NCLEX Practice Questions

A client involved in a head-on automobile crash has awakened from a coma and asks for her husband, who was killed in the same accident. The family does not want the client to know at this time that her husband has died. The family wants all nursing staff to tell the client that the husband was taken by helicopter to another hospital, has a head injury, and is in the intensive care unit (ICU). Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instruction, the nurse faces an ethical dilemma. Which steps should the nurse take to systematically process this ethical dilemma? Arrange in order the steps for systematic processing of the ethical dilemma. All options must be used. List in correct order: Evaluate the action. Verbalize the problem. Negotiate the outcome. Consider possible courses of action. Gather all information relevant to the case. Examine and determine one's own values on the issues.

1. Gather all information relevant to the case. 2. Examine and determine one's own values on the issues. 3. Verbalize the problem. 4. Consider possible courses of action. 5. Negotiate the outcome. 6. Evaluate the action. Ethical reasoning is the process of thinking through what one ought to do in an orderly and systematic manner to provide justification for actions based on principles. First, the nurse determines whether the issue involves an ethical dilemma and gathers information that is relevant to the case. Second, the nurse undertakes personal value clarification and identifies his or her own values regarding the issue. Third, the nurse verbalizes the problem in a simple sentence. Fourth, the nurse considers possible courses of action. In this case, the nurse may choose to seek the counsel of the agency's ethicist regarding the issue. Fifth, the nurse negotiates the outcome by developing confidence in her or his own point of view with deep respect for the opinions of others. In this case, the nurse may negotiate with the family to determine a course of action that would allow the nurse to preserve integrity yet allow the family to determine when the client should be informed of the tragic loss. Sixth, the nurse evaluates the action.

The prenatal clinic nurse asks a nursing student to identify the physiological adaptations of the cardiovascular system that occur during pregnancy. The nurse determines that the student understands these physiological changes if the student makes which statement? A. "An increase in pulse rate occurs." B. "A decrease in blood volume occurs." C. "A decrease in cardiac output occurs." D. "The blood pressure increases by 20 mm Hg."

A. "An increase in pulse rate occurs." Between 14 and 20 weeks gestation, the maternal pulse rate increases slowly by 10 to 15 beats/minute, which lasts until term. Cardiac output and blood volume increase. Blood pressure decreases in the first half of pregnancy and returns to baseline in the second half of pregnancy.

A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? A. "I can give him a tub bath in two days." B. "I should not remove the yellow exudate on the end of the penis." C. "The circumcision will heal completely within a couple of weeks." D. "I will clean his penis with each diaper change."

A. "I can give him a tub bath in two days." The newborn should not be immersed in water until the circumcision has healed and the umbilical cord has detached. The circumcision should heal within two weeks.

The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? A. "I should sleep on my left side." B. "I should sleep on my right side." C. "I should sleep with my head flat." D. "I should not wear my glasses at any time."

A. "I should sleep on my left side." After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also should be placed in a semi-Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.

A nurse is preparing a client for discharge after an anterior-posterior colporrhaphy. Which of the following statements made by the client indicates a need for further teaching? A. "I will increase my fiber intake to stay regular." B. "I will increase my daily fluid intake." C. "I will tighten my pelvic muscles when coughing." D. "I will avoid standing for prolonged periods of time."

A. "I will increase my fiber intake to stay regular." A full liquid diet is provided immediately after surgery, followed by a low-residue diet to decrease bowel movements and allow time for the incision to heal. Foods that are high in fiber should be avoided until it has been determined that normal bowel function has been regained. Stool softeners should be administered as prescribed to facilitate bowel elimination and prevent stress on stitches. The client should tighten and support pelvic muscles when coughing or sneezing to help reduce stress on stitches.

A client in the behavioral health unit began taking fluoxetine 20 mg per day three days ago for depression. Which of the following should the nurse immediately report to the health care provider? A. Agitation and fever B. Headache and nausea C. Weight gain D. Sexual dysfunction

A. Agitation and fever Agitation and fever are symptoms of serotonin syndrome, a potentially life-threatening condition that can develop in client's taking SSRIs such as fluoxetine. These symptoms develop within 2-72 hours after starting treatment and may also include mental confusion, anxiety, hallucinations, tremors, and hyperreflexia.

The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? A. Allow the newborn infant to signal a need. B. Anticipate all needs of the newborn infant. C. Attend to the newborn infant immediately when crying. D. Avoid the newborn infant during the first 10 minutes of crying.

A. Allow the newborn infant to signal a need. According to Erikson, the caregiver should not try to anticipate the newborn infant's needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment.

The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply. A. Antibiotic therapy B. Cold compresses to the affected area C. Warm compresses to the affected area D. Intermittent heat lamp treatments 4 times daily E. Alternating hot and cold compresses continuously

A. Antibiotic therapy C. Warm compresses to the affected area Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.

A nurse is caring for a client who is one month post bariatric surgery and has been diagnosed with dumping syndrome. Which of the following recommendations is appropriate? Select all that apply. A. Avoid consuming milk, sweets, and sugars B. Eat small, frequent meals during the day C. Eliminate liquids with meals, and for one hour before and after meals D. Reduce the amount of protein and fat in the diet E. Sit up for at least an hour after each meal

A. Avoid consuming milk, sweets, and sugars B. Eat small, frequent meals during the day C. Eliminate liquids with meals, and for one hour before and after meals Dumping syndrome frequently occurs after bariatric surgery and symptoms can include vertigo, syncope, pallor, diaphoresis, tachycardia, and palpitations. Therapy includes: small, frequent meals rather than large ones; avoidance of milk, sweets, and sugars; elimination of liquids with meals and for one hour before and after meals; reduction in the amount of fluid ingested at one time, eating a high-protein, high-fat, and low-to- moderate carbohydrate diet; and lying down after meals to slow transit time of food in the intestines. It is contraindicated for the client with Dumping Syndrome to sit up after eating, as that position will speed movement of gastric contents into the duodenum and may trigger the symptoms of Dumping Syndrome.

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin? A. Crusting B. Wrinkling C. Deepening of expression lines D. Thinning and loss of elasticity in the skin

A. Crusting Crusting noted on the skin would indicate a potential complication. The normal physiological changes that occur in the skin of older adults include thinning of the skin, loss of elasticity, deepening of expression lines, and wrinkling.

