 2.2 pounds." 3. "The uterus has a capacity of about 50 milliliters." 4. "The uterus is round in shape and weighs approximately 1000 grams."

1. "The uterus weighs about 2 ounces."

The medication prescribed is heparin 5000 units subcutaneously, every 12 hours. The medication vial reads heparin 10,000 units/mL. The nurse prepares how many milliliters to administer one dose? Fill in the blank.

0.5 mL

The medication prescribed is prochlorperazine 5 mg intramuscularly, every 4 hours as needed. The medication label states prochlorperazine 10 mg/mL. The nurse prepares how much medication to administer the dose? Fill in the blank.

0.5 mL

The medication prescribed is morphine sulfate 6 mg subcutaneously. The medication label states morphine sulfate 10 mg/1 mL. The nurse plans to prepare how much medication to administer the dose? Fill in the blank.

0.6 mL

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply. 1. Slight redness along the incision 2. The presence of purulent drainage 3. A temperature of 98.8° F (37.1° C) 4. The client states that he feels cold. 5. The client states that the incision itches. 6. Tender firmness palpable around the incision

2. The presence of purulent drainage 6. Tender firmness palpable around the incision

A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the primary health care provider for intervention? 1. 75 mg/dL (4.2 mmol/L) 2. 92 mg/dL (5.3 mmol/L) 3. 120 mg/dL (6.9 mmol/L) 4. 240 mg/dL (13.7 mmol/L)

240 mg/dL (13.7 mmol/L)

The primary health care provider prescribes 1000 mL of 0.45% NaCl to run over 8 hours. The drop (gtts) factor is 15. The nurse plans to adjust the flow rate to how many gtts/min? Fill in the blank. Round your answer to the nearest whole number.

31 gtts/min

The primary health care provider (PHCP) has prescribed phenobarbital sodium, 25 mg orally twice daily, for a child with febrile seizures. The medication label reads as follows: "Phenobarbital sodium, 20 mg/5 mL." The nurse has determined that the dose prescribed is a safe dose for the child. How many milliliters per dose would the nurse administer to the child? Fill in the blank.

6.25 mL

The prescription of the primary health care provider (PHCP) prescription reads acetaminophen 240 mg orally every 6 hours as needed for relief of pain, for a 5-year-old child. The medication label reads "acetaminophen 160 mg per 5 mL." How many mL per dose would the nurse administer to the child? Fill in the blank.

7.5 mL

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication would the nurse plan to assist in administering to the client? 1. Calcitonin 2. Calcium chloride 3. Calcium gluconate 4. Large doses of vitamin D

1. Calcitonin

A nurse caring for a 2-month-old febrile infant is asked to collect a urine specimen for a culture and sensitivity. The nurse collects the specimen by performing which action? 1. Catheterizing the infant using the smallest available straight catheter 2. Attaching a urinary collection device to the infant's perineum for collection 3. Place cotton balls in the diaper and then after the infant voids aspirating the urine with a syringe 4. Noting the time of the next expected voiding and preparing to collect the specimen into a cup when the infant voids

1. Catheterizing the infant using the smallest available straight catheter

A pediatric nurse is caring for a hospitalized toddler. The nurse determines that which play activity would be appropriate for the toddler? 1. Listening to music 2. Playing peek-a-boo 3. Hand sewing a picture 4. Playing with a push-pull toy

4. Playing with a push-pull toy

The nurse is preparing to administer 35 mg of a prescribed intramuscular (IM) dose of medication to a client. The medication label reads 50 mg/mL. How many milliliters would the nurse administer to the client? Fill in the blank.

0.7 mL

The medication prescribed is hydromorphone hydrochloride 3 mg intramuscularly, every 4 hours as needed. The medication label reads hydromorphone hydrochloride 4 mg/1 mL. The nurse would prepare to administer how many mL to the client? Fill in the blank.

0.75 mL

The medication prescribed is haloperidol, 4 mg intramuscularly, immediately. The medication label states 5 mg/1 mL. The nurse prepares how much medication to administer the dose? Fill in the blank and round the answer to one decimal place.

0.8 mL

The parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response? 1. "Adolescents love to sleep late in the morning." 2. "The child shouldn't be staying up so late at night." 3. "If the child eats properly, that shouldn't be happening." 4. "The child should have a blood test to check for anemia."

1. "Adolescents love to sleep late in the morning."

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response? 1. "I have a legal obligation to report this type of abuse." 2. "I promise I won't tell anyone, but let's see what we can do about this." 3. "Let's talk about ways that will prevent your daughter from hitting you." 4. "This should not be happening. If it happens again, you must call the emergency department."

1. "I have a legal obligation to report this type of abuse."

The nurse determines a 5-year-old child is in the expected Erikson's psychosocial stage if the child makes which comment? 1. "I like drawing my mommy pictures with my finger paints." 2. "My favorite thing to do is having recess at school with my friends." 3. "All my friends and I hang around the mall on Saturday mornings." 4. "No, mommy, I don't want to take a bath. I don't need to go potty."

1. "I like drawing my mommy pictures with my finger paints."

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, would be reported before administering the dose of furosemide? 1. 3.2 mEq/L (3.2 mmol/L) 2. 3.8 mEq/L (3.8 mmol/L) 3. 4.2 mEq/L (4.2 mmol/L) 4. 4.8 mEq/L (4.8 mmol/L)

1. 3.2 mEq/L (3.2 mmol/L)

The nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The primary health care provider has prescribed an amount of 100 mL/hr. The tube feeding setup is an open system, a bag that has formula added at intervals. How much formula would the nurse plan to add to fill the feeding bag? 1. 400 mL of formula 2. 600 mL of formula 3. 800 mL of formula 4.Enough formula to last for 8 hours

1. 400 mL of formula.

A 6-year-old is hospitalized with a fracture of the femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse most appropriately selects which play activity for the child? 1. A board game 2. A large puzzle 3. A finger-painting set 4. A coloring book with crayons

1. A board game

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client would the nurse assign to the assistive personnel (AP)? 1. A client who requires a 24-hour urine collection 2. A client who requires twice-daily dressing changes 3. A client with diabetes mellitus who requires daily insulin and the reinforcement of dietary measures 4. A client who has been placed on a bowel management program and requires rectal suppositories and a daily enema

1. A client who requires a 24-hour urine collection

The medication prescription states to administer acetaminophen 650 mg orally for a temperature of more than 38° C. The medication bottle states acetaminophen, 325 mg tablets. The nurse takes the client's temperature and notes that it is 101° F. The nurse plans to take which action? 1.Administer two tablets. 2.Administer three tablets. 3.Do not administer at this time. 4.Check the client's temperature in 30 minutes.

1. Administer two tablets.

The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction would the nurse reinforce to the parents? 1. Allow the infant to signal a need. 2. Anticipate all of the needs of the infant. 3. Attend to the crying infant immediately. 4. Avoid the infant during the first 10 minutes of crying.

1. Allow the infant to signal a need.

A mother of a 5-year-old child tells the nurse that the child scolds the floor or table if the child hurts herself on the object. The nurse identifies the child as displaying signs of which stage of Piaget's theory of cognitive development? 1. Animism 2. Egocentric speech 3. Object permanence 4. Global organization

1. Animism

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included? 1. As-needed medications given that shift 2. Normal vital signs that have been normal since admission 3. All of the tests and treatments the client has had since admission 4. Total number of scheduled medications that the client received on that shift

1. As-needed medications given that shift

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style? 1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire

1. Autocratic

The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions would the nurse take in the care of the drain? Select all that apply. 1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8 to 12 hours. 6. Secure the drain by curling or folding it and taping it firmly to the body.

1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8 to 12 hours.

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse would institute which interventions? Select all that apply. 1. Collect data to determine factors for fall risk. 2. Close the blinds and turn off the overhead light. 3. Instruct the client to ask for assistance when getting up to walk. 4. Teach the client to lift legs high while walking, as if walking over planks. 5. Ensure the client is upright when eating and swallows twice after each bite.

1. Collect data to determine factors for fall risk. 3. Instruct the client to ask for assistance when getting up to walk.

An older client is taking multiple medications for a variety of health problems. The nurse would monitor the results of which most important laboratory test(s) when evaluating adverse effects of medication therapy in the older adult? 1. Creatinine 2. Arterial blood gases 3. Complete blood cell count 4. Hemoglobin and hematocrit

1. Creatinine

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action? 1. Decline to sign the will. 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agency.

1. Decline to sign the will.

The nurse is auscultating bowel sounds. Which are appropriate data collection methods and actions? Select all that apply. 1. Divide the abdomen into four quadrants at the umbilicus. 2. Do not feed the client if no sounds are audible in 5 minutes. 3. Listen in each quadrant for gurgling sounds indicating movement. 4. If no sounds are audible in 2 minutes, notify the registered nurse. 5. If 20 sounds are noted within 1 minute, notify the registered nurse.

1. Divide the abdomen into four quadrants at the umbilicus. 2. Do not feed the client if no sounds are audible in 5 minutes. 3. Listen in each quadrant for gurgling sounds indicating movement.

A hospitalized client is a lacto-vegetarian. Which food item would the nurse remove from the meal tray? 1.Eggs 2.Milk 3.Cheese 4.Broccoli

1. Eggs

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention would the nurse suggest to alleviate the child's fears? 1. Encourage the child's parents to stay with the child. 2. Encourage play with other children of the same age. 3. Advise the family to visit only during the scheduled visiting hours. 4. Provide a private room, allowing the child to bring favorite toys from home.

1. Encourage the child's parents to stay with the child.

The licensed practical nurse employed in the ambulatory clinic is assisting the registered nurse in preparing to administer a dose of intravenous immune globulin (IVIG). The licensed practical nurse would ensure that which medication is readily available before the medication is administered? 1. Epinephrine 2. Phytonadione 3. Acetylcysteine 4. Protamine sulfate

1. Epinephrine

The nursing student is caring for a client scheduled for cataract surgery. The student reviews the preoperative prescriptions with the nursing instructor and notes that cyclopentolate eye drops are prescribed to be administered preoperatively. The unit nurse performed an admission health assessment on the client before surgery. Which condition contraindicates using cyclopentolate? 1. Glaucoma 2. Leukemia 3. Liver disease 4. Diabetes mellitus

1. Glaucoma

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse would include which activities in the nursing care plan for the client on the day of surgery? Select all that apply. 1. Have the client void before surgery. 2. Avoid oral hygiene and rinsing with mouthwash. 3. Verify that the client has not eaten for the last 24 hours. 4. Determine that the client has signed the informed consent for the surgical procedure. 5. Report immediately any slight increase in blood pressure or pulse from the client's baseline vital signs.

1. Have the client void before surgery. 4. Determine that the client has signed the informed consent for the surgical procedure.

The nurse is caring for a client at the end of life. Which gastrointestinal findings indicate that death is approaching? Select all that apply. 1. Nausea 2. Incontinence 3. Profuse diarrhea 4. Accumulation of gas 5. Abdominal distention

1. Nausea 2. Incontinence 4. Accumulation of gas 5. Abdominal distention

The nurse is preparing to irrigate a client's sigmoid colostomy. The nurse would plan for which intervention to perform this procedure? 1. Instilling 500 to 1000 mL of lukewarm tap water through the stoma 2. Advises the client to hold the breath if cramping occurs during instillation of the solution 3. Hanging the irrigation solution so that the bottom of the bag is 18 inches above the client's torso. 4. Inserting the irrigation tube with a small amount of force and a twisting motion into the stoma and unclamps the tubing to allow the solution to flow into the stoma

1. Instilling 500 to 1000 mL of lukewarm tap water through the stoma

The nurse is caring for a 14-year-old boy who is hospitalized and placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child's needs? 1. Let the child wear his own clothing when friends visit. 2. Allow the child to have his hair dyed if the parent agrees. 3. Allow the child to play loud music in the hospital room. 4. Allow the child to keep the shades closed and the room darkened at all times

1. Let the child wear his own clothing when friends visit.

The nurse is caring for an older adult and knows that an ethical dilemma is most likely to occur in this population because of which issues? Select all that apply. 1. Limited vision 2. Chronic illness 3. Increased hearing 4. Improved memory 5. Lack of assertiveness

1. Limited vision 2. Chronic illness 5. Lack of assertiveness

The nurse is helping perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which would the nurse include for this type of data collection? Select all that apply. 1. Listening to lung sounds 2. Obtaining the client's temperature 3. Checking the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease

1. Listening to lung sounds 2. Obtaining the client's temperature 4. Obtaining information about the client's respirations

The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results would the nurse report? Select all that apply. 1. Platelets 35,000 mm3 (35 × 109/L) 2. Sodium 150 mEq/L (150 mmol/L) 3. Potassium 5.0 mEq/L (5.0 mmol/L) 4. Segmented neutrophils 40% (0.40) 5. Serum creatinine, 1 mg/dL (88.3 mcmol/L) 6. White blood cells, 3000 mm3 (3.0 × 109/L)

1. Platelets 35,000 mm3 (35 × 109/L) 2. Sodium 150 mEq/L (150 mmol/L) 4. Segmented neutrophils 40% (0.40) 6. White blood cells, 3000 mm3 (3.0 × 109/L)

During data collection on a child for a well-child visit, a parent tells the nurse "We have a chore chart at our house. When our child does chores without prompting for 3 days in a row, the child gets an extra 30 minutes of screen time. So far, it seems to be working!" The nurse determines the child's behavior corresponds with which stage of Kohlberg's moral development? 1. Pre-conventional: Obtaining rewards 2. Pre-conventional: Avoiding punishment 3. Conventional: Obeying rules and regulations 4. Post-conventional: Making and keeping promises

1. Pre-conventional: Obtaining rewards

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level? 1. Prolonged bed rest 2. Adrenal insufficiency 3. Hyperparathyroidism 4. Excessive ingestion of vitamin D

1. Prolonged bed rest

The nurse is caring for a client at the end of life. The client is withdrawn and agitated and is experiencing visual hallucinations. Which actions would the nurse take to provide end-of-life psychological care? Select all that apply. 1. Provide privacy to the client and family. 2. Speak in a soft tone, but not directly to the client. 3. Encourage the family to talk with and reassure the client. 4. Encourage visits by appropriate spiritual services as desired. 5. Encourage family and visitors to avoid talking in the presence of the client to provide a calming environment.

1. Provide privacy to the client and family. 3. Encourage the family to talk with and reassure the client. 4. Encourage visits by appropriate spiritual services as desired.

Which interventions are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling. 2. Talk in a loud voice. 3. Provide the infant with a bottle of juice at naptime. 4. Hang mobiles with black-and-white contrast designs. 5. Caress the infant while bathing or during diaper changes. Allow the infant to cry for at least 10 minutes before responding.

1. Provide swaddling 4. Hang mobiles with black-and-white contrast designs. 5. Caress the infant while bathing or during diaper changes.

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions would the nurse use to perform this procedure? Select all that apply. 1. Put on a mask. 2. Don gown and gloves. 3. Apply shoe protectors. 4. Wear a pair of protective goggles. 5. Have the client wear a mask and goggles.

1. Put on a mask. 2. Don gown and gloves. 4. Wear a pair of protective goggles

The nurse is reinforcing instructions to a client regarding epoetin alfa that will be administered subcutaneously by the client at home. The nurse tells the client to do which action? 1. Refrigerate the medication. 2. Freeze the medication before use. 3. Shake the medicine bottle before use. 4. Obtain syringes with 1-inch needles from the pharmacy.

1. Refrigerate the medication.

The nurse instructs the assistive personnel (AP) assigned to care for an older adult client to place an extra blanket in the client's room. The nurse provides this instruction because the older adult is less able to regulate hot and cold body changes as a result of alterations in the activity of which gland? 1. Pineal gland 2. Sweat glands 3. Parotid glands 4. Thymus gland

2. Sweat Glands

The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction would the nurse reinforce to the parent? 1. Set limits on the child's behavior. 2. Ignore the child when this behavior occurs. 3. Allow the behavior, because this is normal at this age period. 4. Punish the child every time the child says "no" to change the behavior.