The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? Select all that apply. A. Elevated lipase level B. Elevated lactase level C. Elevated trypsin level D. Elevated amylase level E. Elevated sucrase level

A. Elevated lipase level C. Elevated trypsin level D. Elevated amylase level Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively. Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Sucrase is produced in the small intestine and converts sucrose into glucose and fructose.

To perform cardiopulmonary resuscitation (CPR), the nurse should use the method pictured to open the airway in which situation? Refer to figure. A. If neck trauma is suspected B. In all situations requiring CPR C. If the client has a history of seizures D. If the client has a history of headaches

A. If neck trauma is suspected The jaw thrust without the head tilt maneuver is used when head or neck trauma is suspected. This maneuver opens the airway while maintaining proper head and neck alignment, reducing the risk of further damage to the neck.

A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach? A. Milieu therapy B. Interpersonal therapy C. Behavior modification D. Support group therapy

A. Milieu therapy All treatment team members are viewed as significant and valuable to the client's successful treatment outcomes in milieu therapy. Interpersonal therapy is based on a one-to-one. Group therapy approach in which the therapist-client relationship is often used as a way for the client to examine other relationships in her or his life. Behavior modification is based on rewards and punishment. Support groups are based on the premise that individuals who have experienced and are insightful concerning a problem are able to help others who have a similar problem.

Which of the following client care assignments is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Select all that apply. A. Obtain vital signs every 4 hours for a patient with ulcerative colitis B. Transport a patient who is utilizing oxygen and has a peripheral IV catheter C. Apply a dressing to a superficial laceration on the patient's arm D. Assist a patient with a new transurethral prostectomy with perineal care E. Provide initial food by mouth for a patient who has experiences a brain attack.

A. Obtain vital signs every 4 hours for a patient with ulcerative colitis B. Transport a patient who is utilizing oxygen and has a peripheral IV catheter D. Assist a patient with a new transurethral prostectomy with perineal care Assisting followers in identifying situations appropriate for delegation is considered an effective leadership function. Assisting followers to use delegation as a time management strategy and team-building tool is considered an effective leadership function. Functioning as a role model, supporter, and resource person in delegating tasks to subordinates are leadership functions that are associated with delegation.

A nurse is caring for a client with Crohn's Disease. Which of the following foods can be included in this client's diet? Select all that apply. A. Pasta B. Wild rice C. Raisins D. Fresh celery E. Eggs

A. Pasta E. Eggs Low-fiber, low-residue diets are recommended for clients with Crohn's Disease. Foods that are appropriate for clients with Crohn's Disease include: Tender, ground, well-cooked meat, eggs, fish, poultry, refined pasta and cereal, white rice and bread, canned or cooked vegetables without skin or seeds and juices without pulp.

A nurse is teaching a client with right-sided hemiparesis to ambulate with a quad cane. Which instructions are appropriate? A. Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg. B. Place quad cane in right hand, extend left lower extremity, and then right hand with quad cane and left lower extremity. C. Place quad cane in right hand, extend right hand with quad cane and left lower extremity. D. Place quad cane in left hand, extend left hand with quad cane, and then left leg followed by right leg.

A. Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg. Holding the quad cane on the stronger side of the body and moving the cane in unison with the weaker leg gives support and helps to maintain stability for the client.

A nurse is preparing to complete discharge teaching for a hearing impaired client. Which of the following interventions would best facilitate successful teaching? Select all that apply. A. Provide the patient with detailed written instructions B. Include the patient's spouse in the teaching session C. Turn off the TV and close the door to the hallway D. Speak more loudly when talking to the patient E. Sit beside the patient to discuss discharge information

A. Provide the patient with detailed written instructions B. Include the patient's spouse in the teaching session C. Turn off the TV and close the door to the hallway Eliminating background noise will facilitate hearing conversational tones. Written instructions will reinforce and clarify instructions for the hearing impaired client. If the client concurs, inclusion of the spouse will be of benefit when teaching a hearing impaired client because the spouse can serve to clarify and reinforce the information after discharge. It is best to face the client directly rather than sit beside them. Many hearing impaired clients will augment their hearing by lip reading.

A client with pneumonia has an oxygen saturation of 85%, heart rate of 88, respiratory rate of 22, and blood pressure of 132/88. Which of the following is the priority nursing intervention? A. Reassess pulse oximetry B. Place the client on 2 Liters oxygen C. Immediately notify the provider D. Administer albuterol inhaler

A. Reassess pulse oximetry When the other vital signs are within normal range, the immediate intervention would be to reassess the low oxygen saturation using another site before any other interventions are completed. Causes of low readings include client movement, hypothermia, decreased peripheral blood flow, ambient light (sunlight, infrared lamps), decreased hemoglobin, edema, and fingernail polish. If a client with pneumonia is placed on oxygen, the preferred choice would be humidified oxygen via face mask to help thin the secretions.

A client has just returned to the surgical unit after an open cholestectomy. A nurse notes the abdominal dressing is saturated with sanguineous drainage. Which of the following is the most appropriate intervention? A. Reinforce the dressing with additional gauze. B. Remove the dressing to assess the incision. C. Document the assessment findings. D. Outline the drainage size with a marker.

A. Reinforce the dressing with additional gauze. The appropriate intervention for a dressing that becomes wet from drainage is to reinforce the dressing by adding more dressing material to the existing dressing. The first dressing change is performed by the surgeon.

The nurse is reviewing a HCP prescription for a child with sickle cell anemia who was admitted to the hospital for the treatment of vast-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? (Select all that apply) A. Restrict fluid intake. B. Position for comfort. C. Avoid strain on painful joints. D. Apply nasal oxygen at 2 L/minute. E. Provide a high-calorie, high-protein diet. F. Give meperidine, 25 mg intravenously, every 4 hours for pain.

A. Restrict fluid intake. F. Give meperidine, 25 mg intravenously, every 4 hours for pain. Sickle cell anemia is one of a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and intravenous fluids are an important part of treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control.

A newly-licensed nurse is preparing the surgical suite for a client who has a latex allergy. Which action demonstrates a need for further education? A. Scheduling the case late in the day. B. Placing monitoring devices in stockinet. C. Covering IV tubing ports with tape. D. Using glass syringes.

A. Scheduling the case late in the day. Clients with latex allergy should be scheduled as the first case in the morning. This will allow latex dust (from the previous day) to be removed overnight.