1. Set limits on the child's behavior.

When reinforcing appropriate developmental skills interventions for a 1-year-old child who was born 2 months premature, the nurse would plan to encourage the parents to support the child to achieve which developmentally appropriate goal? 1. Sit independently. 2. Build a tower of three blocks. 3. Indicate her wants by pointing. 4. Pull herself up into a standing position

1. Sit independently

The nurse is caring for a hospitalized 5-year-old client. The nurse would recognize that which is normal for this child in this developmental stage? 1. The child believes the moon follows her. 2. The child can consider her friends' points of view. 3. The child demonstrates the ability to think abstractly. 4. The child is able recognize which animals are mammals.

1. The child believes the moon follows her.

Which identifies accurate nursing documentation notations? Select all that apply. 1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital sign measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

The nurse is employed in a newborn nursery. The nurse is reviewing all medications prescribed for newborns to prevent toxicity due to which causes? Select all that apply. 1. The liver is immature. 2. The lungs are not developed. 3. Cerebral function is not fully developed. 4. The kidneys are smaller than those of adults. 5. The kidneys are less able to excrete medications. 6. The neonate has more difficulty retaining body heat.

1. The liver is immature. 5. The kidneys are less able to excrete medications.

The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which procedure accurately identifies this visual acuity test? 1. The right eye is tested, followed by the left eye, and then both eyes are tested. 2. Both eyes are tested together, followed by the testing of the right and then the left eye. 3. The client is asked to stand at a distance of 40 feet from the chart and to read the largest line on the chart. 4. The client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision.

1. The right eye is tested, followed by the left eye, and then both eyes are tested.

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Decreased respirations

1. Tinnitus

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which? 1. Ulnar circulation 2. Carotid circulation 3. Femoral circulation 4. Brachial circulation

1. Ulnar circulation

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions would the nurse use to move this client? Select all that apply. 1. Use a friction-reducing slide sheet. 2. Use a mechanical lift to move the client. 3. Place the client in Trendelenburg's position. 4. Keep elbows close and work close to the body. 5. Administer oral pain medication 5 minutes before moving the client. 6. Obtain assistance of a second caregiver to assist with mechanical aids.

1. Use a friction-reducing slide sheet. 2. Use a mechanical lift to move the client. 4. Keep elbows close and work close to the body. 6. Obtain assistance of a second caregiver to assist with mechanical aids.

The nurse is caring for a 8-month-old infant. The nurse determines the child is at the expected developmental level if the child displays which behavior? 1. Waves bye-bye 2. Uses gestures to communicate 3. Babbles using single consonants 4. Uses simple words such as "mama"

1. Waves bye-bye

The nurse is assisting with planning care for a client with an internal radiation implant. Which would be included in the plan of care? Select all that apply. 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film (dosimeter) badge when in the client's room 4. Wearing a lead apron when providing direct care to the client 5. Placing the client in a semiprivate room at the end of the hallway

1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film (dosimeter) badge when in the client's room 4. Wearing a lead apron when providing direct care to the client

The nurse is preparing to administer an enema to an adult client. Which interventions would the nurse plan to perform for this procedure? Select all that apply. 1.Apply disposable gloves. 2.Place the client in the right Sims' position. 3.Lubricate the enema tube and insert it approximately 4 inches. 4.Clamp the tubing if the client expresses discomfort during the procedure. 5.Hang the enema solution container 24 inches above the client's anus. 6.Ensure that the temperature of the solution is between 100°F (37.8°C) and 105°F (40.5°C).

1.Apply disposable gloves. 3.Lubricate the enema tube and insert it approximately 4 inches. 4.Clamp the tubing if the client expresses discomfort during the procedure. 6.Ensure that the temperature of the solution is between 100°F (37.8°C) and 105°F (40.5°C).

The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse would tell the client to select which food item that is high in riboflavin? 1.Milk 2.Tomatoes 3.Citrus fruits 4.Green, leafy vegetables

1.Milk

The nurse is asked to regulate the flow rate of an intravenous (IV) solution being administered to a client. The IV bag contains 50 mL of solution, and the solution is to be administered over 30 minutes. The administration set has a drop factor of 10 drops (gtts)/mL. The nurse would regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank. Round answer to the nearest whole number.

17 gtts/min

The medication prescribed is metoclopramide hydrochloride 10 mg intramuscularly times one dose. The medication label reads metoclopramide hydrochloride 5 mg/mL. The nurse prepares how much medication to administer the dose? Fill in the blank.

2 mL

The medication prescribed is digoxin 0.25 mg orally, daily. The medication label reads digoxin 0.125 mg/tablet. The nurse would prepare how many tablet(s) to administer the dose? Fill in the blank.

2 tablets

The medication prescribed is levodopa 1 g orally, daily. The medication label states levodopa, 500-mg tablets. The nurse prepares to administer how many tablets at the evening dose? Fill in the blank.

2 tablets

The medication prescribed is zidovudine, 0.2 g orally, three times daily. The medication label states zidovudine, 100-mg tablets. The nurse prepares to administer how many tablets for one dose? Fill in the blank.

2 tablets

A mother of a 3-year-old is concerned because the child is still insisting on a bottle at nap time and at bedtime. The nurse would make which suggestion to the mother? 1. "Allow the bottle if it contains juice." 2. "Allow the bottle if it contains water." 3. "Do not allow the child to have the bottle." 4. "Allow the bottle during naps but not at bedtime."

2. "Allow the bottle if it contains water."

A client is to receive medication via patient-controlled analgesia (PCA), and the nursing instructor asks the nursing student caring for the client to describe the use of the PCA. The instructor determines there is a need for further teaching about the PCA when the student makes which statement? 1. "The PCA gives the client greater control over analgesic administration." 2. "Asking the client to rate pain is unnecessary when the client has a PCA." 3. "PCA delivers predetermined amounts of analgesia within preset intervals." 4. "A continuous intravenous (IV) solution is needed to keep the vein open between analgesia infusions."

2. "Asking the client to rate pain is unnecessary when the client has a PCA."

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement? 1. "This diet will help lower my blood pressure." 2. "Fresh foods such as fruits and vegetables are high in sodium." 3. "This diet is not a replacement for my antihypertensive medications." 4. "The reason I need to lower my salt intake is to reduce fluid retention."

2. "Fresh foods such as fruits and vegetables are high in sodium."

The nurse is reinforcing home-care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statements made by the client indicate an understanding of the instructions? Select all that apply. 1. "I will bend over to tie my shoes." 2. "I will not sleep lying on my left side." 3. "I will sit at the table to eat breakfast." 4. "I will sit in my recliner with my feet elevated." 5. "I will not lift anything heavier than 10 pounds." 6. "I will resume my exercise routine including pushups."

2. "I will not sleep lying on my left side." 3. "I will sit at the table to eat breakfast." 4. "I will sit in my recliner with my feet elevated." 5. "I will not lift anything heavier than 10 pounds."

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply. 1. "An event is termed a mass casualty when it overwhelms local medical capabilities." 2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the heath care facility and could endanger staff." 4. "A mass casualty event occurs if a fight between visitors occurs in the emergency department." 5. "Mass casualty events may require the collaboration of many local agencies to handle the situation."

2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the heath care facility and could endanger staff." 4. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

The nurse is presenting a lecture on disasters and posttraumatic stress disorder (PTSD) to a group of new assistive personnel (AP). Which statements by the AP indicate that teaching has been effective? Select all that apply. 1. "I will never experience PTSD." 2. "PTSD can potentially last a lifetime." 3. "Clients can be easily startled and have difficulty sleeping." 4. "Flashbacks occur, causing the client to relive the experience." 5. "PTSD only occurs in clients who already have a history of depression."

2. "PTSD can potentially last a lifetime." 3. "Clients can be easily startled and have difficulty sleeping." 4. "Flashbacks occur, causing the client to relive the experience."

The mother of a 4-year-old who was recently hospitalized brings the child to the clinic for a follow-up visit. The mother tells the nurse that the child has begun to wet the bed and that it started when the child was brought home from the hospital. The mother is concerned and asks the nurse what to do. Which nursing response is appropriate? 1. "You need to discipline the child." 2. "This is a normal occurrence following hospitalization." 3. "The child probably has developed a urinary tract infection." 4. "We will need to discuss this behavior with the primary health care provider."

2. "This is a normal occurrence following hospitalization."

During a well-child visit a mother states she is frustrated with her 2-year-old child. Whenever she asks him if he wants something to eat, he says "no," but then he starts to cry when she does not give him the food. The nurse would provide which instruction to explain the psychosocial concepts related to growth and development of the toddler? 1. "Your toddler is only 2 years old, and you should not be giving him choices. He is too young." 2. "Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame and doubt." 3. "Your toddler is still in the stage of trust versus mistrust, and you need to spend more time with him so that he feels more secure." 4. "Your toddler is experiencing magical thinking, and with this stage if he says 'no,' he believes you will know he means the opposite."

2. "Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame and doubt."

A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 45 minutes

2. 15 minutes

The nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first? 1. A client in skeletal traction 2. A client who is dependent on a ventilator 3. A postoperative client preparing for discharge 4. A client admitted during the previous shift with a diagnosis of gastroenteritis

2. A client who is dependent on a ventilator

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose? 1. Providing clients with necessary stabilizing treatments 2. A method of promoting quality care and risk management 3. Determining the effectiveness of interventions in relation to outcomes 4. The appropriate method of reporting to local, state, and federal agencies

2. A method of promoting quality care and risk management

The nurse is caring for an older client who is reminiscing about past life experiences in a positive manner. The nurse plans care with the understanding that this behavior indicates which? 1. A mental status alteration 2. A normal psychosocial response 3. A need for psychiatric consultation 4. A sensory deficit requiring social activities

2. A normal psychosocial response

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 30 mm Hg (30 mm Hg), and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value would the nurse expect to note? 1. A sodium level of 145 mEq/L 2. A potassium level of 3.0 mEq/L 3. A magnesium level of 1.8 mEq/L 4. A phosphorus level of 3.0 mg/dL

2. A potassium level of 3.0 mEq/L

When caring for a 3-year-old child, the nurse would provide which toy for the child? 1.A puzzle 2. A wagon 3. A golf set 4. A miniature farm set

2. A wagon

The nurse notes documentation that a client has conductive hearing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply. 1. A defect in the cochlea 2. Acute otitis media with effusion 3. A defect in the 8th cranial nerve 4. A defect in the sensory fibers that lead to the cerebral cortex 5. A physical obstruction to the transmission of sound waves

2. Acute otitis media with effusion 5. A physical obstruction to the transmission of sound waves

When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, which foods would the nurse tell the client are best to include in the diet for this disorder? Select all that apply. 1. Beans 2. Apples 3. Cabbage 4. Brussels sprouts 5. Whole-grain bread

2. Apples 5. Whole-grain bread

The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions would the nurse take to deal with this event? Select all that apply. 1. Turn the client to the side with the knees bent. 2. Apply a sterile dressing soaked with normal saline to the wound. 3. Notify the registered nurse (RN) and primary health care provider (PHCP) at once. 4. Explain to the client that obesity is a risk factor and weight loss should be a future goal. 5. Gently explore the wound with a cotton-tipped applicator to determine whether evisceration has occurred.

2. Apply a sterile dressing soaked with normal saline to the wound. 3. Notify the registered nurse (RN) and primary health care provider (PHCP) at once.

The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which actions would the nurse take? Select all that apply. 1. Ask if the client is thirsty and assist with drinking a glass of water. 2. Ask how the client feels and inquire about any feelings of dizziness. 3. Review the client record to determine time and type of analgesia last received. 4. Review the client record to determine whether the client has voided postoperatively. 5. Assist the client to perform leg exercises and then recheck the blood pressure and pulse rate. 6. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

2. Ask how the client feels and inquire about any feelings of dizziness. 3. Review the client record to determine time and type of analgesia last received. 6. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

A 4-year-old child is hospitalized for severe gastroenteritis. The child is crying and clinging to the mother. The mother becomes very upset and is afraid to leave the child. Which nursing intervention would be most appropriate to alleviate the child's fears and the mother's anxiety? 1. Reassure the mother that the child will be fine after she leaves. 2. Ask the mother if she would like to stay overnight with the child. 3. Give the mother the telephone number of the pediatric unit, and tell the mother to call at any time. 4. Tell the mother to bring the child's favorite toys the next time she comes to the hospital to visit.

2. Ask the mother if she would like to stay overnight with the child.

Which observation indicates that the nurse is performing a whispered voice hearing assessment test procedure correctly? 1. Stands 10 feet away from the client 2. Asks the client to block one ear at a time 3. Conducts the test with back to the client 4. Asks the client to close both eyes during the test

2. Asks the client to block one ear at a time

A licensed practical nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 36.2° C (97.2° F) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action would the nurse take first? 1. Document the findings. 2. Attempt to arouse the client. 3. Contact the registered nurse immediately. 4. Check the medication administration history on the PCA pump.

2. Attempt to arouse the client.

The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage? 1. Gratification of self 2. Beginning of toilet training 3. Tapering off of conscious biological and sexual urges 4. Association with pleasurable and conflicting feelings about the genital organs

2. Beginning of toilet training

A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item? 1. Apples 2. Cheese 3. Oranges 4. Skim milk

2. Cheese

A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing? 1. Veal, potatoes, gelatin, and orange juice 2. Chicken breast, broccoli, strawberries, and milk 3. Peanut butter and jelly sandwich, cantaloupe, and tea 4. Spaghetti with tomato sauce, garlic bread, and ginger ale

2. Chicken breast, broccoli, strawberries, and milk

The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse would tell the client that it is most important to report which signs immediately? 1. Sore throat or earache 2. Chills, itching, or rash 3. Unusual sleepiness or fatigue 4. Mild discomfort at the catheter site

2. Chills, itching, or rash

When the nurse is collecting data from the older adult, which findings would be considered normal physiological changes? Select all that apply. 1. Increased heart rate 2. Decline in visual acuity 3. Decreased respiratory rate 4. Decline in long-term memory 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

2. Decline in visual acuity 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action would the nurse take? 1. Increase oral fluids. 2. Document the findings. 3. Notify the registered nurse. 4. Elevate the head of the bed to 90 degrees.

2. Document the findings.

A client has a terminal illness, and her spouse is distraught about the unrelenting pain she experiences. Which would the nurse implement as the most effective measures to alleviate the spouse's distress? Select all that apply. 1. Convey respect for the couple's wishes. 2. Engage the spouse in providing comfort. 3. Enable the couple in discussing their loss. 4. Maintain a presence to answer questions. 5. Encourage the spouse and client to hold hands. 6. Discourage the spouse and client from talking about the terminal illness.

2. Engage the spouse in providing comfort. 5. Encourage the spouse and client to hold hands

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium 2. Holding the next dose of warfarin 3. Increasing the next dose of warfarin 4. Administering the next dose of warfarin

2. Holding the next dose of warfarin

The nurse is collecting data from parents of a 2-year-old child about mealtime activities. The nurse expects a child this age to have attained which ability? 1. Uses a fork to eat 2. Holds a cup in one hand 3. Pours own milk into a cup 4. Uses a knife for cutting food

2. Holds a cup in one hand

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse would take which action? 1. Document the value in the client's record. 2. Inform the registered nurse of the laboratory value. 3. Place the laboratory result form in the client's record. 4. Reassure the client that the laboratory result is normal.

2. Inform the registered nurse of the laboratory value.

The nurse is preparing to collect client data by examining the abdomen. The nurse should begin the assessment by performing which action first? 1. Palpating the abdomen 2. Inspecting the abdomen 3. Percussing the abdomen 4. Auscultating the abdomen

2. Inspecting the abdomen

The nurse is caring for a client at the end of life. Which late cardiovascular and respiratory findings would the nurse expect to note while collecting data? Select all that apply. 1. Friction rub 2. Irregular heart rate 3. Decreased pulse rate 4. Decreased blood pressure 5. Irregular breathing patterns

2. Irregular heart rate 3. Decreased pulse rate 4. Decreased blood pressure 5. Irregular breathing patterns

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2. Metabolic alkalosis

The nurse is reinforcing teaching about fall prevention to family members of an older client who is at risk for falls. The nurse realizes further instruction is necessary if the family states which concept is relevant to maintenance of balance for the older adult? 1. Older clients often have slower neurological responses to stimuli. 2. Older clients cannot think quickly enough to respond to emergencies. 3. Many medications may have orthostatic hypotension as a side effect. 4. Older clients tend to maintain a broad base of support and thus change direction more slowly.