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. A. The acuity level of the clients B. Specific requests from the staff C. The clustering of the rooms on the unit D. The number of anticipated client discharges E. Client needs and workers' needs and abilities

A. The acuity level of the clients E. Client needs and workers' needs and abilities There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.

A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate medical attention? A. The baby is crying inconsolably for more than three hours B. The baby develops swelling or redness at the injection site C. The baby has an axillary temperature of 100.4o F. (38o C) D. The baby develops a localized or generalized rash

A. The baby is crying inconsolably for more than three hours Inconsolable crying lasting more than three hours and/or seizures within 48 hours of vaccination is a sign of encephalopathy that must be treated immediately.

The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell that staff that which child behavior is characteristic of the formal operations stage? A. The child has the ability to think abstractly. B. The child begins to understand the environment. C. The child is able to classify, order, and sort facts. D. The child learns to think in terms of past, present, and future.

A. The child has the ability to think abstractly. In the formal operations stage, the child has the ability to think abstractly and logically. Option 2 identifies the sensorimotor stage. Option 3 identifies the concrete operational stage. Option 4 identifies the preoperational stage.

An 87-year-old client has been admitted repeatedly to the acute care setting for pneumonia. The client's family asks what measures can help prevent recurrent respiratory issues. Which of the following measures should the nurse discuss to prevent respiratory issues? Select all that apply. A. Use a humidifier to moisten the air in the patient's room when needed B. Encourage a diet high in protein C. Administer a prior dosage of antibiotics when the patient has a cough D. Ambulate the patient regularly, daily E. Reassure the patient during episodes of respiratory distress

A. Use a humidifier to moisten the air in the patient's room when needed D. Ambulate the patient regularly, daily E. Reassure the patient during episodes of respiratory distress Encourage structured activities, after learning the client's physical capabilities and provide rest periods to prevent dyspnea. Using a humidifier during drier seasons can help prevent secretions from becoming thick and difficult to expectorate. If a client is having difficulty breathing, the caregiver(s) should provide support and reassurance to decrease the client's anxiety.

The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? A. Withdraws the NPH insulin first B. Withdraws the regular insulin first C. Injects air into NPH insulin vial first D. Injects an amount of air equal to the desired dose of insulin into each vial

A. Withdraws the NPH insulin first When preparing a mixture of short-acting insulin, such as regular insulin, with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type.

An older adult client with a history of heart failure is admitted to the hospital with a diagnosis of digoxin toxicity. Which of the following assessment findings should the nurse expect? Select all at apply. A. Yellow vision B. Digoxin level of 1.5 C. Heart rate of 52 bpm D. Increased appetite E. Constipation

A. Yellow vision C. Heart rate of 52 bpm An older adult client may experience the toxic effects of digoxin even though the drug level is within normal limits (0.5 - 2 ng/ml). Bradycardia is a sign of digoxin toxicity and is the reason an apical pulse is taken prior to administration of this drug. Clients with digoxin toxicity often have disturbed color vision or see halos.

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply. A. "I'm afraid of spiders." B. "I keep reliving the robbery." C. "I see his face everywhere I go." D. "I don't want anything to eat now." E. "I might have died over a few dollars in my pocket." F. "I have to wash my hands over and over again many times."

B. "I keep reliving the robbery." C. "I see his face everywhere I go." E. "I might have died over a few dollars in my pocket." Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with post-traumatic stress disorder.

A client has been prescribed spironolactone for treatment of heart failure. Which statement made by the client would indicate a need for further teaching? A. "I will need to have routine labs drawn while taking this medication B. "I will limit the use of salt in my diet and use a salt substitute instead." C. "I should take my medication at the same time each day in the morning." D. "I will weigh myself daily and report any changes in weight."

B. "I will limit the use of salt in my diet and use a salt substitute instead."

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? A. "When did the injury occur?" B. "Was the client awake and talking right after the injury?" C. "What medications has the client received since the fall?" D. "What was the client's level of consciousness before the injury?"

B. "Was the client awake and talking right after the injury?" Epidural hematomas are frequently characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase. Epidural hematomas are medical emergencies.

A fire in a first floor operating room is forcing evacuation of clients from a second floor unit to another building. Which of the following clients would have the highest priority for the charge nurse to evacuate? A. A client post left hip replacement of two days ago whose daughter is visiting. B. A client receiving IV antibiotics every six hours for a leg ulcer. C. A client admitted with pancreatitis with nasogastric tube and PCA pump in place. D. A client semi-comatose after a cerebrovascular accident with an indwelling urinary catheter.

B. A client receiving IV antibiotics every six hours for a leg ulcer. The client with a leg ulcer can walk unassisted without an IV pole. In a hospital evacuation, unlike triage and evacuation outside of the hospital, the most stable, ambulatory clients will be evacuated first, followed by those who need assistance with mobility (wheelchairs) or equipment (tubes, catheters), and finally those who need to be moved by stretcher or in their hospital beds. The prevailing concept is to move as many clients as quickly and safely as possible from the area.

A client with a recent myocardial infarction is prescribed digoxin. Which of the following findings indicate to the nurse that a therapeutic response to this medication has been attained? A. A decrease in urinary output. B. A decrease in pulmonary crackles. C. An increase in apical pulse rate. D. A rise in central venous pressure.

B. A decrease in pulmonary crackles.

A client with an ileostomy calls the clinic reporting stomal swelling along with decreased drainage of ileostomy contents. The nurse instructs the client to do which of the following? Select all that apply. A. Lie down in a supine position B. Apply moist towels to the abdomen C. Ensure the pouch is attached correctly D. Drink hot tea E. Begin abdominal massage

B. Apply moist towels to the abdomen D. Drink hot tea E. Begin abdominal massage Moist towels should be applied to the abdomen to facilitate drainage. Abdominal massage should be initiated to promote drainage. Hot tea may facilitate drainage and should therefore be encouraged. The client should be instructed to lie down and assume a knee-chest position to facilitate drainage. If stomal swelling or abdominal cramping occurs, or if ileostomy contents stop draining, the client should be instructed to remove the pouch with faceplate.