2. Older clients cannot think quickly enough to respond to emergencies.

The nurse is caring for an 8-year-old child in the late stage of a terminal illness. The child is semiconscious. The nurse notices that the child has a dry mouth, and the family believes the child is thirsty. The family is attempting to give the child a large glass of apple juice. Which actions would the nurse take? Select all that apply. 1. Give the child the glass of apple juice. 2. Perform frequent oral care with mouth swabs. 3. Provide the child with mouthwash to help with mouth odor. 4. Inform the family that oral intake increases as death approaches. 5. Encourage the family to participate in oral care as much as desired. 6. Give the child small sips of water or ice chips if alert and requested by the child.

2. Perform frequent oral care with mouth swabs. 5. Encourage the family to participate in oral care as much as desired. 6. Give the child small sips of water or ice chips if alert and requested by the child.

The nurse is participating in a care plan session for a client with a terminal illness. Which nursing actions would be included? Select all that apply. 1. Follow standard care plans for end-of-life care. 2. Respond to requests from the client and family promptly. 3. Support the client's decision-making in order to promote client control. 4. Discuss sensitive topics quickly and efficiently to avoid upsetting the client and family. 5. Provide information about what to expect during the dying process to the client and family.

2. Respond to requests from the client and family promptly. 3. Support the client's decision-making in order to promote client control. 5. Provide information about what to expect during the dying process to the client and family.

The nurse notes the physical assessment findings for a client with a diagnosis of possible meningitis. Which findings would the nurse expect to observe because of meningeal irritation? Select all that apply. 1. Pupils are unequal and react slowly to light. 2. The client reports stiffness and soreness in the neck area. 3. The client reports pain in the vertebral column and passively flexes the hip and knee in response to neck flexion. 4. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 5. The client's upper arms are flexed and held tightly to the sides of the body, and the legs are extended and internally rotated.

2. The client reports stiffness and soreness in the neck area. 3. The client reports pain in the vertebral column and passively flexes the hip and knee in response to neck flexion. 4. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for fluid volume deficit? 1. The client with cirrhosis 2. The client with an ileostomy 3. The client with heart failure 4. The client with decreased kidney function

2. The client with an ileostomy

The licensed practical nurse (LPN) in the emergency department is caring for a client who was assaulted and sustained blunt force injuries to the chest and abdomen. Which priority client data would the LPN immediately report to the registered nurse (RN)? 1. Pedal pulses 2+ 2. Tracheal deviation to the left 3. Capillary refill time of 2 seconds 4. Ecchymosis noted on the chest and abdomen

2. Tracheal deviation to the left

The nurse is administering a medication intramuscularly to an assigned client. The nurse would include which actions in administering the medication? Select all that apply. 1. Massage the site after injection. 2. Use a Z-track method for administration. 3. Wear sterile gloves to administer the medication. 4. Hold the syringe as if it is a dart to insert the needle. 5. Select an appropriate injection site such as the ventral gluteus. 6. Cleanse the injection site using a back-and-forth motion with an antiseptic pad.

2. Use a Z-track method for administration. 4. Hold the syringe as if it is a dart to insert the needle. 5. Select an appropriate injection site such as the ventral gluteus.

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse would encourage the client to discuss the use of which product with the primary health care provider? 1. Garlic 2. Valerian 3. Lavender 4. Glucosamine

2. Valerian

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What would the nurse do? Select all that apply. 1.Hold the feeding. 2.Document the amount of residual. 3.Place it into a container for laboratory analysis. 4.Reinstill the residual and administer the feeding. 5.Deduct the amount of the residual from the new feeding before administering.

2.Document the amount of residual. 4.Reinstill the residual and administer the feeding.

The nurse provides instructions to a parent of a toddler experiencing physiological anorexia. The nurse determines the need for further teaching if the parent makes which statement? 1. "I should not force feed my child." 2. "I should limit juice to 6 ounces per day." 3. "I should feed my child if she will not eat." 4. "I should limit snacks to two nutritious ones per day and give them only at my toddler's request."

3. "I should feed my child if she will not eat."

The nurse is reviewing dental care with a client who is edentulous and wears dentures. Which of the following client statements indicates an understanding of proper dental care? 1. "Since I have no teeth, I do not need to brush my mouth." 2. "I need to use hot water when cleaning my dentures to kill bacteria." 3. "I will remove my dentures before bed and keep them in my labeled denture cup covered with water." 4. "When I am not wearing my dentures during the day, I can keep them in the denture cup with no water, as they should only be in water at night."

3. "I will remove my dentures before bed and keep them in my labeled denture cup covered with water."

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse would respond by making which appropriate statement? 1. "I would try anything that I could if I had cancer." 2. "No, because it will interact with the chemotherapy." 3. "Tell me what you know about complementary therapies." 4. "You need to ask your primary health care provider about it."

3. "Tell me what you know about complementary therapies."

A nursing student is assigned to care for a hospitalized 2-year-old child. The nursing instructor reviews the plan of care with the student and asks the student to identify the expected behavior of the child in regard to separation anxiety. Which statement by the student indicates an understanding of separation anxiety that can occur in a 2-year-old child? 1. "The child will withdraw." 2. "Separation anxiety is not an issue in a 2-year-old." 3. "The child may ignore the parents when they visit." 4. "Two-year-olds usually adjust well to hospitalization."

3. "The child may ignore the parents when they visit."

The nurse is teaching a client with a urinary stoma about how to change the collection bag and appliance at home. Which of the following client statements indicate an understanding of the procedure? 1. "The stoma needs to be cleaned with only water." 2. "The best time to change the appliance is at night." 3. "The pouch needs to be changed every 5 to 7 days." 4. "I'll cut the skin barrier 10 millimeters larger than the stoma."

3. "The pouch needs to be changed every 5 to 7 days."

The parent of a 4-year-old child expresses concern because her hospitalized child has started sucking his thumb. The mother states that this behavior began 2 days after hospital admission. Which is the appropriate nursing response? 1. "Your child is acting like a baby." 2. "The doctor will need to be notified." 3. "This is common during hospitalization" 4. "A 4-year-old is too old for this type of behavior."

3. "This is common during hospitalization"

The mother of a 2-year-old child asks the nurse if it is all right to give the child a bottle at naptime. Which response by the nurse is appropriate? 1. "At this age, the child may have a bottle at any time." 2. "A bottle may be given if the child isn't taking fluids well during the day." 3. "You may give the child a bottle if necessary, but if you do, it should contain water." 4. "The child may have a bottle at naptime, but it is best not to give a bottle at bedtime."

3. "You may give the child a bottle if necessary, but if you do, it should contain water."

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client? 1. "Herbal substances are not safe and should never be used." 2. "I will teach you how to take your blood pressure so that it can be monitored closely." 3. "You will need to talk to your primary health care provider (PHCP) before using an herbal substance." 4. "If you take an herbal substance, you will need to have your blood pressure checked frequently."

3. "You will need to talk to your primary health care provider (PHCP) before using an herbal substance."

The nurse is reinforcing instructions to a 16-year-old male adolescent regarding dietary patterns. The nurse instructs the adolescent about the recommended amount of daily calories. How many calories a day does the nurse recommend as the approximate daily caloric allowance for a male adolescent? 1. 1200 2. 1800 3. 2200 4. 3000

3. 2200

During a routine well-child checkup for a 2½ year old, the nurse plans to teach the mother proper nutrition and weight gain expectations for her child. The nurse reviews the chart and finds that the toddler's birth weight was 7 pounds 15 ounces. The nurse expects that the child should weigh approximately how much at this time? 1. 15 pounds 14 ounces 2. 23 pounds 13 ounces 3. 31 pounds 12 ounces 4. 39 pounds 11 ounces

3. 31 pounds 12 ounces

The nurse is caring for a group of clients who are taking herbal medications at home. Which client would be given instructions with regard to avoiding the use of herbal medications? 1. A 60-year-old male client with rhinitis 2. A 24-year-old male client with a lower back injury 3. A 10-year-old female client with a urinary tract infection 4. A 45-year-old female client with a history of migraine headaches

3. A 10-year-old female client with a urinary tract infection

The nurse is monitoring several older adults for adverse drug effects. Which client requires closest monitoring for drug toxicity? 1. A client with an increased hemoglobin 2. A client with an increased plasma protein level 3. A client who consumes a high-carbohydrate, low-protein diet 4. A client who frequently refuses to take prescribed antihypertensive medication

3. A client who consumes a high-carbohydrate, low-protein diet

The nurse is preparing a list of client care activities to be done during the shift. For which of the following clients would the nurse instruct the assistive personnel (AP) to use an electric razor for shaving? Select all that apply. 1. A client with leukocytosis 2. A client with thrombocytosis 3. A client with thrombocytopenia 4. A client receiving an antiplatelet medication 5. A client receiving acetaminophen as needed for mild pain

3. A client with thrombocytopenia 4. A client receiving an antiplatelet medication

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door.