A nurse is caring for a client hospitalized with Guillain-Barré Syndrome who has been in the intensive care unit on a ventilator for four days. Which of the following would be most appropriate in assessing for complications of immobility? Select all that apply. A. Assess rate and depth of respiratory effort B. Assess the character of bowel sounds and frequency of stools C. Observe skin color over sacral, heels, and scapulae areas D. Assessing the client's ability yo move their lower extremities E. Performing range of motion on the client's ankles, knees, and hips

B. Assess the character of bowel sounds and frequency of stools C. Observe skin color over sacral, heels, and scapulae areas E. Performing range of motion on the client's ankles, knees, and hips Potential complications of immobility could include the following: loss of joint motion and contractures, decreased gastrointestinal motility and constipation, deep vein thrombosis with erythema and swelling of the calf areas, and skin breakdown with early evidence of pallor, erythema, blistering over bony prominences. Respiratory effort is frequently compromised in the client with Guillain-Barré disease because of diaphragm and muscle paralysis. To assess for complications of immobility it would be appropriate to auscultate for abnormal breath sounds.

A nurse is providing dietary education for a client with cholecystitis. Which of the following food choices made by the client indicates a need for further teaching? A. Baked potato B. Broccoli with cheese sauce. C. Chicken breast D. Wheat bread

B. Broccoli with cheese sauce Cholecystitis is characterized by inflammation of the gallbladder. The gallbladder stores and releases bile that aids in the digestion of fats. Fat intake should be limited to reduce stimulation of the gallbladder. Other foods that may be contraindicated include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods.

The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding should the nurse expect to note in this client? A. Dry skin B. Bulging eyeballs C. Periorbital edema D. Coarse facial features

B. Bulging eyeballs Hyperthyroidism is clinically manifested by an increase in the size of the thyroid gland (goiter) and bulging eyeballs (exophthalmos). Other clinical manifestations include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance. Additional signs found in this disorder include tachycardia; shortness of breath; excessive sweating; fine muscle tremors; thin, silky hair and thin skin; infrequent blinking; and a staring appearance.

A graduate nurse is performing ostomy care for a client with a new colostomy. Which intervention performed by the nurse indicates the need for more education? A. Positioning the client standing or supine. B. Cleansing the peristomal skin with alcohol. C. Measuring and assessing the stoma. D. Changing the pouch before a meal.

B. Cleansing the peristomal skin with alcohol. This intervention is not appropriate. The peristomal skin should not be cleansed with alcohol.

A nurse is caring for a client after an open radical prostatectomy. Which of the following interventions is the highest priority in the immediate postoperative period? A. Suggest methods for reducing urinary incontinence, such as Kegel exercises. B. Encourage use of patient-controlled analgesia (PCA) as needed. C. Administer a stool softener to prevent constipation. D. Teach the client how to care for a urinary catheter and leg bag.

B. Encourage use of patient-controlled analgesia (PCA) as needed. Assessment of the client's pain level, along with monitoring the effectiveness of pain management given through patient-controlled analgesia, is the priority intervention in the immediate postoperative period. Address actual/present problems before addressing potential problems.

A nurse is caring for a client when the IV infusion pump malfunctions and delivers 1 Liter of IV fluid over 2 hours. Which intervention is the priority? A. Monitor urine output. B. Fill out an incident report. C. Report the defective equipment. D. Document the amount of fluid infused.

B. Fill out an incident report. A malfunctioning device or product should be documented using an incident report. The report is confidential and separate from the medical record. It should never be documented in the client's medical record that an incident report was completed.

A home care nurse suspects that a client's spouse is experiencing caregiver strain. Which nursing action will assist in supporting the nurse's suspicion? A. Obtaining feedback from the client about the coping abilities of the caregiver B. Gathering subjective and objective assessment from the caregiver and the client C. Making a referral to the home care agency social worker to complete the assessment D. Interviewing family members regarding their concerns for the health and well-being of the caregiver

B. Gathering subjective and objective assessment from the caregiver and the client To assess for caregiver strain, the nurse should gather subjective and objective data from the caregiver and the client. The nurse should not expect the client or family members to assess the coping abilities of the caregiver. Although a social worker may be helpful, the nurse needs to perform the assessment of the situation before making the referral.

A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls? A. Place bedside table in close proximity. B. Hourly rounding by the nurse. C. Use of a night-light. D. Demonstrate how to use the call light.

B. Hourly rounding by the nurse. In the health care environment, hourly rounding by nurses significantly reduces the occurrence of client falls, as well as reducing call light usage and increasing client satisfaction.

A clinic nurse is preparing to administer a Penicillin IM injection to a client who has never taken the medication before. Which of the following interventions should be included in the plan of care? A. Ask the client if they are allergic to shell fish before administering. B. Instruct the client to sit in the clinic for 30 minutes after the injection. C. Inject the client with a small test dose of Penicillin subcutaneously. D. Instruct the client to expect a slight rash to develop at the injection site.

B. Instruct the client to sit in the clinic for 30 minutes after the injection.

The nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. How does the nurse correctly interpret these findings? A. It is at the first tracheal cartilaginous ring. B. It is at the bifurcation of the right and left main bronchi. C. It is at the point at which the larynx connects to the trachea. D. It is at the area connecting the oropharynx to the laryngopharynx.

B. It is at the bifurcation of the right and left main bronchi. The carina is a cartilaginous ridge that separates the openings of the 2 main (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main bronchus as a result of the natural curvature of the airway. This is hazardous because then only the right lung will be ventilated. Incorrect tube placement is easily detected because only the right lung will have breath sounds and rise and fall with ventilation.

The nurse is conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by doing which action? A. Contracting and then consciously relaxing different muscle groups B. Massaging the abdomen during contractions, using both hands in a circular motion C. Instructing her partner to stroke or massage a tightened muscle by the use of touch D. Contracting an area of the body, such as an arm or leg, and then concentrating on letting tension go from the rest of the body

B. Massaging the abdomen during contractions, using both hands in a circular motion Effleurage is massage of the abdomen during contractions. Women learn to do effleurage using both hands in a circular motion. Progressive relaxation involves contracting and then consciously releasing different muscle groups. Touch relaxation helps the woman to learn to loosen taut muscles when she is touched by her partner. Neuromuscular disassociation helps the woman to relax her body even when 1 group of muscles is strongly contracted. In this procedure, the woman contracts an area such as an arm or leg and then concentrates on letting tension go from the rest of the body.

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. A. Open doors to client rooms. B. Move beds away from windows. C. Close window shades and curtains. D. Place blankets over clients who are confined to bed. E. Relocate ambulatory clients from the hallways back into their rooms.

B. Move beds away from windows. C. Close window shades and curtains. D. Place blankets over clients who are confined to bed. In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows.

A nurse is providing dietary teaching to a client diagnosed with ulcerative colitis. Which of the following foods should the nurse instruct the client to avoid? A. Roast chicken and cooked spinach. B. Pork chop and brown rice. C. Broiled liver and white rice. D. Grilled salmon and cooked apricots.

B. Pork chop and brown rice. Pork chops and brown rice are high in roughage content which will stimulate peristalsis and makes the symptoms of ulcerative colitis worse. Other foods to be avoided include whole grains, nuts, raw fruits and vegetables, caffeine, alcohol, tough meats, pork and highly spiced meats.

A nurse is managing client care. Which of the following should be implemented when prioritizing care? Select all that apply. A. Respond to needs as soon as they arise B. Postpone items that do not have immediate deadlines C. Avoid delegation of difficult tasks D. Prepare a written list E. Take on a task when inspired

B. Postpone items that do not have immediate deadlines D. Prepare a written list Preparing a written list is a function considered in prioritizing client care. Items that are marked as to do later reflect trivial problems or those that do not have immediate deadlines; thus, they may be postponed when prioritizing care.

The nurse is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The nurse reads that which are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA) in the United States? Select all that apply. A. Provide monetary relief. B. Provide crisis counseling. C. Identify and train personnel. D. Issue presidential declarations. E. Deploy National Guard troops. F. Handle inquiries from families.

B. Provide crisis counseling. C. Identify and train personnel. F. Handle inquiries from families. In general, the ARC provides support to individuals involved in a disaster, whereas FEMA deals with regional responses to disasters, such as issuing presidential declarations, providing monetary relief, and deploying National Guard troops. The ARC has been given authority by the federal government to identify and train personnel for a disaster and provide disaster relief, including crisis counseling, operating shelters, and handling inquiries from families.

A nurse is caring for a client with a diagnosis of sepsis with a temperature of 40.8 C (105.5 F). The provider has ordered a cooling blanket. Which intervention is appropriate to delegate to an Unlicensed Assistive Personnel (UAP)? A. Obtain a fan for the client's use B. Report shivering by the client C. Bathe the client to keep the skin damp D. Assess the client's skin for any reddened

B. Report shivering by the client The unlicensed assistive personnel should be taught to observe for and report shivering during any form of external cooling. Shivering may indicate that the client is being cooled too quickly. The use of fans is discouraged because they can disperse airborne or droplet transmitted pathogens.

A nurse is administering mannitol to the client with increased intracranial pressure. What supplies are necessary when administering this medication? A. Pill cup, glass of water, straw B. Syringe, filter needle, IV filter tubing C. Pressure cuff, 1000mL bag of normal saline D. Alcohol wipe, syringe, 18 gauge needle

B. Syringe, filter needle, IV filter tubing

A client with a digoxin level of 2.4 ng/ml has a heart rate of 39. The health care provider prescribes atropine sulfate. Which of the following best describes the intended action of atropine for this client? A. To dry oral and tracheobronchial secretions. B. To accelerate the heart rate by interfering with vagal impulses. C. To reduce peristalsis and urinary bladder tone. D. To stimulate the SA node and sympathetic fibers to increase the rate.

B. To accelerate the heart rate by interfering with vagal impulses.

A nurse is educating an older adult about food safety in the home. Which of the following instructions should the nurse include in teaching? A. Food poisoning is usually caused by a fungus. B. When preparing a meal raw and fresh foods should be handled separately. C. Clients at risk for food poisoning should follow a low cholesterol diet. D. The older adult recovers from food poisoning in a few days.

B. When preparing a meal raw and fresh foods should be handled separately. Raw and fresh foods should be handled separately to prevent cross contamination.

A nurse is assisting a client with bowel training. When should the nurse instruct the client to attempt defecation? A. Immediately before meals. B. When the client has the urge to defecate. C. Every hour while awake. D. When the client feels abdominal cramping.

B. When the client has the urge to defecate. Failure to heed the call to defecate may lead to overdistention of the rectum with hardening of the stool and subsequent constipation. Therefore, the best time to toilet a client to encourage bowel training is when the client has the urge to defecate.

A child is seen in the health care clinic, and the nurse suspects the presence of pinworm infection (enterobiasis). The nurse instructs the mother as to how to obtain a cellophane tape rectal specimen. Which statement by the mother indicates an understanding of the correct procedure to obtain the specimen? A. "I need to collect the specimen after I give my child a bath." B. "I need to collect the first bowel movement of the day and place it in a sealed container." C. "I need to place a piece of transparent cellophane tape lightly over the anal area as soon as my child awakens and bring it to the clinic for examination." D. "I need to place a piece of transparent cellophane tape lightly over the anal area after my child has a bowel movement and bring it to the clinic for examination."

C. "I need to place a piece of transparent cellophane tape lightly over the anal area as soon as my child awakens and bring it to the clinic for examination." A simple technique, the cellophane tape slide method, is used to capture worms and eggs. Transparent tape is lightly touched to the anus and then applied to a slide for examination. The best specimens are obtained as the child awakens, before toileting or bathing.

A nurse is taking the health history of a school-age girl. Which statement by the client's mother indicates a need for further teaching regarding the client's nutritional status? A. "She enjoys helping to prepare her snacks in the kitchen." B. "She eats a large breakfast every morning." C. "We allow her to pick out a treat at the grocery store for good behavior." D. "We increase her protein intake when she's playing sports."

C. "We allow her to pick out a treat at the grocery store for good behavior." This statement indicates a need for further teaching. This client's mother should be educated about the importance of praising the client's abilities and skills rather than using food as a reward, which may lead to an increased risk for obesity.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? A. A negative Kernig's sign B. Absence of nuchal rigidity C. A positive Brudzinski's sign D. A Glasgow Coma Scale score of 15

C. A positive Brudzinski's sign Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the client for a history of chronic use of which medication? A. Ibuprofen B. Ranitidine C. Acetaminophen D. Acetylsalicylic acid

C. Acetaminophen Acetaminophen is a potentially hepatotoxic medication (causes hepatotoxicity). Use of this medication should be investigated whenever a client presents with signs and symptoms compatible with liver disease (i.e., ascites and jaundice).