3. Activate the fire alarm.

A client with sickle cell anemia has vaso-occlusive pain. After noting that the client is of preschool age, the nurse plans to use which method to determine the adequacy of pain control? 1. Ask the client to use a numerical rating scale of 0 to 10. 2. Institute the use of a patient-controlled analgesia (PCA) pump. 3. Ask the client to point to faces (smiling to very sad) that best describe the pain. 4. Ask the client to use a word descriptive rating scale (no, little, medium, large, worst pain).

3. Ask the client to point to faces (smiling to very sad) that best describe the pain

The nurse employed in a well-baby clinic is collecting data on the language and communication developmental milestones of a 4-month-old infant. Based on the age of the infant, the nurse expects to note which highest level of developmental milestones? 1. Cooing sounds 2. Use of gestures 3. Babbling sounds 4. Interest in sounds

3. Babbling sounds

A client who was struck by a car while jogging is brought to the emergency department by emergency medical services. The client is unconscious, and a ruptured spleen is suspected. Emergency measures are instituted but are unsuccessful. The client's fiancé is with the client and tells the nurse that the client is an organ donor. In anticipation that the client's eyes will be donated, which would the nurse implement? 1. Ask the fiancé to obtain the client's will from the lawyer. 2. Call the National Eye Bank to confirm that the client is a donor. 3. Close the deceased client's eyes and place gauze and a small ice pack on the eyes. 4. Position the deceased client supine and place dry sterile dressings over the eyes.

3. Close the deceased client's eyes and place gauze and a small ice pack on the eyes.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know that they will not be abandoned by the nurse.

3. Encourage expression of feelings, concerns, and fears. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know that they will not be abandoned by the nurse.

The nurse is developing goals for a school-age child with a knowledge deficit related to the use of inhalers and peak flow meters. The nurse identifies which goal as appropriate for this child? 1. Denies shortness of breath or difficulty breathing 2. Has regular respirations at a rate of 18 to 22 breaths per minute 3. Expresses feelings of mastery and competence with breathing devices 4. Watches the educational video and reads printed information provided

3. Expresses feelings of mastery and competence with breathing devices

The nurse in the emergency department is preparing to instill fluorescein into the eye of a client with the complaint of eye pain. Fluorescein dye is used to detect which conditions? Select all that apply. 1. Cataracts 2. Glaucoma 3. Foreign object 4. Corneal abrasion 5. Macular degeneration

3. Foreign object 4. Corneal abrasion

The nurse is observing a parent and child interacting in the clinic waiting room. The child begins to bounce on the couch. The parent removes the child from the couch stating firmly, "Couches are for sitting, not for jumping." The parent then gives the child a toy to play with on the carpet. The child plays with the toy until called by the nurse. The nurse determines the child is acting within which Kohlberg stage of moral development? 1. Egocentric judgment 2. Law-and-order orientation 3. Punishment-obedience stage 4. Good boy-nice girl orientation

3. Punishment-obedience stage

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse would monitor the client for which acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis

The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with the chemotherapy? 1. Anemia 2. Decreased platelets 3. Increased uric acid level 4. Decreased leukocyte count

3. Increased uric acid level

The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent? 1. Flushed and warm skin 2. Eupnea and normal body temperature 3. Irregular, noisy breathing and cold, clammy skin 4. Presence of swallowing reflex and active bowel sounds

3. Irregular, noisy breathing and cold, clammy skin

A client and her husband are being discharged from the hospital after delivering a stillborn infant. They ask about the possibility of attending a bereavement support group in the community. The nurse realizes this action corresponds to which aspect of grieving? 1. Anger 2. Denial 3. Normal grieving 4. Prolonged sadness

3. Normal grieving

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice? 1. A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used when providing client care. 3. Nursing staff are led by the nurse when providing care to a group of clients. 4. A single registered nurse is responsible for providing nursing care to a group of clients.

3. Nursing staff are led by the nurse when providing care to a group of clients.

A licensed practical nurse (LPN) is providing instructions to an assistive personnel (AP) who is preparing to care for a deceased client whose eyes will be donated. The nurse intervenes if the AP performs which action? 1. Closes the client's eyes 2. Elevates the head of the bed 3. Places a dry sterile dressing over the open eyes 4. Places wet saline gauze pads and an ice pack on the eyes

3. Places a dry sterile dressing over the open eyes

The nurse is preparing to administer eardrops to an infant. How would the nurse administer the eardrops? 1. Pull up and back on the ear, and direct the solution onto the eardrum. 2. Pull down and back on the ear, and direct the solution onto the eardrum. 3. Pull down and back on the ear, and direct the solution toward the wall of the canal. 4. Pull up and back on the ear lobe, and direct the solution toward the wall of the canal.

3. Pull down and back on the ear, and direct the solution toward the wall of the canal.

A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Threatening to place a client in restraints 2. Performing a surgical procedure without consent 3. Taking photographs of the client without consent 4. Telling the client that he or she cannot leave the hospital

3. Taking photographs of the client without consent

When checking a child's glossopharyngeal nerve function, the nurse would perform which data collection technique? 1. Have the child shrug the shoulders while applying mild pressure. 2. Have the child follow a light in the 6 cardinal positions of gaze. 3. Test sense of sour or bitter taste on the posterior segment of the tongue. 4. Test sense of sweet or salty taste on the anterior section of the tongue.

3. Test sense of sour or bitter taste on the posterior segment of the tongue.

The nurse is collecting data regarding the motor development of a 24-month-old child. Based on the age of the child, the nurse expects to note which highest level of developmental milestone? 1. The child snaps large snaps. 2. The child builds a tower of two blocks. 3. The child uses a doorknob to open a door. 4. The child puts on simple clothes independently.

3. The child uses a doorknob to open a door.

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss? 1. The client with a draining wound 2. The client with a urinary catheter 3. The client with a fast respiratory rate 4. The client with a nasogastric tube to low suction

3. The client with a fast respiratory rate

The nurse is working with a new nurse employee in a hospice agency. The nurse recognizes the new employee needs further assistance in facilitating effective communication between a client and the family if the new nurse employee performs which action? 1. The new nurse employee encourages the client and family to openly identify and discuss feelings. 2. The new nurse employee assists the client and family in carrying out spiritually meaningful practices. 3. The new nurse employee makes decisions for the client and family in order to relieve them of unnecessary demands. 4. The new nurse employee maintains a calm attitude and one of acceptance when the family or client expresses anger.

3. The new nurse employee makes decisions for the client and family in order to relieve them of unnecessary demands

Penicillin G procaine, 1,000,000 units given intramuscularly, is prescribed for an adolescent with an infection. The medication label reads as follows: "1,200,000 units/2 mL." The nurse has determined that the prescribed dose is safe. How many milliliters per dose would the nurse administer to the adolescent? 1. 0.8 mL 2. 1.2 mL 3. 1.44 mL 4. 1.66 mL

4. 1.66 mL

The nurse prepares to take a blood pressure (BP) on a school-age child. Where would the nurse place the blood pressure cuff to obtain an accurate measurement? 1. One-half the distance between the antecubital fossa and the shoulder 2. One-third the distance between the antecubital fossa and the shoulder 3. Two-thirds the distance between the antecubital fossa and the shoulder 4. One-quarter the distance between the antecubital fossa and the shoulder

3. Two-thirds the distance between the antecubital fossa and the shoulder

The nurse would institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply. 1. Wear a mask if within 3 feet of the client. 2. Place a mask on the client when client is outside the room. 3. Wear gloves and gown while in the room caring for the client. 4. Use soap and water, not alcohol-based hand rub, for hand hygiene. 5. Keep the door of the room shut except when entering or exiting the client's

3. Wear gloves and gown while in the room caring for the client. 4. Use soap and water, not alcohol-based hand rub, for hand hygiene.

The registered nurse (RN) reviews the results of the arterial blood gas (ABG) values with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN would expect to note which on the laboratory result report? 1. pH 7.50, Pco2 52 mm Hg 2. pH 7.35, Pco2 40 mm Hg 3. pH 7.25, Pco2 50 mm Hg 4. pH 7.50, Pco2 30 mm Hg

3. pH 7.25, Pco2 50 mm Hg

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When would the nurse inflate the balloon? 1.Immediately inflate the balloon. 2.Insert the catheter 2.5 cm to 5 cm and inflate the balloon. 3.Advance the catheter to the bifurcation and inflate the balloon. 4.Insert the catheter until resistance is met and inflate the balloon.

3.Advance the catheter to the bifurcation and inflate the balloon.

The parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response? 1."You need to be concerned." 2. "You need to monitor the child's behavior closely." 3. "You need to praise the child more often to stop this behavior." 4. "At this age, the child is developing his or her own personality."

4. "At this age, the child is developing his or her own personality."

The nurse provides information to a client regarding breast self-examination (BSE). Which client statement indicates a need for further teaching regarding BSE? 1. "I examine my breasts in the shower." 2. "I do BSE 7 days after I get my period." 3. "I lie on my back to examine my breasts." 4. "I don't need to do that; I'm too old for that."

4. "I don't need to do that; I'm too old for that."

A licensed practical nurse is precepting a student assigned to care for a client with chronic pain. Which statement, if made by the student, indicates the need for further teaching regarding pain management? 1. "I will be sure to ask my client what their pain level is on a scale of 0 to 10." 2. "I know that I should follow-up after giving medication to make sure it is effective." 3. "I know that pain in the older client might manifest as sleep disturbance or depression." 4. "I will be sure to cue in to any indicators that the client may be exaggerating their pain."

4. "I will be sure to cue in to any indicators that the client may be exaggerating their pain."

The mother of a toddler tells the nurse that she has a difficult time getting the child to go to bed at night. The nurse would make which suggestion to the mother? 1. "Avoid a nap during the day." 2. "Allow the child to set bedtime limits." 3. "Allow the child to have temper tantrums." 4. "Inform the child of bedtime a few minutes before it is time for bed."

4. "Inform the child of bedtime a few minutes before it is time for bed."

The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement? 1. "I know all of my multiplication tables by memory". 2. "The ball is gone," when a ball disappears out of sight. 3. "I'll use a map to help me find my way in a new town". 4. "The moon follows me, and goes to bed when I go to bed".

4. "The moon follows me, and goes to bed when I go to bed"

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? 1. A client complaining of muscle ache, headache, and malaise 2. A client who twisted their ankle when they fell in-line skating 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

A client arrives at the emergency department and has experienced frostbite to the right hand. What would the nurse expect to find when inspecting the client's hand? 1. A pink, edematous hand 2. Fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color of the skin that is insensitive to touch

4. A white color of the skin that is insensitive to touch

The nurse is providing information to assistive personnel (AP) regarding caring for an older adult. The nurse determines the AP understands the information provided if the AP identifies which situation portrays ageism? 1. Informing the older adult of their rights 2. Allowing older adults to make decisions 3. Accepting differences among older adults 4. Advising older adults to forgo aggressive treatment

4. Advising older adults to forgo aggressive treatment

A 16-year-old child is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which intervention is most appropriate to facilitate normal growth and development? 1. Encourage the child to rest and read. 2. Encourage the parents to room-in with the child. 3. Allow the family to bring in favorite computer games. 4. Allow the child to participate in activities with other individuals in the same age group when the condition permits.

4. Allow the child to participate in activities with other individuals in the same age group when the condition permits.

An older adult couple requests to room together at a long-term care facility. When some members of the staff question this, the nurse would provide which response? 1. Aberrant sexual behavior is to be expected among older males. 2. Most people do not engage in sexual activity after the age of 70. 3. Physical beauty is necessary for continued sexual activity in older persons. 4. Although responses may be slower, sexual ability is present in later years of life.

4. Although responses may be slower, sexual ability is present in later years of life.

The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom would the nurse expect to note in this client? 1. Rapid weight loss 2. Flat hand and neck veins 3. A weak and thready pulse 4. An increase in blood pressure

4. An increase in blood pressure

A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax? 1. Anthrax is treated with antibiotic medications. 2. The most lethal form of anthrax is contacted by inhalation of the spores. 3. Anthrax can be transmitted by consumption of meat from an infected animal. 4. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

4. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

A young adult college student begins to throw objects, shout insults, and stamp his feet after an instructor returned his work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered? 1. Initiative vs. guilt 2. Industry vs. inferiority 3. Identity vs. role confusion 4. Autonomy vs. shame and doubt

4. Autonomy vs. shame and doubt

A 4-year-old child is reluctant to take deep breaths following abdominal surgery. Which measure would be effective to encourage deep breathing? 1. Give the child colorful latex balloons to blow up. 2. Tell the child to exhale forcefully through the peak flowmeter. 3. Administer chest percussion in several postural drainage positions. 4. Have the child pretend to be a big bad wolf blowing the little pig's house down.

4. Have the child pretend to be a big bad wolf blowing the little pig's house down.

The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action? 1. Reinsert the implant into the vagina. 2. Call the primary health care provider (PHCP). 3. Pick up the implant with gloved hands and flush it down the toilet. 4. Pick up the implant with long-handled forceps and place into a lead container.

4. Pick up the implant with long-handled forceps and place into a lead container.

Which clients would the nurse determine is at risk for development of metabolic alkalosis? Select all that apply. 1. Client with emphysema 2. Client who is hyperventilating 3. Client with chronic kidney disease 4. Client who has been vomiting for 2 days 5. Client receiving oral furosemide 40 mg daily 6. Client admitted with acetylsalicylic acid overdose

4. Client who has been vomiting for 2 days 5. Client receiving oral furosemide 40 mg daily

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? 1. Uncaps the distal end of the tubing 2. Uncaps the spike portion of the tubing 3. Opens the roller clamp on the IV tubing 4. Closes the roller clamp on the IV tubing

4. Closes the roller clamp on the IV tubing

A licensed practical nurse (LPN) is administering medications to a client who has difficulty swallowing. A time-released film-coated medication is prescribed and the client is unable to swallow the pill. Which action by the LPN is most appropriate? 1. Skip the dose and try again at a later time. 2. Crush the tablet and mix it with applesauce. 3. Give the client a large glass of water to aid in swallowing. 4. Consult with the registered nurse (RN) about contacting the primary health care provider (PHCP) regarding a medication change.

4. Consult with the registered nurse (RN) about contacting the primary health care provider (PHCP) regarding a medication change.

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially? 1. Listen to the client's heart sounds. 2. Determine whether the client has a pulse deficit. 3. Instruct the client to use an incentive spirometer. 4. Determine the client's ability to follow verbal commands.

4. Determine the client's ability to follow verbal commands.

The nurse is teaching a mother how to administer eardrops to an infant. The nurse determines the mother understands instructions if the mother demonstrates pulling the ear in which manner? 1. Up and back and directing the solution onto the eardrum 2. Down and back and directing the solution onto the eardrum 3. Up and back and directing the solution toward the wall of the canal 4. Down and back and directing the solution toward the wall of the canal

4. Down and back and directing the solution toward the wall of the canal

The nurse has a prescription to give ear drops to a 2-year-old child. To administer the drops, the nurse would pull the pinna of the ear in which direction? 1. Upward and outward 2. Upward and backward 3. Downward and outward 4. Downward and backward

4. Downward and backward

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the registered nurse with which action? 1. Administering an antidote 2. Drawing a sample for type and crossmatch and transfuse the client 3. Drawing a sample for an activated partial thromboplastin time (aPTT) level 4. Drawing a sample for prothrombin time (PT) and international normalized ratio (INR)

4. Drawing a sample for prothrombin time (PT) and international normalized ratio (INR)

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn? 1. A dependent position 2. Elevation of the knees 3. Flat, without elevation 4. Elevation above the level of the heart

4. Elevation above the level of the heart

The nurse is assisting with preparing a plan of care for a 4-year-old child hospitalized with nephrotic syndrome. Which intervention is most appropriate for this child? 1. Provide a high-salt diet. 2. Provide a high-protein diet. 3. Discourage visitors at mealtimes. 4. Encourage the child to eat in the playroom.