A hospital has been notified that possible bioterrorist activity has taken place at a large sporting event nearby. A nurse has been put in charge of preparing a holding area to meet the needs of victims who report headache, dizziness, anxiety and shortness of breath, and are noted to have a bitter almond odor to their breath. What medication should the nurse be prepared to administer? A. Cyanide vaccine B. Vitamin K C. Amyl Nitrate D. Acetylcysteine

C. Amyl Nitrate The victims' symptoms are consistent with cyanide poisoning. Amyl Nitrate is given for cyanide poisoning.

A client has a lithium level of 2.4 mEq/L. The nurse should immediately assess the client for which sign or symptom? A. Diarrhea B. Weakness C. Blurred vision D. Cardiac dysrhythmias

C. Blurred vision At lithium levels of 2.0 to 2.5 mEq/L, the client will experience blurred vision, muscle twitching, severe hypotension, and persistent nausea and vomiting. With levels between 1.5 and 2.0 mEq/L, the client experiences vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. At lithium levels of 2.5 to 3.0 mEq/L or higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysrhythmias, peripheral vascular collapse, and death.

The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority? A. Document the finding in the client's record. B. Call the employee health service department. C. Contact the primary health care provider (PHCP). D. Call the radiology department for a chest radiographic study to be done.

C. Contact the primary health care provider (PHCP). The nurse who obtains a positive test reading should call the PHCP immediately. The PHCP will prescribe a chest x-ray study to determine whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be obtained to confirm the diagnosis of active TB. The client can be placed on prophylactic TB precautions until a final diagnosis is made.

A nurse is educating the parents of an infant about symptoms that should be reported to the provider. What finding should be immediately reported? A. Abdominal distension B. Difficulty evacuating bowels C. Decreased urine output D. Mild diarrhea

C. Decreased urine output. Decreased urine output indicates dehydration and should be reported immediately to the provider. Listlessness, sunken eyes, decreased tears, and dry mucous membranes are other symptoms of dehydration that should be immediately reported.

A nurse is assisting a client with an advance directive. Which of the following nursing responsibilities should be included regarding advance directives? Select all that apply. A. Ensure that each family member receives a copy of the advance directive B. Inform all members of the patient's family of the patient's wishes C. Document the patient's advance directive in the medical chart D. Provide written information to the client about advance directives E. Confirm that the advance directive is current

C. Document the patient's advance directive in the medical chart D. Provide written information to the client about advance directives E. Confirm that the advance directive is current The nursing responsibility regarding advance directives is to ensure that the advance directive is current and reflective of the client's current decisions.

A nurse is caring for a client in Buck's Traction. Which of the following nursing interventions would ensure effective therapy? Select all that apply. A. Assist the client to roll from side to side B. Support the leg in adduction C. Ensure that all weights are free hanging D. Prevent wrinkling of the traction bandage E. Maintain counter-traction with weights

C. Ensure that all weights are free hanging D. Prevent wrinkling of the traction bandage All weights must be free hanging to ensure effective traction. To ensure effective Buck's traction, it is important to avoid wrinkling and slipping of the traction bandage and to maintain countertraction. The client should not be assisted to move from side to side to prevent skin breakdown. To prevent bony fragments from moving against one another, the client should not turn from side to side; however, the client may shift position slightly with assistance. The effective leg in Buck's traction should not be adducted. The leg must be maintained in a neutral position.

A nurse applies restraints to a mental health client who is refusing to take his antipsychotic medication. The nurse may be charged with which of the following intentional torts? A. Negligence B. Malpractice C. False Imprisonment D. Assault

C. False Imprisonment False imprisonment - confining a client against their will. Assault - the conduct of one person makes another person fearful and apprehensive.

A nurse is teaching a client about dietary modifications to help control blood pressure. Which of the following food choices by the client indicates an understanding of the teaching? A. French onion soup and salad B. Chicken bouillon and crackers C. Grilled chicken salad with fresh salsa D. Vegetarian wrap with chips

C. Grilled chicken salad with fresh salsa Grilled chicken salad and fresh salsa are both made from fresh (preservative-free) materials and therefore are likely to be of lower sodium content than French onion soup, chips, chicken bouillon, or crackers.

A 10 y/o child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription? A. Injection of factor X B. IV infusion of iron C. IV infusion of factor VIII D. IM injection of iron using the Z-track method

C. IV infusion of factor VIII Hemophilia is a bleeding disorder that results from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor. A child with hemophilia A is at risk for joint bleeding after a fall. Factor VIII would be prescribed intravenously to replace the missing clotting factor and minimize the bleeding.

The nurse prepares to administer acetylcysteine to the client with an overdose of acetaminophen. What is the appropriate action when administering this antidote? A. Administer the medication subcutaneously in the deltoid muscle. B. Administer the medication by intramuscular (IM) injection in the gluteal muscle. C. Mix the medication in a flavored ice drink, and allow the client to drink the medication. D. Administer the medication mixed in 50 mL of normal saline and piggybacked through the main intravenous (IV) line.

C. Mix the medication in a flavored ice drink, and allow the client to drink the medication. Acetylcysteine is the antidote for acetaminophen. Because acetylcysteine has a pervasive flavor of rotten eggs, it must be disguised in a flavored ice drink and is preferably drunk through a straw to minimize contact with the mouth. It is a solution that also is used as a mucolytic agent, administered via nebulization. It is not administered by the IV, IM, or subcutaneous route.

A client admitted with an acute exacerbation of asthma has been prescribed methylprednisolone sodium succinate IV. Which of the following findings should the nurse report to the provider immediately? A. Increased hunger B. Mild wheezing C. Oral temperature of 100.5 F D. Blood glucose 120 mg/dL

C. Oral temperature of 100.5 F

A nurse is caring for a client following a right below the knee amputation. Which of the following should the nurse include in the plan of care to prevent infection? A. Encourage the client to lie supine for 20-30 minutes several times a day. B. Encourage the client to lie prone for 20-30 minutes several times a day. C. Position the affected limb in a dependent position. D. Position the affected limb elevated on a pillow.

C. Position the affected limb in a dependent position. Positioning the extremity in a dependent position will promote blood flow and oxygenation which will decrease the risk of infection. The affected limb should not be elevated on a pillow for the first 24 hour post-operative.