4. Encourage the child to eat in the playroom.

A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action would the nurse plan to take? 1. Perform Allen's test. 2. Prepare the client for dialysis. 3. Administer insulin as prescribed. 4. Encourage the client to slow down breathing.

4. Encourage the client to slow down breathing.

The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What would the nurse tell the client about the purpose of the test? 1. Checks for glaucoma 2. Checks for color blindness 3. Examines pupil constriction 4. Examines visual fields or peripheral vision

4. Examines visual fields or peripheral vision

A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client? 1. Soft custard 2. Orange juice 3. Clam chowder 4. Fat-free beef broth

4. Fat-free beef broth

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance? 1. Twitching 2. Positive Trousseau's sign 3. Hyperactive bowel sounds 4. Generalized muscle weakness

4. Generalized muscle weakness

A client is having problems with blood clotting. Which food item would the nurse encourage the client to eat? 1. Legumes 2. Citrus fruits 3. Vegetable oils 4. Green, leafy vegetables

4. Green, leafy vegetables

A 39-year-old man learned today that his 36-year-old wife has an incurable cancer and is expected to live not more than a few weeks. The nurse identifies which responses by the husband as indicative of effective individual coping? Select all that apply. 1. He states that he will not allow his wife to come home to die. 2. He refuses to visit his wife in the hospital or to discuss her illness. 3. He immediately arranges for their three teenage children to live with relatives in another state. 4. He expresses his anger at God and the primary health care providers for allowing this to happen. 5. He tells the nurse he has prayed that God will allow his wife to live long enough to watch their children's high school graduation. 6. He has asked his wife and children to assist him in making funeral arrangements, such as casket selection and cemetery burial sites.

4. He expresses his anger at God and the primary health care providers for allowing this to happen. 5. He tells the nurse he has prayed that God will allow his wife to live long enough to watch their children's high school graduation. 6. He has asked his wife and children to assist him in making funeral arrangements, such as casket selection and cemetery burial sites.

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding would the nurse expect to note as a result of this long-term use? 1. Gurgling respirations 2. Increased blood pressure 3. Decreased hematocrit level 4. Increased specific gravity of the urine

4. Increased specific gravity of the urine

The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How would the nurse correctly document this observation in the medical record? 1. Apnea 2. Bradypnea 3. Cheyne-Stokes 4. Kussmaul's respirations

4. Kussmaul's Respirations

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed? 1. Discontinuing the heparin infusion 2. Increasing the rate of the heparin infusion 3. Decreasing the rate of the heparin infusion 4. Leaving the rate of the heparin infusion as is

4. Leaving the rate of the heparin infusion as is

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's poor nutritional intake. Which nursing intervention related to poor nutrition would be the initial choice? 1. Weigh the client three times per week, before breakfast. 2. Explain to the client the importance of a good nutritional intake. 3. Report the nutritional concern to the psychiatrist, and obtain a nutritional consult as soon as possible. 4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

The nurse working in a long-term care facility is approached by the son of a resident, who wants his 78-year-old father to have a heating pad because "his feet are always cold at night." The nurse would incorporate which concept when formulating a response to the family member? 1. Heating pads are dangerous and are likely to cause fires. 2. The resident has a right to procure and keep his own property. 3. The long-term care facility strictly prohibits the use of heating pads. 4. Older adults often have slower neurological response times and are therefore more at risk for burns.

4. Older adults often have slower neurological response times and are therefore more at risk for burns.

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks? 1. Document that the task was completed. 2. Assign the tasks that were not completed to the next nursing shift. 3. Allow each staff member to make judgments when performing the tasks. 4. Perform follow-up with each staff member regarding the performance and outcome of the task.

4. Perform follow-up with each staff member regarding the performance and outcome of the task.

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse would take which action after seeing the laboratory results? 1. Report the abnormally low count. 2. Report the abnormally high count. 3. Place the client on bleeding precautions. 4. Place the normal report in the client's medical record.

4. Place the normal report in the client's medical record.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom would the nurse expect to note in this client if hyponatremia is present? 1. Intense thirst 2. Slow bounding pulse 3. Dry mucous membranes 4. Postural blood pressure changes

4. Postural blood pressure changes

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure? 1. Avoiding infection 2. Taking in adequate fluids 3. Preventing and recognizing hypoglycemia 4. Preventing and recognizing hyperglycemia

4. Preventing and recognizing hyperglycemia

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse would plan to take which action? 1. Report the information to the police. 2. Call the impaired nurse organization. 3. Talk with the nurse who gave the medication. 4. Report the information to a nursing supervisor.

4. Report the information to a nursing supervisor.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action? 1. Call the hospital lawyer. 2. Call the nursing supervisor. 3. Refuse to float to the pediatric unit. 4. Report to the pediatric unit and identify tasks that can be safely performed.

4. Report to the pediatric unit and identify tasks that can be safely performed.

The nurse is inserting an indwelling urinary catheter in a client and begins to inflate the balloon when the client starts complaining of pain. Which action would the nurse take? 1. Continue to inflate the balloon 2. Deflate the balloon, slightly withdraw the catheter and attempt to reinflate the balloon 3. Deflate the balloon, completely withdraw the catheter and end the procedure to notify the primary health care provider 4. Stop inflating the balloon, allow the saline solution to drain into the syringe and advance the catheter further before reinflating the balloon

4. Stop inflating the balloon, allow the saline solution to drain into the syringe and advance the catheter further before reinflating the balloon

The nurse is preparing to assist the primary health care provider to test the extraocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done? 1. Testing using the Ishihara chart 2. Testing using a Snellen eye chart 3. Testing the corneal light reflexes 4. Testing the six cardinal positions of gaze

4. Testing the six cardinal positions of gaze

The nurse in the pediatric unit is admitting a 2-year-old child. The nurse plans care, considering the child will likely display which behavior during Erikson's psychosocial stage of development corresponding with the age? 1. The child constantly wants to suck on a pacifier. 2. The child enjoys finger painting on large pieces of paper. 3. The child enjoys sorting blocks according to size and color. 4. The child frequently says "no" when the parents or the nurse asks a question.

4. The child frequently says "no" when the parents or the nurse asks a question.

A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How would the nurse interpret this result? 1. The client is legally blind. 2. The client's vision is normal. 3. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet. 4. The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.

4. The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for a potassium deficit? 1. The client with Addison's disease 2. The client with metabolic acidosis 3. The client with intestinal obstruction 4. The client receiving nasogastric suction

4. The client receiving nasogastric suction

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at the least likely risk for the development of third-spacing? 1. The client with sepsis 2. The client with cirrhosis 3. The client with kidney failure 4. The client with diabetes mellitus

4. The client with diabetes mellitus

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition? 1. The client with watery diarrhea 2. The client with diabetes insipidus 3. The client with an inadequate daily water intake 4. The client with the syndrome of inappropriate secretion of antidiuretic hormone

4. The client with the syndrome of inappropriate secretion of antidiuretic hormone

The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing student would indicate a need for further teaching? 1. The nursing student tells the client to avoid soaking the feet. 2. The nursing student dries the feet thoroughly, including in between the toes. 3. The nursing student advises the client to consult the physician or a podiatrist regarding nail trimming. 4. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes.

4. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes.

The nurse is working with a new nurse who is assisting an older client and family with discharge planning following hospitalization. The nurse realizes the new nurse correctly understands the needs of older adults if the new nurse helps the group plan for which situation? 1. To live alone 2. To live with their children 3. To live in long-term care facilities 4. To live independently, but close to their children if possible

4. To live independently, but close to their children if possible

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? 1. Call the nursing supervisor to initiate a court order for the surgical procedure. 2. Try calling the client's spouse to obtain telephone consent before the surgical procedure. 3. Ask the friend who accompanied the client to the emergency department to sign the consent form. 4. Transport the client to the operating department immediately without obtaining an informed consent.

4. Transport the client to the operating department immediately without obtaining an informed consent.

The nurse is providing an education class to healthy older adults. Which exercise will best promote health maintenance? 1. Gardening every day for an hour 2. Sculpting once a week for 40 minutes 3. Cycling three times a week for 20 minutes 4. Walking three to five times a week for 30 minutes

4. Walking three to five times a week for 30 minutes