After performing an initial abdominal assessment on a patient, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds? A. Waves of loud gurgles auscultated in all 4 quadrants B. Low-pitched swishing auscultated in 1 or 2 quadrants C. Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants D. Very high-pitched loud rushes especially in 1 or 2 quadrants

C. Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants

A monoamine oxidase inhibitor is prescribed for a client. Which sign or symptom is indicative of toxicity? A. Lethargy B. Depression C. Restlessness D. Constipation

C. Restlessness Acute toxicity of monoamine oxidase inhibitors (MAOIs) is manifested by restlessness, anxiety, and insomnia. Dizziness and hypertension can also occur in acute toxicity.

A nurse is providing staff development. The nurse understands that which of the following may impede learning? A. Proven learner. B. Self-directed. C. Self-confidence. D. Intrinsic motivation.

C. Self-confidence.

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height at 30 cm. How should the nurse interpret this finding. A. The patient is measuring large for gestational age B. The patient is measuring small for gestational age C. The patient is measuring normal for gestational age D. More evidence is needed to determine size of gestational age

C. The patient is measuring normal for gestational age During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm. Therefore, if the client is at 28 weeks gestation, a fundal height of 30 cm would indicate that the client is measuring normal for gestational age.

A nurse is to administer morphine sulfate 10 mg intramuscular (IM) to an adult client for post-operative pain. Which injection site is the most appropriate? A. Dorsogluteal B. Epidural C. Ventrogluteal D. Deltoid

C. Ventrogluteal

A nurse is completing a dietary evaluation for a client diagnosed with acute glomerulonephritis. Which of the following statements made by the client demonstrates understanding of necessary restrictions? A. "I should increase my consumption of protein." B. "I should consume a diet low in carbohydrates." C. "I should increase my fluid intake to 8-10 glasses of water a day." D. "I should limit my sodium intake to 4 grams per day."

D. "I should limit my sodium intake to 4 grams per day." Excessively high protein and sodium diets put clients at risk for glomerulonephritis. Clients with this condition should implement sodium and protein restriction.

A nurse has just taught a client about the side effects of levodopa. Which client statement would indicate to the nurse that further instructions is needed? A. "I will get out of bed slowly." B. "I will administer the medication with food." C. "I will not eat bananas." D. "I still can drive."

D. "I still can drive." This medication may cause sudden onset of sleep, drowsiness and dizziness. Instruct client to avoid driving and other activities that required alertness.

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? A. A client who requires a bed bath B. An older client requiring frequent ambulation C. A client who requires hourly vital sign measurements D. A client requiring abdominal wound irrigations and dressing changes every 3 hours

D. A client requiring abdominal wound irrigations and dressing changes every 3 hours The licensed practical nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by an AP.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? A. A client who is ambulatory demonstrating steady gait B. A postoperative client who has just received an opioid pain medication C. A client scheduled for physical therapy for the first crutch-walking session D. A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C

D. A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C The nurse should plan to care for the client who has an elevated white blood cell count and a fever first, because this client's needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? A. A client complaining of muscle aches, a headache, and history of seizures B. A client who twisted her ankle when rollerblading and is requesting medication for pain C. A client with a minor laceration on the index finger sustained while cutting an eggplant D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number-1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a number-2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a number-3 priority.

A nurse is caring for a client who is receiving intermittent tube feedings. What intervention reduces the risk of aspiration? A. Instructing the client to cough forcefully as the feeding is started. B. Performing nasotracheal suctioning before initiation of the feeding. C. Assisting the client into a supine position in preparation for the feeding. D. Assessing gastric residual volume immediately before administering the feeding

D. Assessing gastric residual volume immediately before administering the feeding Measuring the gastric residual volume (GRV) every 4 to 6 hours in clients who are receiving continuous feedings and immediately before the feeding in clients receiving intermittent feedings is an effective way to reduce the risk of aspiration. Nursing measures to reduce the risk of aspiration, such as keeping the head of bed elevated and routine assessment for aspiration, should be implemented for clients who are receiving tube feedings. Feedings should be withheld if the GRV is greater than 200 mL in two successive measurements. The head of the bed should be elevated to 30 degrees or higher for clients who are receiving enteral feedings.

A nurse is caring for a client with a spinal cord injury who has an indwelling catheter. Which of the following is the highest priority when providing perineal care for this client? A. Assess for perineal pain or discomfort. B. Examine condition of catheter and drainage tubing. C. Assess the client's knowledge of importance of perineal hygiene. D. Avoid inadvertently advancing the catheter into the bladder.

D. Avoid inadvertently advancing the catheter into the bladder. Accidental advancement of the catheter into the bladder during cleansing increases the risk of introducing bacteria into the bladder. Therefore, avoiding inadvertent advancement of the catheter into the bladder is the priority intervention.

A client has begun taking phenelzine. At the initiation of therapy, the client is taught which foods are acceptable to consume? Select all that apply. A. Avocados B. Figs and raisins C. Bologna or salami D. Carrots or radishes E. Sweet potatoes and squash F. Red wine, such as Chianti or sherry

D. Carrots or radishes E. Sweet potatoes and squash Phenelzine is a monoamine oxidase inhibitor (MAOI). The client should avoid foods that are high in tyramine because they could trigger a potentially fatal hypertensive crisis. Foods to avoid include aged cheeses, smoked or processed meats, red wines, avocados, raisins, and figs. Vegetables are generally acceptable, with the exception of broad beans, including fava beans.

A client has a new tracheostomy. Which of the following interventions should the nurse include when performing tracheostomy care? A. Remove soiled dressing with sterile gloves. B. Clean disposable inner cannula with hydrogen peroxide. C. Suction the tracheostomy before beginning care. D. Change tracheostomy ties when soiled.

D. Change tracheostomy ties when soiled Tracheostomy ties should be changed once a day or when soiled. Secure new ties in place before removing old soiled ones to prevent accidental decannulation. One or two fingers should be able to be placed between the tie tape and the neck.

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriatenursing action? A. Finish the bed bath and then administer the pain medication to the other client. B. Ask the AP to find out when the last pain medication was given to the client. C. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Option 2 is not a responsibility of the AP.

A client is a Jehovah's Witness and is scheduled for an elective hysterectomy secondary to prolonged and heavy menses. Which medication would the nurse anticipate being ordered prior to surgery for this client? A. Retrovir B. Methylergonovine C. Interferon D. Epoetin Alfa

D. Epoetin Alfa Epoetin Alfa is a growth factor used to treat anemia related to renal disease, chemotherapy, HIV / AIDS treatment and for clients who are anemic undergoing elective surgery. Jehovah's Witness' clients generally do not accept blood transfusions, and this client has had prolonged and heavy menstrual bleeding and is likely anemic. In this case, Epoetin Alfa dosing 2-4 weeks prior to surgery (generally once per week for four weeks prior to surgery) would be indicated to raise the hemoglobin to a therapeutic level.

The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands? A. Every 2 hours B. Every 3 hours C. Every 4 hours D. Every 30 minutes

D. Every 30 minutes The nurse should instruct the AP to check safety devices for tightness every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked by the registered nurse every 30 minutes. The safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed.

A nurse is triaging clients following a mass casualty event. The nurse should place a client who has sustained fatal injuries in which of the following triage categories? A. Emergent Category (Class I) B. Urgent Category (Class II) C. Nonurgent Category (Class III) D. Expectant Category (Class IV)

D. Expectant Category (Class IV) Class IV (Expectant Category) is reserved for clients who are not expected to live and will be allowed to die naturally. Comfort measures may be provided, but restorative care will not. These clients are the lowest priority when a mass casualty has occurred. Class I (Emergent Category) is reserved for clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized. These clients are given highest priority.

A client diagnosed with bipolar disorder and prescribed lithium carbonate is being discharged from the hospital. Which of the following medication prescriptions should the nurse should question? A. Ranitidine 150 mg by mouth daily B. Valproic acid 250 mg by mouth three times per day C. Captopril 25 mg by mouth twice per day D. Furosemide 20 mg by mouth twice per day

D. Furosemide 20 mg by mouth twice per day

The nurse is caring for a patient with myasthenia graves who has received edrophonium by the intravenous route to test for myasthenia crisis. The patient asks the nurse how long the improvement in muscle strength will last. Which response should the nurse make to the client? A. It will last for 4-5 minutes B. It will last for about 30 minutes C. It will last longer than 60 minutes D. It will last approximately 10 minutes

D. It will last approximately 10 minutes

The parents of an adolescent client ask the nurse why the meningiococcal conjugate vaccine is recommended before attending college. Which of the following statements best explains the reason why college-aged students should receive this vaccine? A. Upper respiratory infections are more common on college campuses. B. Receiving the vaccine provides guaranteed immunity to the disease. C. Adults who contract meningitis rarely have complications from it. D. Living in a dormitory increases the risk of exposure to the disease.

D. Living in a dormitory increases the risk of exposure to the disease. Living in close quarters, like dormitories or barracks, greatly increases the risk of being exposed to meningococcal pneumonia. Other risk factors include travel to a country where the disease is endemic, biologists who work with the organism and clients who have no spleen function (and consequently are immunosuppressed).

The nurse is caring for a client with acute pulmonary edema. The primary health care provider (PHCP) tells the nurse that medication will be prescribed to help reduce preload and afterload. Based on the PHCP's statement, what medication should the nurse anticipate administering? A. Digoxin B. Prednisone C. Furosemide D. Nitroprusside sodium

D. Nitroprusside sodium Intravenous nitroprusside is a potent vasodilator that reduces preload and afterload. It is a medication used to treat the client with pulmonary edema. Prednisone is a steroidal anti-inflammatory medication that is not usually prescribed for acute pulmonary edema and could aggravate the symptoms due to sodium and retention effects of this medication. Digoxin is a cardiac glycoside that increases cardiac contractility. Furosemide is a loop diuretic and can reduce preload by enhancing the renal excretion of sodium and water, which reduces circulating blood volume. Furosemide is often prescribed for acute pulmonary edema, but the action of the medication is not to decrease both preload and afterload.

The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the preconventional level? A. Peer pressure B. Social pressure C. Parents' behavior D. Punishment and reward

D. Punishment and reward In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the child's actions are good, the child is praised. If the child's actions are bad, the child is punished.

When the nurse takes morning medications to a client, the client states "I've never seen that one before." Which of the following is the most appropriate action for the nurse to take? A. Tell the client that the medication must be new and to go ahead and take it. B. Recheck the medication with the medication administration record (MAR). C. Administer the rest of the medications and recheck the one that was questioned. D. Return to the nurse's station and check all medications against provider orders

D. Return to the nurse's station and check all medications against provider orders The best action would be to hold off on administering any of the medications until they are all verified against provider orders in the client record. Once that is complete, the nurse can tell the client with certainty that the medications have all been verified with the provider order, and then answer any questions about the medications the client or family asks. These actions prevent errors and build trust.

A nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following outcomes best demonstrates that TPN therapy is effective? A. The client gains one kilogram per day. B. The client's urinary output increases by 800 mL per day. C. The client reports less frequent bowel movements. D. The client maintains an albumin level of 5.0 g/100mL.

D. The client maintains an albumin level of 5.0 g/100mL.

A nurse is to administer nitroglycerin to a client for the treatment of angina. Which of the following should the nurse first advise the client? A. A headache may occur. B. To sit or lie down. C. Dizziness may occur. D. To rise slowly

D. To rise slowly

The nurse is a responder at the scene of a building collapse. Which victim should the nurse care for first? A. Victim with an open fracture of the left lower extremity B. Victim who is crying hysterically and complaining of pain in the right ankle C. Victim who is unresponsive and not breathing and whose left pupil is fixed and dilated D. Victim with an apparent chest wall defect and asymmetrical chest wall movement

D. Victim with an apparent chest wall defect and asymmetrical chest wall movement The victim in option 4 will continue to have a decline in respiratory status and imminent threat to life unless immediate intervention is instituted. The victim in option 3 is dead.

A nurse is instructing a client with a right fractured tibia on the correct technique for using a three-point gait with crutches. Which of the following should be included in teaching? A. Partial weight is placed on the right foot moving the crutch at the same time as the right leg. B. Weight is evenly distributed, with each leg being moved alternately with the opposing crutch. C. Weight is placed on both legs, and crutches are placed one stride in front and then legs swing to the crutches. D. Weight is distributed on both crutches and then on the unaffected leg with the sequence being repeated.

Weight is distributed on both crutches and then on the unaffected leg with the sequence being repeated. Three point gait requires the client to bear all of the weight on one foot. The affected leg does not touch the ground.